Guidelines for Homoeopathic practitioners for clinical management of Dengue

Introduction

Dengue fever, also known as break bone fever, is an infectious tropical disease caused by the dengue virus. Symptoms include fever, headache, muscle and joint pains, and a characteristic skin rash. In a small proportion of cases the disease develops into the life - threatening dengue hemorrhagic fever, resulting in bleeding, low levels of blood platelets and plasma leakage, or into dengue shock syndrome, where dangerously low blood pressure occurs.
Homoeopathy has a long record of success in the treatment of epidemics and recent experiences in Brazil and India favour its usefulness in the management of dengue. The treatment is holistic and individualized and selection of homoeopathic medicines depends upon the individual response to infection, severity of disease and clinical presentation of the case. Homoeopathy has a potential to reduce the intensity of fever, headache, body ache, weakness, loss of appetite, nausea and other associated symptoms and, also reduce the probability of developing shock, hemorrhage and other complications.

Salient points

• DF is an acute viral infection characterized by high fever, severe headache & intense body ache.
• It can be caused by any one of the four types of dengue viruses; DEN - 1, DEN - 2, DEN - 3 & DEN - 4.
• Infection may lead to 'classical dengue fever' (DF) or DHF with or without out shock.
• DHF is a more severe form of disease, which may cause death.
• Recovery from infection by one serotype provides lifelong immunity against that particular serotype. However, cross - immunity to the other serotypes after recovery is only partial and temporary.
• It can be more severe and fatal in children.
• Homoeopathic intervention can be used along with standard treatment for clinical management.
• Homoeopathic genus epidemicus can be identified for its prevention.

Mosquito - Dengue Carrier

Aedes mosquitoes are the carriers of the dengue virus. These mosquitoes can be easily distinguished as they are larger in size and have black and white stripes on their body, so they are sometimes called tiger mosquitoes. The mosquito breeds in artificial accumulation of water in and around human dwellings, such as water found in discarded tins, broken bottles, fire buckets, flower pots, coconut shells, earthen pots, tree holes etc. during and immediately after the rainy season.

It takes about 7 to 8 days to develop the virus in its body and transmit the disease. They usually bite during the daytime.The female Aedes aegypti usually becomes infected with dengue virus when it takes blood meal from a person during febrile (viremia) phase of dengue illness. After an extrinsic incubation period of 8 to 10 days, the mosquito becomes infected and the virus is transmitted when the infective mosquito bites and injects the saliva into the person.

Clinical Description

Incubation period

The period from the entry of virus through mosquito bite to appearance of first sign/symptoms is 4 - 7 days (range 3 - 14 days). Clinical criteria for DF/DHF/DSS Dengue viral infected person may be asymptomatic or symptomatic and clinical manifestations vary from undifferentiated fever to florid haemorrhage and shock.

Clinical features of DF

An acute febrile illness of 2 - 7 days duration with two or more of the following manifestations:

• Severe headache
• Retro - orbital pain - Pain behind the eyes which worsens with eye movement
• Myalgia
• Arthralgia
• Rash - Flushing over chest and upper limbs
• Mild haemorrhagic manifestations (petechiae bleeding from mucous membrane)

Dengue Haemorrhagic Fever

• A case with clinical criteria of dengue fever
plus
• Haemorrhagic tendencies evidenced by one or more of the following:
1. Positive tourniquet test
2. Petechiae, ecchymoses or purpura
3. Bleeding from mucosa, gastrointestinal tract, injection sites or other sites plus
plus
• Thrombocytopenia (<100,000 cells per cu.mm)
plus
• Evidence of plasma leakage due to increased vascular permeability, manifested by one or more of the following:

1. A rise in average, haematocrit for age and sex ≥ 20%
2. A more than 20 % drop in haematocrit following volume replacement treatment compared to baseline
3. Signs of plasma leakage (pleural effusion, ascites, hypoproteinaemia)

Dengue Shock Syndrome

All the above criteria of DHF plus evidence of circulatory failure manifested by rapid, weak pulse and narrow pulse pressure (≤ 20 mm Hg) or hypotension for age, cold and clammy skin and restlessness.

It is likely to occur in cases with mixed infection of more than one type of dengue virus. This is due to hypersensitivity which develops to one strain can trigger if there are more than one strain of virus at the same time. Co-existing conditions that may make dengue or its management more complicated include pregnancy, infancy, old age, obesity, Diabetes mellitus, renal failure, chronic haemolytic diseases, etc.

Course of Illness

After the incubation period, the illness begins abruptly and is followed by the three phases -- Febrile, Critical and Recovery.

Febrile phase

Patients typically develop high - grade fever suddenly. This acute febrile phase usually lasts 2 – 7 days and is often accompanied by facial flushing, skin erythema, generalized body ache, myalgia, arthralgia, headache, anorexia, nausea and vomiting. Mild haemorrhagic manifestations like petechiae and mucosal membrane bleeding (e.g. nose and gums) may be seen. The earliest abnormality in the full blood count is a progressive decrease in total white cell count, which should alert the physician to a high probability of dengue. Rash may be maculopapular or rubelliform and usually appear s after 3 ^rd or 4^th day of fever and commonly seen on face, neck, and other part s of body and generally fades away in the later part of the febrile phase.

Critical phase

Around the time of defervescence, when the temperature drops to 37.5⁰ –38⁰ C or less and remains below this level, usually on days 3 – 7 of illness, an increase in capillary permeability in parallel with increasing haematocrit levels may occur. Progressive leukopenia followed by a rapid decrease in platelet count usually precedes plasma leakage. The period of clinically significant plasma leakage usually lasts 24 – 48 hours. At this point patients without an increase in capillary permeability will improve, while those with increased capillary permeability may become worse as a result of lost plasma volume. Shock occurs when a critical volume of plasma is lost through leakage. It is often preceded by warning signs. The body temperature may be subnormal when shock occurs. With prolonged shock, the consequent organ hypoper fusion results in progressive organ impairment, metabolic acidosis and disseminated intravascular coagulation.

Recovery phase

If the patient survives the 24 – 48 hour critical phase, a gradual re - absorption of extra - vascular compartment fluid takes place in the following 48 – 72 hours. General well - being improves, appetite returns, gastrointestinal symptoms abate, haemodynamic status stabilizes and diuresis ensues. The haematocrit stabilizes or may be lower due to the dilutional effect of reabsorbed fluid. White blood cell count usually starts to rise soon after defervescence but the recovery of platelet count is typically later than that of white blood cell count

Diagnosis

Blood test for leukocyte, platelet and hematocrit are conducted to diagnose dengue fever and for assessment. Laboratory diagnosis of dengue is best made during the acute phase of the illness when dengue virus circulates in the blood and can be detected by assays to detect the viral RNA genome or soluble antigens (i.e. NS1 antigen) or through serology.

ELISA – based NS1 antigen tests

• It has been found to be useful as a tool for diagnosis of acute dengue infection.
• It is a simple test that is more specific and shows high sensitivity.
• It enables detection of the cases early, ie. in the viremic stage, which has epidemiological significance for containing the transmission.
• The NS1 assay may also be useful for differential diagnostic between falvi viruses because of the specificity of the assasy. IgM capture Enzyme Linked Immunosorbent Assay (MAC - ELISA) is a simple rapid test based on detection of dengue specific IgM antibodies in the test serum. The anti - dengue IgM antibody develops a little faster than IgG and is usually detectable by day five of the illness.

For confirmation of dengue infection, Government of India recommends use of ELISA – based antigen detection test (NS1) for diagnosing the case from 1^st day onwards and antibody detection test IgM capture ELISA (MAC - ELISA) for diagnosing the cases after 5^th day of onset of disease.

Management

Approach towards patients suffering from dengue involves detailed history taking including details of onset & nature of fever/illness, individual characterizing symptoms especially physical generals and mentals and assessment for warning signs, and conditions in which, dengue is likely to be more severe.

Examination is done to identify warning signs and conditions in which dengue is likely to be more severe and includes assessment of hydration, hemodynamic status (pulse, systolic and diastolic blood pressure), checking for tachypnoea, pleural effusion, examination of rash and bleeding manifestations, assessment of abdominal tenderness, ascites and hepatomegaly. Appropriate investigations are advised for diagnosis and assessment of disease severity.

Indications for domiciliary management:

• No tachycardia
• No hypotension
• No narrowing of pulse pressure
• No bleeding
• Platelet count > 100,000/cu.mm

Laboratory investigations for assessment

• Complete blood count: haemoglobin, haematocrit, total leukocyte count, differential leukocyte count, platelet count, peripheral blood smear.
• In epidemic situation, for every patient reporting with fever, these tests are recommended, unless some other cause is identified.

Specific laboratory investigation for diagnosis

• NS1 ELISA test to be done on patients reporting during the first five days of fever
• Serology to be done on or after day 5 by MAC ELISA (in an outbreak all suspected patients of dengue need not undergo serology for purpose of clinical management).

Homoeopathic Medicines

There are several references in the literature for treatment of dengue with homeopathic medicines. The aim of treatment is to provide symptomatic improvement, minimize complications and promote early recovery. Suggestive list of drugs is as follows, however, physician may choose beyond this list on the basis of indication.

For Dengue Fever

Medicines most frequently indicated in cases of classical dengue fever are Aconitum napellus, Arnicamontana, Arsenic album, Belladonna, Bryonia alba, Eupatorium perfoliatum, Ferrumphosphoricum, Gelsemium, Ipecacuanha, Natrummuriaticum, Nux vomica, Pulsatilla and Rhustoxicodendron which are prescribed on the basis of symptom similarity.

For Dengue Haemorrhagic Fever

Homoeopathic medicines can be given only as an add on supportive therapy. The group of medicines usually indicated includes Carbovegetabilis , China officinalis , Crotalushorridus, Ferrummetallicum,Hamamelis, Ipecac., Lachesis, Millefolium, Phosphorus, Secalecornutum and Sulphuric acidum.

Prevention of Dengue fever

General Measures

Personal prophylactic measures

• Use mosquito repellent creams, liquids, coils, mats, etc.
• Wear full sleeve shirts and full pants with socks
• Use bed nets for sleeping infants and young children to prevent mosquito bite

Environmental management & source reduction methods

• Identify & eliminate mosquito breeding sources
• Prevent collection of water on rooftops, porticos and sunshades
• Properly cover stored water
• Frequently change water in water pots, flower vases, water coolers, etc.
• Waste must be disposed properly and should not be allowed to collect

Biological & Chemical control for control of mosquitoes breeding

• Use larvivorous fishes in ornamental tanks, fountains, etc
• .Use biocides or chemical larvicides for control of mosquitoes breeding
• Aerosol space spray

Health education

• Impart knowledge to common people regarding measures to reduce vector breeding and safeguards for preventing mosquito bites.

Homoeopathic medicine as preventive

As per the principles of homoeopathy, a genus epidemicus (a drug capable of prevention of a disease) can be identified for the sporadic and epidemic situations. The process of selection of genus epidemicus is specialized and involves following steps:

• The totality of symptoms (TOS) related to the current epidemic is formulated by in depth study of all the signs and symptoms of minimum 20-30 cases preferably from different regions to cover the complete spectrum of diseases in the community.
• The TOS to be thoroughly studied and following appropriate repertorization process, a group of medicines are to be identified. These medicines are required to be given to these cases on the basis of individualization. The medicine, which is most frequently indicated and has potential of providing the quick and favorable response to the patient, shall be the geniusepidemicus,
• Drugs commonly found indicated as geniusepidemicusin the past are Eupatorium perfoliatum, Rhustoxicodendron, Bryoniaalba. One of these in 30 or 200 potency can be safely taken twice daily for three days as prophylactic. Further research in this area is being undertaken.

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Source: Central Council for Research in Homoeopathy