Pediatric emergency medicine trisk 2312 2312
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intervention. Phase 2 is called the critical or capillary leak phase and consists of clinical or radiographic evidence
of serositis, ascites, or pulmonary edema. Children in phase 2 are at risk for developing hypotension and
uncompensated shock. Patients may be refractory to fluid resuscitation and may develop abdominal pain,
persistent emesis, tender hepatomegaly, mucosal bleeding, and altered mentation. Phase 3 (the convalescence or
reabsorption phase) begins approximately 2 to 3 days after the initiation of phase 2. Patients typically experience
both clinical and laboratory rapid improvement as the body reabsorbs extravasated plasma and fluid. Some patients
develop a pruritic vasculitic rash that may desquamate during resolution of the illness (2 to 3 weeks).
Triage considerations: Dengue should be considered in every patient seen in the ED presenting with fever and
recent return (<2 weeks) from tropical or subtropical regions.
Clinical assessment: Dengue is predominantly a clinical diagnosis. Definitive diagnosis is via RT-PCR or
ELISA; IgM antibodies are detectable by day 4 to 5 after fever onset, but can cross-react with Zika and other
flaviviruses. Children with suspected dengue should get the following laboratory evaluation: complete blood count
(to evaluate for leukopenia, anemia, and thrombocytopenia), BUN and creatinine to evaluate for acute kidney
injury, type and screen, hepatic transaminases, prothrombin time, and partial thromboplastin time to evaluate for
disseminated intravascular coagulation.
Management: Treatment of dengue is supportive including fever control, and fluid resuscitation and red blood
cell transfusion. NSAIDs should be avoided. There appears to be no indication for platelet transfusion; the
consumptive coagulopathy seen in dengue appears to be refractory to transfusions. There are no antivirals that are
of use in dengue. There are some small, nonrandomized trials of corticosteroids for dengue shock syndrome that
have shown some possible benefit, but more data are lacking. Standard precautions are recommended.
Chikungunya
CLINICAL PEARLS AND PITFALLS
Chikungunya is endemic in Africa, the Indian subcontinent, and Southeast Asia.
Clinical manifestations mimic dengue and include fever and bilateral polyarthralgia. Hemorrhagic
manifestations are more common in children. Most recover fully over a period of weeks, but
approximately 5% to 10% experience chronic joint symptoms.
Current Evidence
The main vectors for chikungunya are the A. aegypti and Aedes albopictus mosquitoes, which also transmit dengue
and Zika. Chikungunya is found throughout Africa, India, China, and Southeast Asia, but cases in travelers
returning to North America, the Caribbean, France, and Italy have been reported. In late 2013, the first
transmission in the western hemisphere was reported in St. Martin and other French territories in the Caribbean. As
the incubation period is relatively short, it is most common in travelers who have recently returned from endemic
regions.
Goals of Treatment
As with other travel-related infections, it is important for the clinician to recognize that some imported infections
will present similarly to infections endemic in the United States (e.g., influenza virus). Asking about recent travel
will help broaden the differential diagnosis.
Clinical Considerations
Clinical recognition: The incubation period is 1 to 12 days and the first symptom is often rapid-onset arthralgia of
multiple joints. Subsequently, patients develop myalgia, high fever, generalized lymphadenopathy, and
conjunctivitis. Initial symptoms usually resolve over 2 to 3 days and are followed by the development of a
maculopapular rash in about 50% of patients. Fever may recur and some develop hemorrhagic manifestations
(more common in children).
Triage Considerations
Clinical assessment: Chikungunya mimics dengue in symptomatology and geographic distribution. One of the
distinguishing features between the two is that the arthralgia in Chikungunya is polyarticular, something rarely
seen with dengue. Chikungunya is more likely to present with lymphopenia than dengue, while dengue is more
