DENGUE FEVER

1. 1
WELCOME
AEDES AEGYPTI

2. 2
DIAGNOSIS AND
MANAGEMENT OF
VISHAMA JWARA W.S.R. TO
DENGUE FEVER
DR. VINAY TIWARI
3rd YEAR P.G. SCHOLAR
DEPARTMENT OF KAYACHIKITSA
SKAMCH&RC
VIJAYANAGAR
BANGALORE

3.  Introduction
 Nirukti, Nidanas, Poorvaroopa,
Roopa
 Samprapti, Samprapti ghatakas
 Dengue Fever
 Synonyms
 On examination
3

4.  Dengue fever/DHF/DSS
 Diagnostic criteria
 Investigations
 Precaution
 Management
 Understand vishama jwara
 Chikitsa
 Pathya
 Discussion
 Conclusion
4

5.  Acharya charaka introduces jwara
as a disease entity causing dehe
indriya mana santapa and as
sarvaroga agraja.
 There are different type of cause
for the vishama jwara where
agantuja nidana plays a major role.
Vishmajwara is irregular in its
arambha, kriya and kala.
5

6.  Dengue fever is a mosquito borne disease caused by
dengue virus which includes a high grade fever,
headache, and a characteristic skin rash.
 In its severe form i.e, dengue haemorragic fever &
dengue shock syndrome have become major
international public health concerns. Over the past
three decades, there has been dramatic global increase
in the frequency of dengue fever, DHF, DSS
6

7.  In India, the risk of dengue has shown an increase in
recent years due to rapid urbanization, lifestyle changes
and deficient water management including improper
water storage practices in urban & rural areas, leading to
proliferation of mosquito breeding sites.
 An estimated 50 million dengue infection occur
worldwide annually and about 5 lakh people with DHF
requires hospitalization each year.
7

8. NIRUKTI
 विषमोविषमारम्भ: क्रियाकालोनुषन्ड्िान ् । (वाग्भट्टट्ट)
The arambha (onset), kriya (course), & kala (duration)
is vishama.
 य: स्याद ननयतात ् कालात ् शीतोष्णाभयाां तथेि च ।
िेगतस्चावि विषम: स ज्िरो विषम: स््त ्: ॥
(सिद्धान्त निदाि
ज्वर)
 Some time shita, some time daha.
 Vega of jwara is anischita (vishama)
8

9. NIDANAS
 अभभघाताभभषन्डगभभचराभभशािेभय आगन्डतु (Ch.Ni.1/30)
 अभभघातग्रहणेन शरीराभभहननिचचनासत्मम्य गन्डधदयो ग्र्या
(Teeka. Ch.Ni.1/38)
 िरो हेतु: स्िभािो िा विषमे के श्चचदीररत: ।
 आगन्डतुस्चानुबन्डधो हह प्रायशो विषमज्िरे ॥ (su.ut.39/56)
 There will be involvement of external factors in vishama
jwara.
9

10. PURVAROOPA
 Avyakta.
 Here the time taken for the manifestation of vishama
jwara is very fast so that we can’t appreciate the
purvaroopa here.
10

11. ROOPA
 क्िचचदुष्णेन शीतेन ् क्िचचद्र्रात्रो क्िचचहदिो ।
प्रशमां यानत कोिां च ज्िर: स विषम: स्रुत: ॥ (Y.R. 28)
 In Vishama jwara the presentation of jwara happens
during ushna kala or sheeta kala, or during day and night
& some time it is getting aggravated, some time it will
subside by itself .
 In this specific vishama jwara the following lakshanas
can be appreciated. 11

12. 12
Asthi ruja Chardi Bahistapa
Angamarda Bhrama Trushna

13. 13
Swasa Netra shrava Sandhi ruja
Shiroruja Tandra Raktastheevana

14. 14
Nidranasha Shirolotanam Hrudayabadha
kasa Daha Raktavalochana

15. 15
 Saswano karnou
 Raktoushmana
 Karna ruja, guruta
 Krushatam, mookatvam
 Gurutwa udarsya
 Pralapa, raga, moha
 Paridagda
 Dainyata
 VijrumbhaKota
 Mada , sadana, kharasparsha
 Kaphonmishrita
raktashteevana
 Sweda mootra pureesha
chirat
 darshanam/alpadarshanam
 Srasthangata
 Shyaava rakta mandala

16. CRITICAL ANALYSIS OF VISHAMA JWARA
SAMPRAPTI
Due to agantuja nidana( abhighatadi)
Vata prakopa
Rakta dushti causing rasadi dhatu vruddhi, Dosha prakopa,
mala vruddhi Ojo kshaya
(vayuna dushta shonita adhishtanena)
 Vishama jwara lakshanas, if not managed properly
then it will lead to Sannipataja jwara.
16

17. SAMPRAPTHI GHATAKA
 Dosha – Rasa, Rakta
 Agni – Jataragni Dhatwagani
 Udbhav sthana – Amashaya
 Strotas – Rasa & Rakta
 Stroto dusthi prakara – Vimargagamana & Atipravratti
 Adhishtana – Rasa, Rakta
 Vyakta sthana – Sarva shareera
 Sanchara sthana – Rasayani
17

18.  Vyadhi swabhava – Aashukari
 Rogamarga – Bahya
 Sadhya asadhyata – Initial phase – Sadhya
If not managed properly- Asadhya
18

19. 19

20. WHAT IS DENGUE ?
 Dengue is a viral disease.
 Dengue can be caused by an infection with any one of
four closely related dengue viruses.
 DENV 1
 DENV 2
 DENV 3
 DENV 4
20
CULPRIT
TIGER MOSQUITO

21. DENGUE IS ALSO KNOWN AS
 Break – Bone fever
 Dandy fever
 Heamorrhagic fever
 Thai heamorrhagic fever
 Philippine hemorrhagic fever
 Singapore hemorrhagic fever
 West nile fever
21

22. HOW DOES IT SPREAD ?
 The dengue viruses are transmitted to human by the bite
of an infected female AEDES AEGYPTI mosquito.
 About 50 – 100 million infections worldwide every year.
 Dengue is caused by Flaviviruses.
22

23. INCUBATION PERIOD
 2 to 7 days (Harrison’s 18th ed)
23

24. ON EXAMINATION
 Raised temperature, comes down by crisis on 3rd day,
but again goes up on 4th or 5th day.
 This is typical Saddle Shaped Temperature curve for
dengue.
 Rash – Prodromal rash (blotchy erythema or simple
flushing of face). True rash appears on 6th day
(measles like character, but on dorsal aspects of hand
& feet then spreads towards trunk) 24

25.  lymphadenopathy (cervical)
 Pulse – Relative bradycardia
25

26. EPIDEMOLOGY
 In India first outbreak of dengue was recorded in 1812
 A double peak hemorrhagic fever epidemic occurred
in india for the first time in Calcutta in between july
1963 & march 1964
 In New Delhi, outbreaks of dengue fever reported in
1967, 1970, 1982, & 1996, 2016.
26

27. RECENT CASES RECORDED
27
Fighting dengue: 4,065 positive cases recorded in
Karnataka from January 1 to September 14 2016

28. DID YOU KNOW ?
 Only the female Aedes mosquito bites as it needs the
protein in blood to develop its eggs.
 The mosquito becomes infective approximately seven
days after it has bitten a person carrying the virus.
 Once infected, a mosquito remains infective for life
and passes on the virus to the eggs it lays.
 Peak biting time is at dawn and dusk – 2 hours after
sunrise and 2 hours before sunset.
28

29. DENGUE FEVER SYMPTOMS
Fever headache
Retroorbital
pain
29Back pain Myalgia Arthralgia

30. DENGUE HAEMORRHAGIC FEVER/DSS
30
Severe
headache
Dizziness
Retroorbital
pain
Anorexia
Abdominal
pain
Chest pain

31. 31
Rash Petechia Epistaxias
Positive tor
Nausea or
vomitting
G.I
disturbances

32. Bleeding
from gums
Intestinal
bleeding 30

33. DENGUE SHOCK SYNDROME
 All symptoms that are mentioned in DHF
 Evidence of circulatory failure
 Rapid and weak pulse
 Narrow pulse pressure
 Hypotension
 Cold, clammy skin and restlessness.
33

34. GRADING OF SEVERITY OF DHF
I Positive tourniquet test and/or easy bruising.
II Spontaneous bleeding.
III Early signs of circulatory failure.
IV Profound shock.
34

35.  WHO diagnostic criteria for DHF/DSS
 Fever or history of acute fever.
 Hemorrhagic tendencies demonstrated by alteast one of
the following
1) Positive tourniquet test
2) Ptechiae
3) Ecchymoses or purpura 35

36. PROGNOSTIC FACTORS
 Blood pressure 90/60
 Hematocrit 50%
 Platelet count <50,000
 Bleeding other than petechiae e.g. ecchymosis,
hematemesis or epistaxis.
36

37. WARNING SIGNS
 Immediate medical attention
 Severe abdominal pain or vomiting
 Red spots or patches on the skin
 Bleeding from nose or gums
 Vomiting blood
 Black, tarry stools
 Drowsiness or irritability
 Pale, cold or clammy skin
 Difficulty in breathing
37

38. STAGES
 First 4 days – Febrile or invasive stage
 High fever, abdominal pain, headache.
 Later flushing which may accompanied by vomiting, conjunctival
infection and epistaxis.
 4th – 7th day – Toxic or Hemorrhagic Stage
 Lowering of temperature , Unstable B.P.
 Severe abdominal pain, Vomitting, & frequent bleeding from GIT
 Unstable B.P.
 Shock
 7th – 10th day – Convalescent or Recovery Stage
 B.P. stable generalised weakness. 38

39. LABORATORY FINDINGS
 NS1AG
 IgM ELISA
 IgG
 RT-PCR
 Serum aminotransferace
 Thrombocytopenia
 Leukopenia
39

40. 40

41. PRECAUTIONS
 Bed rest – In acute phase with plenty of fluids
 Cold sponging for reducing fever
 Avoid aspirin, brufen etc – these can cause gastritis,
bleeding tendencies, vomiting, platelete dysfunction.
 Paracetamol is preferable for fever management 41

42.  Oral electrolyte therapy for excessive sweating vomiting.
 Protect yourself from mosquito bites.
 Wear full sleeves clothes an long dresses to cover as much
of your body as possible.
 Use repellents, mosquito coils, electric vapor mats.
 Use mosquito nets to protect children, elderly and others
who may rest during day.
 Consult physician.
 Take plenty of fluids
42

43. CRITICAL PERIOD
 Critical period may be after 3 – 5 days of fever
 In few patients, the smallest blood vessels (capillaries)
may become excessively permeable (leaky), allowing
the fluid component to escape from the blood vessels
into body cavities.
 This may lead to failure of the circulatory system and
shock if properly not managed with fluid resuscitation.
43

44. RECOVERY
 Most people who suffers from dengue fever recover in
1 – 2 weeks time.
44

45. PREVENT DEHYDRATION
 Dehydration can occur when a person loses too much
fluids (from high fever, vomiting, or poor oral intake).
 Give plenty of fluids – ORS and juices are preferable to
water.
 Watch for any signs of dehydration
 Decrease in urination
 Few or no tears when child cries
 Dry mouth, tongue or lips
 Sunken eyes
 Confused
 Fast heart beat (more than 100bpm)
 Cold or clammy fingers and toes.
45

46. MANAGEMENT
 There is no specific antiviral therapy.
 Treatment for shock – Crystalloids like Dextrose
normal saline or Ringer’s lactate 10-20 ml/kg over 30
minutes, then every hour till pulse, blood pressure,
CVP and urine output normalise. In profound shock
initially colloids like hetastarch or hemaccel.
 Platelet transfusion for symptomatic thrombocytopenia.
46

47.  Dengue fever – Paracetamol. Avoid aspirin because of
increased bleeding tendency and risk of developing
Reye’s syndrome.
 DHF / DSS – Plasma expansion with crystalloid
solutions is the mainstay of therapy.
47

48. 4 S OF THE ANTI DENGUE CAMPAIGN
 1) Search and destroy.
 2) Self protection.
 3) Seek early consultation.
 4) Say no to indiscriminate fogging.
48

49. RECENT ADVANCES
 Gene – modified mosquitoes could stop dengue fever :
genetically modified mosquitoes wee released last year
at sites in Malaysia and the Cayman island.
49

50. SOME SILENT FEATURES
 From dengue fever chances of death are less but from
DHF/DSS there are chances of life lose
 Patient suspected to be suffering from DHF/DSS
should be admitted to a hospital without delay.
 With proper treatment, the patient with dengue
hemorrhagic fever and dengue shock syndrome can
recover fully.
 Good treatment provide in time can save lives. 50

51. UNDERSTANDING OF VISHAMA JWARA
W.S.R DENGUE FEVERVISHAMA JWARA DENGUE FEVER
Nidana is agantuja
Acharya Dalhan have
described paro hetu’ as
„bhoot’ i.e. microbes.
Aedes aegypti virus infestation
Microbes
Some hold intermittent fever as
caused by invasion of evil spirits
(or micro-organisms).
Nature of fever Vishama Nature of fever irregular
51

52. Rasagata lakshans
Guruta
Hradayotklesha
Sadana
Chardi
Arochaka
Dainyata
Bahistapa
Angamarda
Vijrumbha
High grade fever
Nausea
Vomiting
Fatigue
Retro orbital pain
Myalgia
52

53. Raktoushmana
Pidaka
Trushna
Raktastheevana
Daha
Raga
Bhrama
Mada
Pralapa
Headache, retro orbital pain,
back pain, severe Muscular
pain, red rash may appear
over most of the body 2 - 5
days after the fever starts.
Other symptoms include
Fatigue, Joint aches, Muscle
aches, Nausea, Vomiting,
Haemoptysis, Epistax,
Delirium is in DHF.
Giddiness & unconscious in
DSS
Liver cell injury induced by
tissue ischemia
hepatocellular necrosis.
53

54. Sannipata jwara lakshanas
Asthi sandhi, shiro shola
Netra srava/ kalusha/ rakta
Saswana/ ruja karno
Tandra, kaphon mishrita rakta pittasava
nisthivana
Moha, Sirasho lotanam
Pralapa, trushna, Nidranasha,
Hridavyatha
Kasa, Sweda mootra purisha chira/ alpa
darshanam
Swasa, kotha, shyava rakta, mandalanam
darsham
Aruchi, Gurutvam. udarasrava
Bhrama, Paridagdha, Kharasparsha
Srasthangata
.DHF
Nausea,
Vomiting,
Haemoptysis,
Epistax,
Delirium
Giddiness & unconscious
54

55. CHIKITSA
 िातप्रधानां सवििभभििश्स्तभभ: सानुिासने: ॥
 श्स्नग्धोष्णेरन्डनिानेस्च् शमयेद्विषमज्िरम् ।
(ch.chi.3/293)
 In vishama jwara we have to follow the line of
treatment of vataja jwara in the the initial phase.
 Swacha grutha paana in vishama jwara
 As the nidana is agantuja we have to select swacha
grutha paana.
55

56.  It is contraindicated if the nidana for vishama jwara is
mithyahara and vihara as there is chance of aama
utpathi.
 Yapana basthi as well as matrabasthi.
 Any dravya in Kashaya form should be mixed with
sneha/ksheera.
56

57. RAKTAPITTA HARA CHIKITSA
Urdwaga raktapitha chikitsa-
 langhanam and tarpana
 Karjuradi tarpana
 Laajatarpana
 Vasaadi ghrutha
Nasya -
 palandu moola/ doorva mula/draksha - swarasa.
 Goksheera 57

58.  Adhoga raktapitha chikitsa- tarpana and peya
 Mootramarga-
 Shathavariksheerapaka
 Gudamarga
 Mocharasa kalka ksheerapaka
 Grutha prayoga
 Balaadi grutha
 Shathavari grutha
 Vasadi grutha
58

59.  Mahakalyanaka grutha
 Shatpalagruta
Avaleha
 Kushmanda avaleha
Ksheerapaka
 Panchamoola sadhita ksheera
 Nagaradi ksheerapaka
 Kiratatiktadi ksheera
 Guduchyadi ksheerapaka
59

60. PATHYA IN VISHAMA JWARA
 Raktashaali odana
 Purana shali odana
 Laja in the form of odana/yavagu
 Sarpi, Snighdha anna pana
60

61. DISCUSSION
 Based on the etiological factors jwara has been
classified as nija and agantu. In dengue fever as the
etiological factor is the mosquito we can consider under
agantuja vishama jwara.
 Acharya Madhavakara has mentioned Vishamajwara is
having bhootanubandha where bhoota stands for
 “antargate shareere upadrava kaarino janthu vishesha”.
61

62.  The fever is presenting as vishama arambha, vishama
kaala, vishama kriya so it can categorised under
vishama jwara.
 Dengue fever we can’t compare to any specific type of
vishamajwara. But most of the dengue fever symptoms
are similar to rasa,raktagata jwara, and
sannipathajwara.
 Acharya charaka have described about
“Janopadhodhwansa” is dedicated to diseases causing
epidemics. 62

63.  It says that when air, water, country and time get
polluted, they cause diseases. Aedes mosquito breeds
in clean, stagnant water and spread dengue virus to
larger population.
 Mula dosha for agantuja jwara is vata so we have to
adopt vatika jwara chikitsa.
 Acharya susrutha has mentioned swacha grutha pana
in jwara poorvaroopa and vatika jwara.
63

64.  We cant adopt general line of treatment for jwara in case
of agantuja vishama jwara. As vata is dominate the
langhana will cause further depletion of dhatus and it is
easy to progress the disease. So we have to be more
cautious in the selection drugs where it should not
aggravate vata and also should nourish dhatus.
64

65. CONCLUSION
 The term virus is derived from the word visa which
means poison or poisonous fluid which will be virulent
in nature so the pathogenesis of dengue virus will be
very faster.
 Understanding of dengue fever through Ayurveda due
to virus infestation and irregular nature of fever it can
be co-related with Agantuja vishama jwara described
in ayurvedic classics. 65

66.  Sannipathaja jwara lakshanas are very much similar to
DHF symptoms such as Hemoptysis, burning sensation,
vomiting, giddiness, delirium, boils, thirst etc.
 Considering the dominance of vata dosha in vishama
jwara we have to adopt vataja jwara line of treatment in
the initial phase and other symptomatical treatment
depends on the presenting complaints. In DHF we have
to adopt raktapithahara chikitsa.
66

67.  Role of immunity is very much important in this
condition as the ojoguna is opposite to visha guna.
 If a person is having good immunity, there will be less
chance of severity.
67

68. Thank You
68