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Dengue and dengue hemorrhagic fever (DHF) are caused by one of falicivirus. The mosquito vector is the same that carries the Yellow fever virus. Dengue is primarily a disease of the tropics, and the viruses that cause it are maintained in a cycle that involves humans and Aedes aegypti, a domestic, day-biting mosquito that prefers to feed on humans. Infection with dengue viruses produces a spectrum of clinical illness ranging from a nonspecific viral syndrome to severe and fatal hemorrhagic disease. Important risk factors for DHF include the strain and serotype of the infecting virus, as well as the age, immune status, and genetic predisposition of the patient.

In the United States, there have been infections in south Texas and southeastern United States. The increase in air travel has resulted in the spread of this disease beyond the usual geographical areas.

Dengue fever usually starts suddenly with a high fever, rash, severe headache, pain behind the eyes, and muscle and joint pain. Nausea, vomiting, and loss of appetite are common. A rash may appear 3 to 4 days after the start of the fever. Overall, the illness can last up to 10 days. A complete recovery can take as long as a month.

Older children and adults are usually sicker than young children. Most dengue infections result in relatively mild illness, but some can progress to dengue hemorrhagic fever.


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SYNONYMS Breakbone fever

One of the most important mosquito-borne viral diseases

Over 10 million cases/year

See map below
Dengue hemorrhagic fever in a British travel guide

Sonja Radakovic-Fijan, MD
Wolfgang Graninger, MD
Christian Müller, MD
Herbert Hönigsmann, MD
Adrian Tanew, MD

Vienna, Austria

J Am Acad Dermatol 2002;46:430-3 Abstract quote

A 44-year-old female British travel guide suddenly had fever, nausea, vomiting, and diarrhea develop during her stay in South India. Four days later she was transported to our hospital. At admission she had a high temperature, impaired respiration, and abdominal pain. Clinical examination revealed bilateral pleural effusion, hepatomegaly, and ascites. Two days later the patient showed a generalized macular rash with a conspicuous sparing of small islands of normal skin. Hemorrhagic erythema on the palms and soles as well as focal petechiae on the hard palate and scleral and conjunctival bleeding were also observed. Hypotension and renal insufficiency developed 1 week after the illness started. Laboratory investigations revealed highly elevated levels of hepatic enzymes, severe hemolytic anemia, decreased platelet counts, and abnormal coagulation values. The presumptive clinical diagnosis of dengue hemorrhagic fever was supported by serologic testing that disclosed sustained high titers of hemagglutination inhibition antibodies. Symptomatic therapy with substitution of volume and albumin, blood transfusions, and administration of antipyretics resulted in complete recovery within 6 weeks.


Serotypes No cross-protective immunity with each serotype-in theory, a person living in an endemic region may have four infections during their lifetimes
Case Fatality rate 5%
Most fatal cases occur in children and young adults


Dengue virus

Closely related, but antigenically distinct, virus serotypes
(DEN-1, DEN-2, DEN-3, and DEN-4)

Genus Flavivirus

Mosquito vector

Aedes aegypti
Aedes albopictus

The time between the bite of a mosquito carrying dengue virus and the start of symptoms averages 4 to 6 days, with a range of 3 to 14 days

An infected person cannot spread the infection to other persons but can be a source of dengue virus for mosquitoes for about 6 days


Viral serology markers Only way to confirm the diagnosis by laboratory testing


Dengue fever  
Dengue hemorrhagic fever Extensive hemorrhage and easy bruising
May lead to dengue shock syndrome
The exanthem of dengue fever: Clinical features of two US tourists traveling abroad.

Department of Dermatology at University of California, San Francisco, California, USA.


J Am Acad Dermatol. 2008 Feb;58(2):308-16. Abstract quote

BACKGROUND: Dengue fever is the most common identifiable cause of acute febrile illness among travelers returning from South America, South Central Asia, Southeast Asia, and the Caribbean. Although the characteristic exanthem of dengue fever occurs in up to 50% of patients, few descriptions of it are found in the dermatology literature, and discussions of how to distinguish the dengue exanthem from other infectious disease entities are rare. Chikungunya fever is an emerging infectious disease now seen in returning US tourists and should be considered in the differential diagnosis of dengue fever in the appropriate patient.

OBJECTIVE: The purpose of our study was to report two cases of dengue fever among returning US tourists, provide a review of dengue fever, offer an extensive differential diagnosis of dengue fever, and raise awareness among dermatologists of chikungunya fever.

METHODS: This study includes clinical findings of two returning travelers, one who traveled to Mexico and the other to Thailand, complemented by a discussion of both dengue fever and its differential diagnosis.

LIMITATIONS: Limited to 2 case reports.

CONCLUSION: Dengue fever should be considered in the differential diagnosis of fever and rash in the returning traveler. Dermatologists should be aware of the distinctive exanthem of dengue fever. Recognition of the dengue fever rash permits a rapid and early diagnosis, which is critical, as dengue fever can progress to life-threatening dengue hemorrhagic fever or dengue shock syndrome.



Dengue fever mimicking plasma cell leukemia.

Gawoski JM, Ooi WW.

Department of Laboratory Medicine, Lahey Clinic, Burlington, Mass 01805, USA.

Arch Pathol Lab Med. 2003 Aug;127(8):1026-7. Abstract quote

Extreme plasmacytosis in peripheral blood is a rare finding most often associated with plasma cell leukemia but rarely with other malignancies, infectious diseases, or drug reactions.

We report the case of a 40-year-old man who was a US expatriate working and traveling in East Asia. He presented with complaints of fever, myalgia, headache, vomiting, and diarrhea of 3 days' duration. An initial evaluation revealed elevated liver function tests, thrombocytopenia (68 x 10(3)/microL), and a white blood cell count of 5.8 x 10(3)/microL with 19% plasma cells (1100/microL), 9% abnormal plasmacytoid lymphocytes (520/microL), 37% polymorphonuclear leukocytes, 3% band forms, 27% lymphocytes, 4% monocytes, and 1% eosinophils. An extensive evaluation was performed, including infectious disease serologies, a bone marrow biopsy, and flow cytometry. During the course of 3 days, his symptoms and hematologic findings improved dramatically. Serologic results were reactive for dengue (immunoglobulin M [IgM] positive, reciprocal IgG titer, 655 360), consistent with a secondary infection of unknown serotype. He remains well 4 years later.

To our knowledge, plasmacytosis to this degree has not been described in dengue fever, but atypical lymphocytosis is common. In patients from dengue-endemic areas, even extreme plasmacytosis should be assessed to determine whether it is transient and related to an acute illness before proceeding to an extensive evaluation.


Survival Dengue hemorrhagic fever is fatal in about 5 percent of cases, mostly among children and young adults
TREATMENT Supportive

Attenuated candidate vaccine viruses have been developed in Thailand

Effective dengue vaccine for public use will not be available for 5 to 10 years

  Developing second-generation recombinant vaccine viruses using the Thailand attenuated viruses as a template

Macpherson and Pincus. Clinical Diagnosis and Management by Laboratory Methods. Twentyfirst Edition. WB Saunders. 2006.
Rosai J. Ackerman's Surgical Pathology. Ninth Edition. Mosby 2004.
Sternberg S. Diagnostic Surgical Pathology. Fourth Edition. Lipincott Williams and Wilkins 2004.
Robbins Pathologic Basis of Disease. Seventh Edition. WB Saunders 2005.
DeMay RM. The Art and Science of Cytopathology. Volume 1 and 2. ASCP Press. 1996.
Weedon D. Weedon's Skin Pathology Second Edition. Churchill Livingstone. 2002
Fitzpatrick's Dermatology in General Medicine. 6th Edition. McGraw-Hill. 2003.
Weiss SW and Goldblum JR. Enzinger and Weiss's Soft Tissue Tumors. Fifth Edition. Mosby Elesevier 2008

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Last Updated February 5, 2008

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