Manifestations of bleeding in patients with dengue fever

Dengue fever has 2 main symptoms: fever and hemorrhage. Bleeding when dengue fever is manifested as nosebleeds, bleeding gums, bruises under the skin, gastrointestinal bleeding, vaginal bleeding, severe cases causing red blood cell rupture, extravasation, blood concentration, bleeding massive bleeding in and out of the body, threatening death.

Dengue fever, if there is no bleeding, is called Classic Dengue, usually occurs in people who have never had the disease. Usually, hemorrhagic disease is more common in people who are re-infected with dengue virus, that is, the body has active immunity (because the immune system has been exposed to disease-causing antigens) or passive immunity. (transferred by the mother) to a dengue virus antigen. If the patient has dengue fever for the second time, it means that the patient may have been re-infected with a different virus, called Dengue Hemorrhagic.
The disease usually becomes more severe after the antipyretic phase (from day 2 to day 5). Damage to blood vessels and lymphatic vessels causes signs of bleeding, with the most common manifestation being nosebleeds, bleeding in the gums or bleeding under the skin, causing bruising. In more severe cases, the patient goes into shock, the blood pressure drops, the plasma escapes from the blood vessels, causing massive bleeding inside and outside the body. This form of dengue fever is common in school-age children. However, at present, the proportion of adults with the disease is not uncommon. Although young children's resistance is still relatively weak and incomplete, sometimes adults have more serious illnesses than children, even threatening to die.

Signs of bleeding usually appear when the patient has a fever. Mild manifestations of hemorrhage include the appearance of blood spots, petechiae, erythema under the skin, nosebleeds, and bleeding gums. These are relatively common symptoms even with mild and moderate dengue, occurring in about one-third of all cases reported. Mild bleeding may be caused by capillaries becoming thin because of thrombocytopenia or platelet dysfunction. Platelets play an important role in blood clotting, helping to maintain the integrity of endothelial adhesions. Meanwhile, the majority of cases of mucosal bleeding (gastrointestinal or vaginal bleeding) in dengue patients are associated with prolonged shock and metabolic acidosis. In general, the cause of bleeding during dengue fever is related to thrombocytopenia and coagulation disorders.
2.1. Thrombocytopenia “Thrombocytopenia” is a concept defined by the World Health Organization (WHO) as when the platelet count is less than or equal to 100,000 units/μL. Thrombocytopenia occurs in most patients with dengue, even in mild cases (accounting for more than two-thirds of all mild and moderate cases).
The cause of thrombocytopenia is thought to originate from bone marrow cell suppression, caused by direct infection of progenitor cells or the action of macrophages that activate T cells release cytokines and inhibit hematopoiesis. In addition, thrombocytopenia may be due to peripheral immune-mediated platelet destruction under the influence of dengue virus and NS1 antibodies. As a result, the half-life of platelets is reduced, leading to a rapid decrease in platelet counts in patients with dengue fever.
2.2. Coagulation disorders Coagulation disorders are common in patients with dengue fever. It has been suggested that the patient may experience disseminated intravascular coagulation.
Diffuse intravascular coagulation is an acquired syndrome that activates the coagulation process, leading to the formation of intravascular clots, a lack of platelets and clotting factors. These blood clots have the potential to lead to vascular occlusion, ischemia, and multi-organ failure.
The cause of coagulation disorders may be due to the loss of essential proteins involved in blood clotting due to plasma leakage. The interaction between dengue virus NS1 and the glucide envelope on the outer surface of the cell membrane can cause plasma protein leakage and release of heparan sulfate into the circulation. Heparan sulfate acts as an anticoagulant, which is a predisposing agent for coagulation disorders.

Hemorrhagic manifestations can appear in many places on the patient's body:
Bleeding under the skin forming dots, patches, sometimes red all over the body, stretching like a banana; Gastrointestinal bleeding leading to abdominal pain, black stools, bloody or bloody diarrhea; Mucosal hemorrhage causes bleeding gums, nosebleeds, in women with dengue fever may have prolonged vaginal bleeding. When there are signs of bleeding, the patient should be monitored in a medical facility because it is often a sign of shock and dehydration, a lack of circulating blood. Unlike bacterial infections, viral infections are often more complex and difficult to treat, and antibiotics are rarely effective.
When infected with a virus, the body's reactions such as fever, muscle pain, headache, dizziness ... are all signs that antibodies are fighting against harmful viral antigens. Therefore, dengue fever can go away on its own. Treatment is mainly symptom resolution, pain relief, fever reduction and prevention of the most dangerous complications.
The cause of death from dengue fever is related to many factors: Heavy bleeding, myocardium inflammation, red blood cell rupture, extravasation, hemoconcentration, disseminated intravascular coagulation. Lack of circulating blood volume can easily cause a prolonged drop in blood pressure and a difficult-to-recovery coma.

To give emergency treatment to patients with heavy bleeding during dengue fever, the doctor will give electrolytes, fresh blood transfusions, platelet supplements... In addition, use more anti-inflammatory corticosteroids, heart drugs, sedation and close monitoring, prevention of severe shock complications with a very high risk of death.
When treating dengue at home, absolutely do not steam, or use fumigant leaves. Patients with anemia, the heart muscle is inflamed, while the sauna drains the fluid and loses water, which will make the disease worse. In addition, drugs such as aspirin, ibuprofen, and naproxen sodium (a class of NSAIDs) should be avoided because these are drugs that have antiplatelet activity, inhibit blood clotting, and thus make bleeding complications worse. more serious.
In the case of a dengue patient experiencing serious complications such as shock or heavy bleeding, a hospital emergency is an absolute requirement.

Reference source: Cdc.gov