() ------------------------------------------------------------------------------- 1 () ---------------------------------------------------------- 3 () ------------------------------------------------------------- 5 () ---------------------------------------------------------- 6 () ---------------------------------------------------------------- 7 () ------------------------------------------------------------- 8 () ------------------------------------------------------------- 9 () -------------------------------------------------------------------------------------10 () -------------------------------------------------------------------11 () Q&A --------------------------------------------------------------12 () -------------------------------------------------------------------------------------15 () -------------------------------------------------------------------------------16 () -------------------------------------------------------------------------------17 () ----------------------------------------------------------------------------18 () -------------------------------------------------------------------------------------19 () -------------------------------------------------------------------------------------23 () -------------------------------------------------------------------------36 () Q&A --------------------------------------------------------------38 ---------------------------------------------------------45 ----------------------------------------------------------------------------------------46 ------------------------------------------------------------------47 ------------------------------------------------------55
/ 1987 1996 / /
() 1. (1) 38 (2) 12 (3) 39 40 36 3 12 2 3 (4) 24 (breakbone fever) (5) 4 7 2. 1
Dengue virus infection Asymptomatic Symptomatic Undifferentiated fever Dengue fever syndrome Dengue hemorrhagic fever (plasma leakage) Without Hemorrhage Unusual hemorrhage No shock Dengue Shock syndrome Fig.1 Manifestations of the dengue syndrome. \CAB INTERNATIONAL 1997. Dengue and Dengue Hemorrhagic Fever (eds D.J. Gubler and G.Kuno) 2
( ) (dengue fever) (DHF/DSS) 1. 絶 PMN 45 atypical lymphocytes large nuclei fine homogenous nuclear chromatin azurophilic cytoplasm, monocytes hypocellular megakaryocytes cortical paracortical area lymphocytes active germinal center 2. DHF/DSS (1) petechiae tourniquet test vasculopathy histamine mediator (2) consumption coagulopathy PT APTT DIC FDP 3
fibrinogen (3) megakaryocytes hemostatic defect 4
( ) 47 47 5
( ) 酶 6
( ) (1) teratogenic effect dengue hemorrhagic fever (DHF)dengue shock syndrome (DSS) (2) teratogenic effectaspirin indomethacin bleeding diathesis acetaminophen (3) (4) DHF/DSS DHF/DSS 7
( ) GOTGPT SGOT 8
3 5 3~4 5 9 15 9
( ) NSAIDS 10
(ITP) (Toxic Shock Syndrome) 11
Q&A Q A Q CBC A CBC Q A Q A (ITP) (Toxic Shock Syndrome) Q A 12
Q A Q A Acetaminophen Aspirin NSAID Aspirin Q A Q A 13
Q10 A10 20% ( ) 14
() 200 1950 1953 (Philippines hemorrhagic fever)1956 (Thai hemorrhagic fever) (Dengue hemorrhagic fever) DHF Dr. Halstead & Dr. Suchitra 2040 15 30 1977 1980 45 1981 344,203 116,143 24,000 DHF 158 1/3 2/3 15
( ) 38 110 36 (Confluent convalescent rash) (Plasma leakage) (hypovolemic shock) 20 mmhg (Dengue shock syndrome) DSS 12 DIC 16
( ) 14 17
( ) 3 5 8 9 10 (HCT) 20 GOT GPT GOT>GPT A/G 1 APTT PT 18
( ) 1. 36 2. 3. 10 4. (HCT) 20 (Tourniquet test) 10 20 18 42% 45% 50% 1 (WHO) 10 10 (spontaneous bleeding) 19
2 (RT-PCR) 10 10 (HCT) 20 HCT HCT 20 [HCT (max) - HCT (min) ] 100 20 HCT (min) 10 DFHem DSAS 10 20
21
1 / tourniquet test 20 10 20 * * 22
/ Cytokine 23
/ Paracetamol <1 60 / 1~3 60~120 / 3~6 120 / 6~12 240 / >12 500 / 24
39 C 24 6 1 2 5 50 / 1:2 1:1 1 10 / Halliday & Segar ( maintenance fluid) (replacement fluid) (overhydration) 25
. sodium chloride 3.5 ( trisodium citrate dihydrate ) 2.9 2.5 ( sodium bicarbonate) ( potassium chloride) 1.5 ( glucose) 20.0 1-2 10 37 120 100/70 0-1 / 100 45 35 20 5 10 50500 10 1001000 500+10001500 / 500 5 50 / 1:2 1:1 26
500 6 1-2 3-4 1. 24 10 100 / 10-20 1000 50 >20 1500 20 20 Halliday MA, Segar WE. Maintenance need for water in parental fluid therapy. Pediatrics, 1957, 19: 823. Reproduced by permission of Pediatrics. 27
1. 20 5 5 6-7 / / 20 5 / / 10 / / 3 / / 15 / / 24-48 28
>10 >2 <20 48 (Ringer s lactate) (Ringer s acetate) 5 1:2 1:1 29
40dextran 40 5 <20 10-20 / 20-30 / 5 10-20 / 20-30 / 35 10 / 30
2. 10-20 / (Ringer s lactate) (Ringer s acetate)5 >35 10 / 10-20 / 5 31
(Ringer s lactate) 24-48 40 48 32
chloral hydrate 12.5-50 / 1 50 40 33
GOT GPT 30 6 2 4 34
/ 24 2 50,000 35
(Whole blood) (Packed RBC) (Whole blood) (Packed RBC) 50 40 (Platelet transfusion) 20,000/ul (Spontaneous bleeding) 20,000/ul (DIC) 20,000-50,000/ul random donor single donor single donor random donor random donor 5,000-10,000/ul 36
(plasma) (DIC) (Frozen plasma, FP) (Fresh Frozen Plasma, FFP) FFP FP (DIC) (FFP) (DIC) 37
Q&A Q A 34 20% Q A Q A CBC Chest PA X GOT / GPTAlbuminPT / APTT DIC DIC profile Q A 38
Q A Ringr s lactate Detrose saline Dextran Q A Lasix Q A (Whole Blood) (DIC) (FFP) 20,000/ul 20,000/ul (DIC) 20,000-50,000/ul random donor single donor single donor random donor random donor 5,000-10,000/ul 39
TRALI APTT 2 Q A Q A Q10 A10 Q&A Aspirin NSAID Acetaminophen Aspirin IV Steroid 40
DF IgGDF IgMRT-PCR Q11 A11 WHO http:www.whosea.org/ guideline.htm. 41
3 \CAB INTERNATIONAL 1997. Dengue and Dengue Hemorrhagic Fever (eds D.J. Gubler and G.Kuno) 42
4 43
44 5 10 10
76-90 45
1. 2. 3. 4. 5. 6. 46
47
( ) 48
( ) 1. 2. 3. 4. 2,500 5. 5cc 30 60 4 6. 7. 49
() 8. 50
CDC/Taiwan 1. 5~10 2. 30 60 4 3. 1500 10 4 4. 5. 6. 1. 1 reverse transcriptase-polymerase chain reaction RT-PCR2 51
3 Capture IgM and IgG ELISA 1. 7 8-13 14-30 2. 1 7 2 1.5 3 8 3. :, IgM IgG IgM IgM IgG 1. 52
2. 1-7 8-30 8-14 3. 14-30 4. 14 8-13 5. 1. 1-7 RT-PCR 70-80% 14-30 53
1-2 IgM IgG 2. 14-30 / IgM IgG 3. IgM IgG 4. 54
6 022395-9825 161 022785-0513 161 022785-0513 20 042473-9940 180 07557-0025 5 038227-117 1 022728-7072 132 072881-1568 192-1 022258-6923 141 039322-634 55 033363-270 1 035511-287 6 037336-781 136 042526-5394 2 162 047221-091 6 049220-904 34 05537-3487 3 053620-608 72 066335-140 834-1 077334-872 272 087362-986 336 089331-171 200 038226-975 115 2 069272-162 266 022427-6154 111 035264-094 811 042380-1180 1 052341-150 1 418 062906-386 1 12 082330-697 216 083622-095 55
.., 91 ISBN 957-01-2269-2 1. 415.259 91016582 6 (02)2395-9825 www.cdc.gov.tw 50 GPN 1009103364 ISBN957-01-2269-2 ( ) 56
57