Case PresentationFrancine Lu

Identifying DataGem R. 8/MstudentRoman CatholicTaytay, RizalInformant: mother, 80% reliability

Chief ComplaintFever

History of Present Illness

Fever (Tmax 39.4), remittentGeneralized body weaknessFronto-temporal headache, 7/10Paracetamol, unrecalled dose, provided some reliefNo rash, no gum bleeding, no epistaxis

2 days PTA

History of Present Illness

On/off abdominal pain, 5/10, epigastric and periumbilical, crampy, nonradiatingVomiting of recently ingested food, 2 episodes, non bloodyStill with fever, no signs of bleedingConsult at ER

1 day PTA

Admission

Past Medical History(+) Asthma (1997)

Last attack: First quarter of 2011

Family History(+) Asthma – paternal(+) DM – paternal(+) HTN – maternal

Birth HistoryBorn full termNSD28 year old G2P2Attended by OBNo complicationsBirth weight unrecalled

Nutritional HistoryBreastfed until 2 monthsFormula BonnaWeaning 6 monthsNo food allergiesPrefers chicken, juiceUsual diet: soup, rice, chicken

Immunization HistoryBCGDPT x 3Polio x 3Measles x 1InfluenzaNo MMR, rotavirus, varicella, Hib, Pneumococcal

Developmental HistoryCan write fairly well at 6Can count to ten at 5Can add and subtract at 6Dresses self completely at 6Backward heel to toe walk at 6Language

Personal Social HistoryGrade 2 studentLikes Math and SibikaParents work at a cable company

Father is a technicianMother is an office employee

Up and down houseDrinking water: purifiedAdequate ventilation and lightingDaily garbage collection

Review of SystemsNo weight loss; with good appetiteNo pruritus or skin lesionsNo eye or ear discharge, no epistaxis, no coldsNo bleeding gums, no dysphagiaNo cough, dyspnea or hemoptysisNo cyanosis or pallorNo change in bowel movements or jaundice, no hematochezia or melenaNo change in bladder habitsNo limping, swelling of the extremities

Physical ExamConscious, coherent, not in distressWeight 35.1kg (z=2)Height 140 cm (z=2)BMI 17.9 (normal for age)Vitals

BP 120/80, HR 90, RR 24, T 38.2

Skin: warm, flushed, no active lesions, no pallor or cyanosis

Physical ExamHead normocephalic, atraumaticEyes: pink palpebral conjunctivae, anicteric sclerae, no dischargeEars: patent ear canal, intact TM, no dischargeNose: no alar flaring, midline septum, no nasal discharge, no bleedingOropharyngeal cavity: no tonsillopharyngeal congestion, no lesions, no bleeding

Physical ExamNeck: no CLADChest/Lungs: Equal chest expansion, resonant on all lung fields, no retractions, clear breath soundsCardiovascular: Adynamic precordium, apex beat 5th ICS left midclavicular line, normal rate, regular rhythm, no murmurs

Physical ExamAbdomen: flat, normoactive bowel sounds, tympanitic, (+) epigastric tenderness, no palpable masses. Liver edge palpable 1 cm below right subcostal margin. No obliteration of Traube space. No CVA tenderness.DRE and Genitalia: not assessedExtremities: full and equal pulses, CRT<2s, no edema, no clubbing, no cyanosisMusculoskeletal: no gross deformities

Salient Features8 year old maleRemittent fever of 2 days durationGeneralized body weaknessFronto-temporal headache, 7/10On/off abdominal pain, 5/10, epigastric and periumbilical, crampy, nonradiatingVomiting of recently ingested food, 2 episodes, non bloodyFlushed skin, (+) epigastric tenderness

DifferentialsSystemic Viral IllnessDengue FeverUrinary Tract InfectionTyphoid fever

Work-UpCBC

Hgb: 137 [115-145]Hct 0.39 [33-43]WBC 11.40 [4-12]

Neut 0.60 [54-62]Lym 0.36 [25-33]Mono 0.04 [3-7]

Plt 302 [150-400]

Dengue NS-1: Positive

AssessmentDengue Fever

Course in the Wards

Hospital Day 1Day 3 of illness

S O A P

- Still with fever and intermittent abd pain

- Good appetite

- No recurrence of vomiting

- conscious, coherent, not in distress

- 100/70, 90, 24, 38.2

- Clear breath sounds

- AP, NRRR, no murmurs

- Soft abdomen, (+) epigastric tenderness

- Pulses full and equal, CRT <2s

- Dengue Fever

- IV hydration- CBCPC

monitoring- Paracetamol- I&O

monitoring- WOF

bleeding, hypotension, narrow pulse pressure

Hgb Hct WBC Plt128 (N) 0.38

(N)8.3 (N) 250 (N)

Neut 0.49 (L), Lymp 0.45 (H), Mono 0.05 (N)

Hospital Day 2Day 4 of illness

S O A P

- Last febrile episode at 4am

- No abd pain- No bleeding

manifestations

- Good appetite

- No recurrence of vomiting

- conscious, coherent, not in distress

- 100/70, 112, 22, 37.1

- Clear breath sounds

- AP, NRRR, no murmurs

- Soft abdomen, nontender

- Pulses full and equal, CRT <2s

- Dengue Fever

- continue hydration, I&O monitoring and CBCPC monitoring

- Paracetamol PRN

- WOF bleeding, hypotension, narrow pulse pressure

Hgb Hct WBC Plt131 (N) 0.38 (N) 5.6 (N) 248 (N)Neut 0.42 (L), Lymp 0.49 (H), Mon 0.06 (N), Eos 0.03 (N)

Hospital Day 3Day 5 of illness, Day 1 afebrile

S O A P

- No fever, abd pain, vomiting

- No bleeding manifestations

- Good appetite

- conscious, coherent, not in distress

- 90/60, 84, 20, 37

- Clear breath sounds

- AP, NRRR, no murmurs

- Soft abdomen, non tender

- Pulses full and equal, CRT <2s

- Dengue Fever

- Continue present care and management

Hgb Hct WBC Plt130 (N) 0.39 (N) 5.5 (N) 259 (N)Neut 0.36 (L), Lymp 0.58 (H), Mono 0.02 (L), Eos 0.04 (H)

Hospital Day 4Day 6 of illness, Day 2 afebrile

S O A P

- No fever, abd pain, vomiting

- No bleeding manifestations

- Good appetite

- conscious, coherent, not in distress

- 90/60, 88, 20, 36.8

- Clear breath sounds

- AP, NRRR, no murmurs

- Soft abdomen, non tender

- Pulses full and equal, CRT <2s

- Dengue Fever

- IVF to consume

- Increase oral fluid intake

- May go home tomorrow if with no problems

Hgb Hct WBC Plt134 (N) 0.39 (N) 5.2 (N) 267 (N)Neut 0.29 (L), Lymp 0.52 (H), Mono 0.04 (N), Eos 0.15 (H)

Discussion

Dengue FeverDengue is the most rapidly spreading mosquito-borne viral disease in the world estimated 50 million dengue infections occur annually approximately 2.5 billion people live in dengue endemic countries

Classification: WHO

Classification: PPSFever

Nonspecific symptoms

(+) tourniquet testGrade 1

+Spontaneous

bleeding

Circulatory failure

Profound shock

Transmissionsingle-stranded RNA virus comprising four distinct serotypes (DEN-1 to -4) genus Flavivirus, family Flaviviridaegenotypes of DEN-2 and DEN-3 are frequently associated with severe disease transmitted to humans through the bites of infected Aedes mosquitoes, principally Ae. Aegypti

TransmissionIncubation period 4-10 daysvirus enters via the skin while an infected mosquito is taking a bloodmealacute phase: virus is present in the blood and its clearance from this compartment generally coincides with defervescence

Endothelial cell dysfunction plasma leakageAlterations in megakaryocytopoeisis by infection of human hematopoeitic cells and impaired progenitor cell growth platelet dysfunction

PhasesFebrile PhaseCritical PhaseRecovery Phase

Febrile PhaseSudden onset of high grade feverLasts 2-7 daysFacial flushing, skin erythema, generalized bodyache, myalgia, arthralgia, headache, sore throat, injected pharynx, conjunctival injection, Anorexia, nausea, vomitingFrom mild to massive bleeding

Petechia and mucosal membrane bleeding --- massive vaginal bleeding and GI bleeding

Enlarged and tender liverEarliest abnormality: decreased WBC

Critical PhaseTime of defervescence; Days 3-7

Increase in capillary permeability paralleling with increasing hematocrit

period of clinically significant plasma leakage usually lasts 24–48 hours.

Progressive leukopenia followed by a rapid decrease in platelet count usually precedes plasma leakage.

No increase in capillary permeability: will improveOtherwise: may become worse as a result of lost plasma volume

Critical PhasePlasma leakage: pleural effusion, ascites

degree of increase above the baseline hematocrit often reflects the severity of plasma leakageIf critical volume is lost Shock

Below normal body temperatureprogressive organ impairment, metabolic acidosis and disseminated intravascular coagulation

Severe hemorrhage – increase in WBCHepatitis, encephalitis, myocarditis

Critical PhaseIf with improvement after defervescence = non-severe dengue

If defervescence does not occur, take CBC to guide the onset of critical phase and plasma leakageIf with deterioration = dengue with warning signs

will probably recover with early intravenous rehydration Some will deteriorate to severe dengue

Recovery PhaseIf patient survives 24-48h critical phase gradual reabsorption of extravascular compartment fluid in the following 48-72 hBetter, good appetite, no GI symptoms, hemodynamic status stable, diuresis ensuesRash: “isles of white in the sea of red”Pruritus, bradycardia, ECG changesHCT stabilizes or may be lower (dilutional)WBC rises soon after defervescence; Platelets recover laterExcessive IVF: pleural eff, ascites, pulmo edema, CHF

Severe Denguei. plasma leakage that may lead to shock

(dengue shock) and/or fluid accumulation, with or without respiratory distress, and/or

ii. severe bleeding, and/or iii. severe organ impairment

Severe DengueProgression of vascular permeability worsening hypovolemia shockUsually around the time of defervescence, usu day 4 or 5 (d 3-7)Preceded by warning signsInitially: tachycardia, peripheral vasoconstriction with reduced skin perfusion -- cold extremities and delayed capillary refill time Narrowed pulse pressure, as peripheral vascular resistance increasesDecompensation – both pressures disappear abruptly

DiagnosisFever of 2-7 days durationAny 2 of the following: (WHO – 2 or more)Positive tourniquet testRestlessnessSpontaneous petechiaeFlushingHemoconcentrationThrombocytopeniaAbdominal Pain

HeadacheRetroorbital painMyalgiaAnorexiaEpistaxisCongested oropharynxInjected conjunctivae

DiagnosisDF/DHF suspected do CBC and actual platelet count

Done daily to determine hemoconcentration and thrombocytopenia

PT and PTT not routinely doneNS1 antigen test useful for rapid early diagnosis (Day 1-4)Other serological tests not routinely done; but best results obtained starting on Day 5 of illness

Dengue IgM and IgG ELISADengue Dot Blot ELISADengue Immunochromatography (ICT)Dengue Dipstick ELISA

Admission CriteriaShockSpontaneous bleedingDanger signs: inability to drink or feed, vomits everything, convulsions, lethargy, unconsciousness, no urine output for 6-8 hoursIncreased vascular permeability: hematocrit, serous effusion, hypoproteinemiaAbdominal pain

Fluids: OutpatientORS based on weight

>3-10 kg 100 ml/kg/day>10-20 kg 75>20-30 kg 50-60>30-60 kg 40-50

Fluids: Admitted, without Shock

Isotonic solutions (D5LRS, D5NSS, D5 0.9%NaCl)Holiday Segar MethodBody Weight

Fluid per day

0-10 100 ml/kg11-20 1,000 + 50ml/kg for each kg>10>20 1,500 + 20ml/kg for each kg>20

Fluids: Admitted, with Shock

Isotonic crystalloid (LRS, NSS, 0.9%NaCl)Glucose containing solutions should be avoided to prevent osmotic diuresisInfuse 20ml/kg bolus

If with no improvement, repeat 2-3 times; consider inotropic agentIf stable, gradually decrease IVF rate

Continuous monitoringOxygen 2-3L/min

Blood TransfusionFresh whole blood/whole blood if with significant bleeding (hematemesis, hematochezia)If with DIC, blood component therapy (CP, FFP, Plt)Preventive transfusion has no role in DHF

OthersSteroids, Vitamin C, antihistamines, Vitamin K, Albumin No added benefitDischarge: 72 hours after defervescence in those with DHF

72 hours after termination of shock for those with DSS

PreventionInsect repellants with N,N-diethyl-1-3 methylbenzamide as active ingredient effective and safe in children >2mosInsecticides containing propoxur, organophosphates and pyrethrium most effective only indoors for a short period of timeScreening of windows and doors, mosquito netsDefogging during dengue epidemic, larvicidingCovering and regular emptying and cleaning of water storageProspective dengue vaccine still mostly in Phase 1 and 2