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Clinical Medicine
Case Presentation
Atif RahimNasreen AkhterZain Ul Abidin
History Mrs. Nishat 60 years old Female Housewife Gulistan E Joher, KHI Admitted in DSH on 14/11/2015 via ER
C/O
Fever Headache For 3 DaysMalaise
HOPC According to my patient she was in usual state of
health 3 days back when she started having Abrupt onset high grade continuous fever documented at 103 F, Associated with chills, headache, Generalised body ache and Easy Fatiguability, NO Aggreviating and Relieving Factors.
Temp mildly ↓paracetamol but recurred.
Persistent above symptoms brought Patient to the Hospital
Contd.. No h/o
Polyarthralgia Rash Abdominal pain/swelling Hematemesis/melena/Mucosal bleeds Yellowish discoloration of mucosa & skin Altered consciousness/Seizures Hematuria/oliguria Chest pain/palpitations/breathlessness Cough with expectoration
Contd… Past History
Not contributory Personal History
not smoker/ No other addiction Occupation
Housewife Family History
Not contributory Socioeconomic History
Patient lives in her own 2 rooms, ventilated houseWith her husband And 3 children, use tap water.
On Examination My Patient was Lying comfortably on the bed, was well
oriented with time place and person.
Vitals BP – 100/70 mmhg Pulse – 94/min RR – 28/min Temp – 1020F
O/EOn General Physical Examination My Patient is of Moderate built & nourishment, She has a Fever at 102 F, She is mildly Tachypneic, Not dyspneic.Besides that no abnormal finding on GPE.
Contd..Systemic Examination CVS
JVP not raised S1, S2+ No additional sounds No murmurs
Contd… RS
Tachypneic Normal Vesicular Breathing Sounds No added sounds
Abdomen Non tender No organomegaly/free fluid BS +
CNS No Functional Neurological Disorders
Differential Diagnosis
Dengue FeverMalariaTyphoidViral Hepatitis
Investigations• CBC• MP• Dengue Serology
Investigations 13/11/15 – done outside
Hb – 13.6 TC – 3500 DC – P-55/L-42/E-3 ESR – 5/8 Platelet – 80,000 RBS – 97 Urea – 27 Creatinine – 0.7 Sodium – 136 Potassium – 3.6 Smear for MP – negative
14/11/15 – DSH Hb – 13.6 TC – 3400 DC – P-45/L-52/E-3 PCV – 39 ESR – 3/7 Platelet – 70,000 RBS – 94 Urea – 21 Creatinine – 0.8 Sodium – 139 Potassium – 3.8
MP Test NegativeDengue IgM & IgG Positive
Final DiagnosisDengue Fever
ManagementTab Panadol 2+2+2IV Ringer Lactate
Dengue Fever
History of Dengue Fever The Word Dengue is derived from the Swahili
phrase "Ka-dinga pepo", meaning "cramp-like seizure caused by an evil spirit
The first record of a case of probable dengue fever is in a Chinese medical encyclopedia from the Jin Dynasty (265–420 AD) which referred to a “water poison” associated with flying insects
The first confirmed case report dates from 1789 and is by Benjamin Rush, who coined the term "breakbone fever" because of the symptoms of myalgia and arthralgia.
Dengue Fever
WHO says some 2.5 billion people, two fifths of the world's population, are now at risk from dengue and estimates that there may be 50 million cases of dengue infection worldwide every year.
epidemic in more than 100 countries
Dengue fever genus Flavivirus, family Flaviviridaealso known as breakbone
fever.(bonecrusher disease) -Dandy Fever
Aedes aegypti main mosquito vector
Distribution
Endemic in more than 100 tropical and subtropical countries
Pandemic began in Southeast Asia after WW II with subsequent global spread
Several epidemics since 1980s
Distribution is comparable to malaria
Manifestations of dengue virus infection:
ASYMPTOMATIC
SYMPTOMATIC
UndifferentiatedFever
Dengue Fever
DengueHaemorrhagicFever
Without haemorrhagic
With unusualhaemorrhagic
No shock
DSS
Virology
Flavivirus family Small enveloped
viruses containing single stranded positive RNA
Four distinct viral serotypes (Den-1, Den-2, Den-3, Den-4)
Dengue Viruses
Four closely related single-stranded RNA Dengue viruses (DEN-1, DEN-2, DEN-3 and DEN-4)
Each serotype provides specific lifetime immunity, and short-term cross-immunity (A person can be infected as many as four times, once with each serotype)
All serotypes can cause severe and fatal disease
Pathophysiology
Transmitted by the bite of Aedes mosquito (Aedes aegypti)
Incubation 3-14 days
Acute illness and viremia 3-7 days
Recovery or progression to leakage phase
Dengue Mosquito
Aedes aegypti is the most important dengue mosquito
It breeds in collections of water close to dwellings
Common breeding sites are;- Domestic water storage containers - tanks, jars, drums, flower vases with water- Roof gutters /sun shades- Used tyres, discarded tins, cans, pots, yogurt cups, polythene bags, tree axils & - Many more places where rain watercollects
The most common epidemic vector of dengue in the world is the Aedes aegypti mosquito. It can be identified by the white bands or scale patterns on its legs and thorax.
Replication and Transmissionof Dengue Virus (Part 1)
1. Virus transmitted to human in mosquito saliva
2. Virus replicates in target organs
3. Virus infects white blood cells and lymphatic tissues
4. Virus released and circulates in blood
3
4
1
2
Replication and Transmissionof Dengue Virus (Part 2)
5. Second mosquito ingests virus with blood
6. Virus replicates in mosquito midgut and other organs, infects salivary glands
7. Virus replicates in salivary glands
6
7
5
Dengue Clinical Syndromes
Undifferentiated feverClassic dengue feverDengue hemorrhagic fever
Dengue shock syndrome
Undifferentiated Fever May be the most common
manifestation of dengue Prospective study found that
87% of students infected were either asymptomatic or only mildly symptomatic
Other prospective studies including all age- groups also demonstrate silent transmission
Clinical Characteristicsof Dengue Fever Fever Headache Muscle and joint pain Nausea/vomiting Rash Hemorrhagic manifestations
Hemorrhagic Manifestationsof DengueSkin hemorrhages:
petechiae, purpura, ecchymosesGingival bleedingNasal bleedingGastro-intestinal bleeding:
hematemesis, melena, HematuriaIncreased menstrual flow
Clinical Case Definition forDengue Hemorrhagic Fever
Fever, or recent history of acute fever Hemorrhagic manifestations Low platelet count (100,000/mm3 or
less) Objective evidence of “leaky
capillaries:” elevated hematocrit (20% or more
over baseline) low albumin pleural or other effusions
4 Necessary Criteria:4 Necessary Criteria:
Clinical Case Definition for Dengue Shock Syndrome
4 criteria for DHF Evidence of circulatory failure manifested indirectly by
all of the following: Rapid and weak pulse Narrow pulse pressure ( 20 mm Hg) OR hypotension
for age Cold, clammy skin and altered mental status
Frank shock is direct evidence of circulatory failure
Physical Exam
Nonspecific findings Conjunctival
injection, pharyngeal erythema, lymphadenopathy, hepatomegaly (20-50%)
Macular or maculopapular rash (50%)
Laboratory Findings Leukopenia Thrombocytopenia (<100,000) Modest liver enzyme elevation (2-5x nml) Serology:• Acute phase serum IgM (+6-90 days) ELISA• Acute and convalescent IgG (99% sens,
96% spec) • Hemagglutination inhibition assay (HI) is
gold standard. Paired acute and convalescent HI assay, positive if >4 fold titer rise
Treatment No specific therapy Supportive measures: adequate hydration acetaminophen (if no liver dysfunction) avoid ASA and NSAIDs DHF or DHF w/ shock: IV fluid resuscitation and hospitalization blood or platelet transfusion as needed
Traditional and emerging treatments Emerging evidence suggests that
mycophenolic acid and ribavirin inhibit dengue replication.
Brazilian traditional medicine,-cat's claw herb
Malaysia,-natural medicine. Mas Amirtha, Semalu & Kolostrum
Mas Amirtha – Two Capsules 3 times A Day Mas Semalu – Two Capsules 3 times A Day Mas Kolostrum – Two Capsules 3 times A Day
Philippines -tawa-tawa herbs
Sweet potato tops juice
Mortality/Morbidity
Treated DHF/DSS is associated with a 3% mortality rate.
Untreated DHF/DSS is associated with a 50% mortality rate.
Advice Stay in air-conditioned or well-
screened housing Reschedule outdoor activities Wear protective clothing Use mosquito repellent Reduce mosquito habitat
Mosquito control: Options available
“Mosquitoes take about 7 days to
complete life cycle.
The first three Stages: eggs,larva
and pupa are aquatic.
Therefore, the best way to
prevent mosquito breeding isto remove
stagnant clear water”
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