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Case Report – Dengue Hemorrhagic Fever
CASE
I. PATIENT IDENTITY
Name : F.S.K
Age : 53 y.o
Sex : Female
Date of Admission: 7 March 2010
II. ANAMNESIS (AUTOANAMNESIS & ALLOANAMNESIS, 11 MARCH 2010)
Chief Complaint
Fever
Present Illness
The patient came to Siloam Kebon Jeruk Hospital with a chief complaint of fever
since 3 days before hospital admission. The fever is continuosly. The patient also
complains of weakness, loss of appetite, nausea without vomiting, and numbness
in both legs. The patient has no problem on urinating and defecation. According
to the patient, she experience no features of cough or flu. The patient has not
been travelling out of town and none of her neighbours or family member suffer
from the same sickness. The patient admits that she consumed panadol for her
fever with no effect. She also had Diabetes Mellitus since 5 years ago, and is on
medication glucovance 2.5 mg twice daily (morning and afternoon).
Past Medical History
The patient was previously hospitalized in the Siloam Kebon Jeruk Hospital on
2009 with complaint of numbness and treated by the neurologist. The patient
deny any kind of surgery and has no history of allergies to any type of drugs or
food.
Clinical Clerkship of Internal Medicine Division
Pelita Harapan University – Siloam Hospital Kebon Jeruk
1 March – 9 May 2010
1
Case Report – Dengue Hemorrhagic Fever
Family History
None of this patient’s family member is experiencing this sort of sickness. Her
uncle also has Diabetes Mellitus. No family member has a history of hypertension
and heart disease.
Social history
This Patient comes from a middle economical family. There is no history of
smoking and alcoholic drinks.
III. PHYSICAL EXAMINATION (11 MARCH 2010)
General State : Moderately ill
Consciousness : Compos Mentis
GCS : E4M6V5
Blood pressure : 100/60
Pulse : 82 x/minute
Temperature : 37.5 oC
Respiration : 22 x/minute
Skin
Warm and dry, turgor is adequate, color is normal.
There is no icterus, petechia, purpura, rash, or unusual pigmentation noted.
Head
Normocephaly and no sign of traumatic; no lesions noted.
Hair short and black, the face is symmetrical, no edema.
Eyes
Eyelids ptosis (-), exopthalmos (-), laceration (-).
cornea is without lesion, no secret.
conjunctiva anemic (-), Sclera icterus (-),
Clinical Clerkship of Internal Medicine Division
Pelita Harapan University – Siloam Hospital Kebon Jeruk
1 March – 9 May 2010
2
Case Report – Dengue Hemorrhagic Fever
pupils are equal, measuring approximately 3 mm-3 mm in diameter, round,
reactive to light; direct light reflex (+,+), indirect light reflex (+,+).
Extraocular movements are conjugated, no signs of Nystagmus or strabismus.
Ears
Normal in appearance, auditory canal appear clean and without lesion,
hearing is adequate, pain upon tragus’s pressure (-)
Nose
Septum appears to be within normal limits and without deviation. Nasal mucosa
appear pink without any abnormal discharge. No nasal polyp or other lesion are
noted, frontal and maxillary sinuses are nontender.
Mouth
Lips are symmetris; no cyanosis or pallor. Surface is rather dry.
Buccal mucosa is normal in appearance.
Tounge
symmetrical in shape, shows no lesions or tremor,
movement is free in every direction.
Throat
Pharyngeal mucosa is pink and does not reveal any lesion, exudates, erythema,
or evidence of tonsils inflammation.
Gag reflex is intact. Uvula is centered.
Neck
Neck is symmetry. Full range of motion is present. There is no evidence of
tracheal deviation or neck lymphadenopathy. Thyroid gland is in normal size, it’s
palpation does not reveal any nodule or masses.
Clinical Clerkship of Internal Medicine Division
Pelita Harapan University – Siloam Hospital Kebon Jeruk
1 March – 9 May 2010
3
Case Report – Dengue Hemorrhagic Fever
Thorax
-inspection :Symmetrical, normal intercostals space, no enlargement nor
shrinkage, no venectation, no tumor. Movement is
accordingly to respiration. Apical impulse not visible.
-Palpation : No signs of mass, tactil fremitus equal bilaterally.
-Percussion : Lung fields are resonant throughout.
Lung – Liver border : right midclavicular line ICS V
-auscultation Lung : vesicular breath sound, ronchi (-/-), wheezing (-/-)
Heart : S1S2 are regular, murmur (-), gallop (-).
Abdomen
-Inspection :Abdominal wall is symmetric, normal size and contour. There
are no vein dilatations.
Abdominal wall moves accordingly to respiration.
-Palpation :Abdominal wall is supple, no abdominal distention or
masses. Pain on epigastric pressure is present, no pain on
other abdominal field.
Liver : not palpable.
Spleen : not palpable
Kidney : No CVA tenderness
-Percussion : Tympanic on all four abdominal quadrants.
-Auscultation : Normoactive bowel sounds.
Extremity
Both hands and feet are normal in size and shape
Acrals are warm, no sign of cyanotic
No edema on all four extremities
No tremor on all four extremities
Clinical Clerkship of Internal Medicine Division
Pelita Harapan University – Siloam Hospital Kebon Jeruk
1 March – 9 May 2010
4
Case Report – Dengue Hemorrhagic Fever
Anogenitalia
Not examined.
IV. SUPPORTIVE
Laboratorium test ( 7 March 2010 )
Complete Blood Count
Hemoglobin 12.8 g/dL 13 – 18
Leukocyte count 6.3 103/µL 4.0 – 10.0
Diff. Leukocyte Count
Basofil 0 % 0 - 1
Eosinofil 5 % 0 - 4
Band 0 % 2 – 6
Segmented 64 % 50 – 70
Lymphocyte 28 % 20 – 40
Monocyte 3 % 2 – 8
ESR 13 Mm 0 – 15
Erythrocyte 4.06 106/µL 4.5 – 6.2
Hematocrite 36.5 % 40 – 54
MCH 89.9 fL 81 – 96
MCV 31.5 Pg 27 – 36
MCHC 35.1 g/L 31.0 – 37.0
Platelet 197 103/µL 150 - 400
Chemistry
Blood Gluc. 2pp morning 239 mg/dL 60 - 140
Blood Gluc. 2pp
afternoon
250 mg/dL 60 - 140
Blood Gluc. 2pp evening 265 mg/dL 60 – 140
SGOT 23 U/L 11 - 42
SGPT 58 U/L 10 – 65
Clinical Clerkship of Internal Medicine Division
Pelita Harapan University – Siloam Hospital Kebon Jeruk
1 March – 9 May 2010
5
Case Report – Dengue Hemorrhagic Fever
Ureum 13 mg/dL 10 – 40
Kreatinin 0.50 mg/dL 0.00 – 1.20
Natrium 136 mmol/L 135 – 145
Pottasium 3.3 mmol/L 3.5 – 5.1
Chlorida 99 mmol/L 98 - 107
Hematologi (08/03/10)
malaria No malaria parasite found
Serologi (08/03/10)
S. Typhi O Negative
S. Typhi H Negative
S. Paratyphi AO Negative
S. paratyphii AH Negative
S. paratyphii BO Negative
S. paratyphii BH (+) 1/320
S. paratyphii CO Negative
S. paratyphii CH Negative
Anti dengue IgG Negative
Anti dengue IgM Negative
Hematologi (11/03/10)
Hb 10.1 g/dL
Leucocyte 6.4 10^3/µL
Hematocrite 29.7 %
Platelet 140 10^3/µL
Clinical Clerkship of Internal Medicine Division
Pelita Harapan University – Siloam Hospital Kebon Jeruk
1 March – 9 May 2010
6
Case Report – Dengue Hemorrhagic Fever
Blood Chemistry (11/03/10)
Fasting Blood Glucose 175 mg/dL
Blood Gluc. 2pp morning 276 mg/dL
Blood gluc. 2pp afternoon 257 mg/dL
Blood gluc. 2pp evening 121 mg/dL
Serologi (11/03/10)
Anti dengue IgG Positive
Anti dengue IgM Positive
Laboratory Observation
Date Haemoglobin Haematocrite Platelet Leucocyte
7/3 12.8 36.5 197 6.3
10/3 10.8 31 160 8.9
11/3 10.1 29.7 140 5.1
12/3 9.6 28.4 147 5.1
Blood Glucose Observation
7/3 9/3 10/3 11/3
Fasting blood glucose 294 133 175
Blood gluc. 2pp morning 239 233 252 276
Blood gluc. 2pp
afternoon
250 228 342 257
Blood gluc. 2pp evening 265 190 271 121
V. RESUME
Clinical Clerkship of Internal Medicine Division
Pelita Harapan University – Siloam Hospital Kebon Jeruk
1 March – 9 May 2010
7
Case Report – Dengue Hemorrhagic Fever
A patient, female, 53 y.o., came to Siloam Kebon Jeruk hospital with a chief
complaint of fever since 3 days before hospital admission. The fever is continuosly.
The patient also complains of weakness, loss of appetite, nausea without vomiting,
and numbness in both legs. The patient has no problem on urinating and defecation.
According to the patient, she experience no features of cough or flu. The patient has
not been travelling out of town and none of her neighbours or family member suffer
from the same sickness. The patient admits that she consumed panadol for her fever
with no effect. She also had Diabetes Mellitus since 5 years ago, and is on
medication glucovance 2.5 mg twice daily (morning and afternoon).
Physical examination showed relatively stable hemodynamic with blood pressure
: 100/60, pulse : 82 x/min, temperature : 37.5 0C, respiratory : 22x/min. Lips looked
dried, present of pain on epigastric pressure.
Significant features found on laboratory test are; Haemoglobin 10,1 g/dL;
Haematocrite 28.7%; platelet count : 140.000/μl, The daily curve on blood glucose
shown hyperglycemic, on serologic test shown that antidengue IgM and IgG are
positive.
VI. WORKING DIAGNOSIS
1. Dengue Haemorrhagic Fever (DHF)
2. DM type II
3. Polyneuropathy diabeticum
1. Dengue Haemorrhagic Fever (DHF)
DHF is diagnosed based on findings during anamnesis, physical examination &
laboratory finding such as :
1. Fever since 3 days before admission
2. GIT symptoms (nauseous)
3. Lab ↓ platelet 147.000/μl
Anti dengue IgM (+)
Clinical Clerkship of Internal Medicine Division
Pelita Harapan University – Siloam Hospital Kebon Jeruk
1 March – 9 May 2010
8
Case Report – Dengue Hemorrhagic Fever
Differential Diagnosis :
1. Typhoid fever
Theraphy :
a. Medication:
ORAL: Paracetamol (Sumagesic ® 500mg, 3 x 1)
IV: Pantoprazole (Pantozol® 40mg IV, 1 x 1)
Ondansetron (Narfoz® 4 mg IV, 3 x 1)
FLUID: Ringer Asering 30 drops per minute.
b. Nonmedication:
Bedrest
2. Diabetes mellitus tipe II
Diabetes Mellitus is diagnosed based on findings during anamnesis, laboratory
finding such as :
The patient having Diabetes Mellitus since 5 years ago and consume
glucovance 25 mg twice daily.
Fasting Blood glucose 175 mg/dL
Blood Glucose 2pp in the morning 276 mg/dL
Blood glucose 2pp in the afternoon 257 mg/dL
Theraphy :
1. Medication:
ORAL : Glimepiride (Amaryl® 1mg 1x1)
SC : insulin (actrapid® 3x8 U)
2. Non medication :
Education & motivation to exercise
Control the food with low glucose
Clinical Clerkship of Internal Medicine Division
Pelita Harapan University – Siloam Hospital Kebon Jeruk
1 March – 9 May 2010
9
Case Report – Dengue Hemorrhagic Fever
3. Polyneurophaty diabeticum
Polyneuropathy diabeticum is diagnosed based on findings during anamnesis,
physical examination such as :
Hipestesia and parastesi
Theraphy :
1. Medication:
ORAL : Anti neuropathy pain (Lyrica® 75 mg 1x1)
Nootropik&neurotonik (Arcalion® 200mg 2x1)
IV : Mecobalamin (Methycobal® 1x1)
2. Non medication :
fisioterapi
VII. PROGNOSIS
Ad vitam : dubia ad bonam
Ad functionam : dubia ad bonam
Ad sanationam : dubia ad bonam
Clinical Clerkship of Internal Medicine Division
Pelita Harapan University – Siloam Hospital Kebon Jeruk
1 March – 9 May 2010
10
Case Report – Dengue Hemorrhagic Fever
DENGUE HAEMORRHAGIC FEVER
Dengue is a mosquito-borne infection that in recent decades has become a major
international public health concern. Dengue is found in tropical and sub-tropical regions
around the world, predominantly in urban and semi-urban areas.
Dengue haemorrhagic fever (DHF), a potentially lethal complication, was first
recognized in the 1950s during dengue epidemics in the Philippines and Thailand. Today
DHF affects most Asian countries and has become a leading cause of hospitalization and
death among children in the region.
There are four distinct, but closely related, viruses that cause dengue. Recovery from
infection by one provides lifelong immunity against that virus but confers only partial and
transient protection against subsequent infection by the other three viruses. There is good
evidence that sequential infection increases the risk of developing DHF.
Global burden of dengue
The incidence of dengue has grown dramatically around the world in recent decades.
Some 2.5 billion people – two fifths of the world's population – are now at risk from dengue.
WHO currently estimates there may be 50 million dengue infections worldwide every year.
In 2007 alone, there were more than 890 000 reported cases of dengue in the Americas, of
which 26 000 cases were DHF.
The disease is now endemic in more than 100 countries in Africa, the Americas, the
Eastern Mediterranean, South-east Asia and the Western Pacific. South-east Asia and the
Western Pacific are the most seriously affected. Before 1970 only nine countries had
experienced DHF epidemics, a number that had increased more than four-fold by 1995.
Not only is the number of cases increasing as the disease is spreading to new areas, but
explosive outbreaks are occurring. In 2007, Venezuela reported over 80 000 cases, including
more than 6 000 cases of DHF.
Some other statistics:
Clinical Clerkship of Internal Medicine Division
Pelita Harapan University – Siloam Hospital Kebon Jeruk
1 March – 9 May 2010
11
Case Report – Dengue Hemorrhagic Fever
During epidemics of dengue, infection rates among those who have not been
previously exposed to the virus are often 40% to 50%, but can reach 80% to 90%.
An estimated 500 000 people with DHF require hospitalization each year, a very large
proportion of whom are children. About 2.5% of those affected die.
Without proper treatment, DHF fatality rates can exceed 20%. Wider access to
medical care from health providers with knowledge about DHF - physicians and
nurses who recognize its symptoms and know how to treat its effects - can reduce
death rates to less than 1%.
The spread of dengue is attributed to expanding geographic distribution of the four dengue
viruses and their mosquito vectors, the most important of which is the predominantly urban
species Aedes aegypti. A rapid rise in urban mosquito populations is bringing ever greater
numbers of people into contact with this vector, especially in areas that are favourable for
mosquito breeding, e.g. where household water storage is common and where solid waste
disposal services are inadequate.
Transmission
Dengue viruses are transmitted to humans through
the bites of infective female Aedes mosquitoes. Mosquitoes
generally acquire the virus while feeding on the blood of an
infected person. After virus incubation for eight to 10 days,
an infected mosquito is capable, during probing and blood
feeding, of transmitting the virus for the rest of its life.
Infected female mosquitoes may also transmit the virus to
their offspring by transovarial (via the eggs) transmission, but the role of this in sustaining
transmission of the virus to humans has not yet been defined.
Infected humans are the main carriers and multipliers of the virus, serving as a
source of the virus for uninfected mosquitoes. The virus circulates in the blood of infected
humans for two to seven days, at approximately the same time that they have a fever;
Aedes mosquitoes may acquire the virus when they feed on an individual during this period.
Clinical Clerkship of Internal Medicine Division
Pelita Harapan University – Siloam Hospital Kebon Jeruk
1 March – 9 May 2010
12
WHO/TDR/Stammers
Case Report – Dengue Hemorrhagic Fever
Some studies have shown that monkeys in some parts of the world play a similar role in
transmission.
Characteristics
Dengue fever is a severe, flu-like illness that affects infants, young children and
adults, but seldom causes death.
The clinical features of dengue fever vary according to the age of the patient. Infants
and young children may have a fever with rash. Older children and adults may have either a
mild fever or the classical incapacitating disease with abrupt onset and high fever, severe
headache, pain behind the eyes, muscle and joint pains, and rash.
Dengue haemorrhagic fever (DHF) is a potentially deadly complication that is
characterized by high fever, often with enlargement of the liver, and in severe cases
circulatory failure. The illness often begins with a sudden rise in temperature accompanied
by facial flush and other flu-like symptoms. The fever usually continues for two to seven
days and can be as high as 41°C, possibly with convulsions and other complications.
In moderate DHF cases, all signs and symptoms abate after the fever subsides. In
severe cases, the patient's condition may suddenly deteriorate after a few days of fever; the
temperature drops, followed by signs of circulatory failure, and the patient may rapidly go
into a critical state of shock and die within 12 to 24 hours, or quickly recover following
appropriate medical treatment (see below).
Treatment
There is no specific treatment for dengue fever.
For DHF, medical care by physicians and nurses experienced with the effects and
progression of the complicating haemorrhagic fever can frequently save lives - decreasing
mortality rates from more than 20% to less than 1%. Maintenance of the patient's
circulating fluid volume is the central feature of DHF care.
Clinical Clerkship of Internal Medicine Division
Pelita Harapan University – Siloam Hospital Kebon Jeruk
1 March – 9 May 2010
13
Case Report – Dengue Hemorrhagic Fever
Immunization
There is no vaccine to protect against dengue. Although progress is underway,
developing a vaccine against the disease - in either its mild or severe form - is challenging.
With four closely related viruses that can cause the disease, the vaccine must
immunize against all four types to be effective.
There is limited understanding of how the disease typically behaves and how the
virus interacts with the immune system.
There is a lack of laboratory animal models available to test immune responses to
potential vaccines.
Despite these challenges, two vaccine candidates have advanced to evaluation in human
subjects in countries with endemic disease, and several potential vaccines are in earlier
stages of development. WHO provides technical advice and guidance to countries and
private partners to support vaccine research and evaluation.
Prevention and control
At present, the only method of controlling or preventing dengue virus transmission is
to combat the vector mosquitoes.
In Asia and the Americas, Aedes aegypti breeds primarily in man-made containers
like earthenware jars, metal drums and concrete cisterns used for domestic water storage,
as well as discarded plastic food containers, used automobile tyres and other items that
collect rainwater. In Africa the mosquito also breeds extensively in natural habitats such as
tree holes, and leaves that gather to form "cups" and catch
water.
In recent years, Aedes albopictus, a secondary
dengue vector in Asia, has become established in the United
States, several Latin American and Caribbean countries, parts
of Europe and Africa. The rapid geographic spread of this
species is largely attributed to the international trade in used tyres, a breeding habitat.
Clinical Clerkship of Internal Medicine Division
Pelita Harapan University – Siloam Hospital Kebon Jeruk
1 March – 9 May 2010
14
WHO/TDR/Crump
Case Report – Dengue Hemorrhagic Fever
Vector control is implemented using environmental management and chemical
methods. Proper solid waste disposal and improved water storage practices, including
covering containers to prevent access by egg-laying female mosquitoes are among methods
that are encouraged through community-based programmes.
The application of appropriate insecticides to larval habitats, particularly those that
are useful in households, e.g. water storage vessels, prevents mosquito breeding for several
weeks but must be re-applied periodically. Small, mosquito-eating fish and copepods (tiny
crustaceans) have also been used with some success.
During outbreaks, emergency vector control measures can also include broad
application of insecticides as space sprays using portable or truck-mounted machines or
even aircraft. However, the mosquito-killing effect is transient, variable in its effectiveness
because the aerosol droplets may not penetrate indoors to microhabitats where adult
mosquitoes are sequestered, and the procedure is costly and operationally difficult. Regular
monitoring of the vectors' susceptibility to widely used insecticides is necessary to ensure
the appropriate choice of chemicals. Active monitoring and surveillance of the natural
mosquito population should accompany control efforts to determine programme
effectiveness.
Clinical Clerkship of Internal Medicine Division
Pelita Harapan University – Siloam Hospital Kebon Jeruk
1 March – 9 May 2010
15
Case Report – Dengue Hemorrhagic Fever
Bibliography
1. Fauci, Braunwald, Kasper, Hauser, Longo, Jameson, Loscalzo. Harrison’s Principles of
Internal Medicine 17th edition.2008.USA:McGraw-Hill
2. Suhendro, Nainggolan L, Chen K, Pohan HT. Demam Berdarah Dengue. Dalam
Sudoyo AW, Setiyohadi B, Alwi I, Simadibrata MK, Setiati S, editor : Buku Ajar Ilmu
Penyakit Dalam edisi 4 jilid 3.2006.Jakarta:Fakultas Kedokteran Universitas
Indonesia. Hal 1709-13.
3. WHO. Dengue Haemorrhagic Fever.
http://www.who.int/mediacentre/factsheets/fs117/en/index.html
Clinical Clerkship of Internal Medicine Division
Pelita Harapan University – Siloam Hospital Kebon Jeruk
1 March – 9 May 2010
16
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