Case PresentationFrancine Lu

Identifying Data

Gem R.

8/M

student

Roman Catholic

Taytay, Rizal

Informant: mother, 80% reliability

Chief Complaint

Fever

History of Present Illness

Fever (Tmax 39.4), remittent

Generalized body weakness

Fronto-temporal headache, 7/10

Paracetamol, unrecalled dose, provided some relief

No rash, no gum bleeding, no epistaxis

2 days PTA

History of Present Illness

On/off abdominal pain, 5/10, epigastric and periumbilical, crampy, nonradiating

Vomiting of recently ingested food, 2 episodes, non bloody

Still with fever, no signs of bleeding

Consult 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 History

Born full term

NSD

28 year old G2P2

Attended by OB

No complications

Birth weight unrecalled

Nutritional History

Breastfed until 2 months

Formula Bonna

Weaning 6 months

No food allergies

Prefers chicken, juice

Usual diet: soup, rice, chicken

Immunization History

BCG

DPT x 3

Polio x 3

Measles x 1

Influenza

No MMR, rotavirus, varicella, Hib, Pneumococcal

Developmental History

Can write fairly well at 6

Can count to ten at 5

Can add and subtract at 6

Dresses self completely at 6

Backward heel to toe walk at 6

Language

Personal Social History

Grade 2 student

Likes Math and Sibika

Parents work at a cable companyFather is a technician

Mother is an office employee

Up and down house

Drinking water: purified

Adequate ventilation and lighting

Daily garbage collection

Review of SystemsNo weight loss; with good appetite

No pruritus or skin lesions

No eye or ear discharge, no epistaxis, no colds

No bleeding gums, no dysphagia

No cough, dyspnea or hemoptysis

No cyanosis or pallor

No change in bowel movements or jaundice, no hematochezia or melena

No change in bladder habits

No limping, swelling of the extremities

Physical Exam

Conscious, coherent, not in distress

Weight 35.1kg (z=2)

Height 140 cm (z=2)

BMI 17.9 (normal for age)

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

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

Physical Exam

Head normocephalic, atraumatic

Eyes: pink palpebral conjunctivae, anicteric sclerae, no discharge

Ears: patent ear canal, intact TM, no discharge

Nose: no alar flaring, midline septum, no nasal discharge, no bleeding

Oropharyngeal cavity: no tonsillopharyngeal congestion, no lesions, no bleeding

Physical Exam

Neck: no CLAD

Chest/Lungs: Equal chest expansion, resonant on all lung fields, no retractions, clear breath sounds

Cardiovascular: Adynamic precordium, apex beat 5th ICS left midclavicular line, normal rate, regular rhythm, no murmurs

Physical Exam

Abdomen: 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 assessed

Extremities: full and equal pulses, CRT<2s, no edema, no clubbing, no cyanosis

Musculoskeletal: no gross deformities

Salient Features

8 year old male

Remittent fever of 2 days duration

Generalized body weakness

Fronto-temporal headache, 7/10

On/off abdominal pain, 5/10, epigastric and periumbilical, crampy, nonradiating

Vomiting of recently ingested food, 2 episodes, non bloody

Flushed skin, (+) epigastric tenderness

Differentials

Systemic Viral Illness

Dengue Fever

Urinary Tract Infection

Typhoid fever

Work-Up

CBCHgb: 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

Assessment

Dengue Fever

Course in the Wards

Hospital Day 1

Day 3 of illnessS 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 Plt

128 (N) 0.38 (N)

8.3 (N) 250 (N)

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

Hospital Day 2

Day 4 of illnessS 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 Plt

131 (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 3

Day 5 of illness, Day 1 afebrileS 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 Plt

130 (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 4

Day 6 of illness, Day 2 afebrileS 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 Plt

134 (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 Fever

Dengue 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

Transmission

single-stranded RNA virus comprising four distinct serotypes (DEN-1 to -4)

genus Flavivirus, family Flaviviridae

genotypes 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

Transmission

Incubation period 4-10 days

virus enters via the skin while an infected mosquito is taking a bloodmeal

acute phase: virus is present in the blood and its clearance from this compartment generally coincides with defervescence

Endothelial cell dysfunction plasma leakage

Alterations in megakaryocytopoeisis by infection of human hematopoeitic cells and impaired progenitor cell growth platelet dysfunction

Phases

Febrile Phase

Critical Phase

Recovery Phase

Febrile PhaseSudden onset of high grade fever

Lasts 2-7 days

Facial flushing, skin erythema, generalized bodyache, myalgia, arthralgia, headache, sore throat, injected pharynx, conjunctival injection, Anorexia, nausea, vomiting

From mild to massive bleedingPetechia and mucosal membrane bleeding --- massive vaginal bleeding and GI bleeding

Enlarged and tender liver

Earliest abnormality: decreased WBC

Critical Phase

Time 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 improve

Otherwise: may become worse as a result of lost plasma volume

Critical Phase

Plasma leakage: pleural effusion, ascitesdegree of increase above the baseline hematocrit often reflects the severity of plasma leakage

If critical volume is lost ShockBelow normal body temperature

progressive organ impairment, metabolic acidosis and disseminated intravascular coagulation

Severe hemorrhage – increase in WBC

Hepatitis, encephalitis, myocarditis

Critical Phase

If with improvement after defervescence = non-severe dengue

If defervescence does not occur, take CBC to guide the onset of critical phase and plasma leakage

If 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 h

Better, good appetite, no GI symptoms, hemodynamic status stable, diuresis ensues

Rash: “isles of white in the sea of red”

Pruritus, bradycardia, ECG changes

HCT stabilizes or may be lower (dilutional)

WBC rises soon after defervescence; Platelets recover later

Excessive IVF: pleural eff, ascites, pulmo edema, CHF

Severe Dengue

i. 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 shock

Usually around the time of defervescence, usu day 4 or 5 (d 3-7)

Preceded by warning signs

Initially: tachycardia, peripheral vasoconstriction with reduced skin perfusion -- cold extremities and delayed capillary refill time

Narrowed pulse pressure, as peripheral vascular resistance increases

Decompensation – both pressures disappear abruptly

Diagnosis

Fever of 2-7 days duration

Any 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 done

NS1 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 Criteria

Shock

Spontaneous bleeding

Danger signs: inability to drink or feed, vomits everything, convulsions, lethargy, unconsciousness, no urine output for 6-8 hours

Increased vascular permeability: hematocrit, serous effusion, hypoproteinemia

Abdominal pain

Fluids: Outpatient

ORS 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/kg

11-20 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 diuresis

Infuse 20ml/kg bolusIf with no improvement, repeat 2-3 times; consider inotropic agent

If stable, gradually decrease IVF rate

Continuous monitoring

Oxygen 2-3L/min

Blood Transfusion

Fresh 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

Others

Steroids, Vitamin C, antihistamines, Vitamin K, Albumin No added benefit

Discharge: 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 >2mos

Insecticides containing propoxur, organophosphates and pyrethrium most effective only indoors for a short period of time

Screening of windows and doors, mosquito nets

Defogging during dengue epidemic, larviciding

Covering and regular emptying and cleaning of water storage

Prospective dengue vaccine still mostly in Phase 1 and 2