ppt dengue hany

CASE REPORTDengue Fever

Presenters: - Okmaronab Febriza (080100375) - Hanidya fazwat (080100381)Supervisor : dr. Lily Irsa, SpA (K)

DEPARTMENT OF PEDIATRICSHAJI ADAM MALIK GENERAL HOSPITAL

FACULTY OF MEDICINEUNIVERSITAS SUMATERA UTARA

2012

Dengue fever is disease that cause by one of the four serotype of dengue virus (den-1, den-2, den-3, den-4).

DEFINITION & ETIOLOGY

Dengue fever is transmitted from human to human by the mosquito aedes aegypti.

- Family: flaviviridae- Genus: flavivirus- ɸ = 50 nm

1968 First reported in Surabaya

1980

Spread across the country in Indonesia

EPIDEMIOLOGY

pathogenesis

pathophysiology•Vasculopathy

•Thrombocytopenia and platelet dysfunction

•Coagulopathy

•Evidence of plasma leakage

CLINICAL MANIFESTATIONS FEBRILE PHASE

TAKEN PLACE FOR 3-7 DAYS

FEVER : ≥ 38,50 C

HEADACHE

VOMITING, MYALGIA AND JOINT PAIN

CRITICAL PHASE Increasing hemoconcentration, hypoprotein, pleural effusion,

ascitesSkin bleeding, mucosal bleeding

(gastrointestinal or vaginal)

Moderate to severe thrombocytopenia

RECOVERY PHASE

CLINICAL MANIFESTATION

S

Diagnose

Acute febrile illnes with two or more of the following manifestation

Headache, Retro-orbital, Myalgia, Rash, Haemorrhagic manifestation, leukopenia

• Dengue Haemorrhagic fever• Fever• Haemorrhagic tendencies• Thrombocytopenia (100.000 cell per mm 3 • A rise in the haematocrit equal than 20%• A drop in the haematocrit following volume replacement

treatment equal to or • greater than 20% of baseline• Sign of plasma leakage

• Dengue fever

Complete Blood CountHaematrocritHaemoglobinThrombocyteLeucocyteBleeding timeaPTTPTT

Laboratory Finding

Virus IsolationRT-PCRDetection of antigensIgM/IgG ratioIgA

Further Examination

DF/DHF Grade Symptoms Laboratory

DF Fever with two or more of the

following sign : headache, retroorbital

pain, myalgia, arthralgia

leukopenia occasionally.

Thrombocytopenia, may be

present,no evidence of plasma

loss

DHF I Above sign plus posisitve tourniquet

test

Thrombocytopenia < 100.000,

Hct rise ≥ 20%

DHF II Above sign plus spontaneous bleeding Thrombocytopenia < 100.000,

Hct rise ≥ 20%

DHF III Above sign plus circulatory failure

(weak pulse, hypotension, restlessness)


Hct rise ≥ 20%

DHF IV Profound shock with undetectable

blood pressure and pulse


Hct rise ≥ 20%

Grading

Differential Diagnose

chinkungunya

Scarlet fever

malaria

leptospirosis

Thypoid and typhus

Influenza

measles

Treatment of dengue infection

Dengue FeverBed restAdequate NutritionSymptomatic :

Oral fluids sent homeIntravena fluidsParacetamol

Suspect of Dengue Infection

18

High fever, < 7 daysMalaise, no ARI

Emergency signs (-)Emergency signs (+)

ShockSeizureEncephalopathyBleeding

Tourniquet test

Positive Negative

Inpatient

One day observation

Observe for 24 hoursSymptoms & lab

Leucocyte < 4.000/uL

Normal leucocyte

+ Thrombocyte < 100.000/uL+ Rise of Ht > 10%

OutpatientControl until fever(-)Advice the parent

Fever persist > 3 daysCheck Hb, Ht, leucocyte & thrombocyte

Treatment of DHF without shockFluid

Drink 2 litre/day to prevent dehydrationMineral water, juice, oralit

SymptomaticGive antipiretic if high fever or history of febrile

seizure occured. Suggestion is paracetamol. Asetosal & ibuprofen are contraindicated

DiazepamDomperidon 1 mg/kgBB, 3 dose, 1-2 daysH2 blocker (ranitidine, cimetidine)Antibiotic is not givenSteroid is not effective

19

Treatment of DHF without shock (DHF grade I and II)

20

Able to drink Unable to drinkVomit

Drink 2 L/dayParacetamolAnticonvulsive, if necessary

Infuse D5%:NaCl 0,9% = 3:1Maintenance dripsCheck Hb, Ht, thrombocyte every 6-12 hoursEvaluate the symptoms & lab

Signs of shockDiuresisBleeding

Hb, Ht, thrombocyte every 6-12 hours

Discharge Improve Worsen Change to RL D5%

21

Treatment of DHF grade I and IIInitial fluid 6 – 8 ml/kg/hour

RLD5% or RAD5%

Monitor the vital signsHb, Ht, thrombocyte every 6-12 hours

Improvement

No Improvement

Not agitatedStrong pulseStable BPHt decreaseDiuresis 1 ml/kg/hour

AgitatedRespiratory distressHR increaseHt increasePulse pressure < 20mmHgDiuresis <1 ml/kg/hrFluid decrease

to 5 ml/kg/hourFluid increase to

10-15 ml/kg/hour3 ml/kg/hour

Stop in 24-48 hours

Unable vital signs

Evaluate in 12-24 hours

Treatment of DSS

22

SHOCK

O2 2-4 L/minIsotonic fluid 20 ml/kg/hour

RL/RA/NS

in 30 min

Evaluate in 30 minute, has the shock resolved?

Yes No

Adjust the fluid

Monitor

Stable

Stop the fluid not more than 48 hours after the

shock has resolved

Continue the RL+ Kolloid+ Correct acidosisEvaluate in 1 hourShock has

resolvedNot

resolvedHt

Decrease Increase

Transfusion

Inotropic

Kolloid

No improvement

Environment-drain the tub or water reservoirs at least once

a week-replace or drain the vase-bury the cansBiological-use of larvae-eating fishChemical-fogging using malathion and fenthion or abate

powder in water reservoirs

Prevention

COMPLICATION

encephalopathyIntra

cranial

bleeding

Liver failure and renal failur

e

Central nervous system

C A S E

D, 3 years old, male, weight 17 kg, was admitted to Haji Adam Malik Hospital at the Infection Unit Pediatric Department on May 28th 2012 with the main complaint fever. This occurred since 2 days ago, high fever tipical, temperature get lower after the medicine given but fever still remain, seizure (-), freezing (-). While the first time get fever, followed by swollen eyes, fever get worst at night. Cough(+), flu (-), dypsneu (-), disfagia (-). vomit (+) 2 times this morning, volume of vomit is ¼ glass of water. Spontantly bleeding history : epistaksis(+), bleeding gum (-), black feaces (-), rash found on the hand and foot, BAK and BAB (+) N.

History of previous illness : coughHistory of previous medication : Paracetamol

Physical Examination :

Presence Status :

Compos Mentis, Temperature : 38,2ºC, Body Weight : 17kg, Dyspnea (-), Edema (-), Cyanosis (-), Icteric (-), Anemic (-)

Head : Eye : light reflexes (+/+), isochoric pupil, pale inferior conj. palpebra (-/-). Ear/Nose/Mouth: normal.

Neck :Lymph node enlargement (-).

Thorax :Symmetrical fusiform , retraction (-)

Physical Examination :

HR: 90 bpm, regular, murmur (-)

RR : 24 bpm, regular, rales (-) Abdominal :

Soepel, peristaltic (+) N, liver and spleen not palpable, maculopapular erythematous rash (-)

Extremities :Pulse = 90 bpm, regular, adequate pressure/volume, warm acral, maculopapular erythematous rash (-) in superior and inferior dextra and sinistra extremities.

Urogenital :Male, within normal limit

Differential Diagnosis:typhusmeasles, chinkungunya, malaria, leptospirosis, thypoid,

Working Diagnosis:Dengue Fever

Management :

- IVFD RL 50 gtt/ minute micro

- Paracetamol 3x250 mg

- Diet MB 1350 kkal with 35 gram protein

Laboratorium

Test (28-05-2012) Results Normal ValueComplete Blood Count :

Hemoglobin (Hb) 11.60 g% 11.3 – 14.1

Erytrocyte (RBC) 4.40 x 106/mm3 4.40 – 4.48

Leukocyte (WBC) 2.27 x 103/mm3 4.5 – 13.5

Hematocrite 42.90 % 37 – 41

Trombocyte (PLT) 90 x 103/mm3 217 – 497

MCV 70.30 fL 81 – 95

MCH 20.00 pg 25 – 29

MCHC 33.20 g% 29 – 31

RDW 14.10 % 11.6 – 14.6

MPV 9.20 Fl 7.2 – 10.0

PCT 0.19 %

PDW 10.5 fL

LED 45 <15

Test (28-05-2012) Results Normal Value

Cell Count :

Neutrofil 75.10 % 37 – 80

Limfosit 15.50 % 20 – 40

Monosit 9.40 % 2 – 8

Eosinophil 0.00 % 1 – 6

Basophil 0.000 % 0 – 1

Neutrophil absolute 3.21x 103/µL 2.4 – 7.3

Limfosit absolute 0.00 x 103/µL 1.7 – 5.1

Monosit absolute 0.40 x 103/µL 0.2 – 0.5

Eosinophil absolute 0.10 x 103/µL 0.10 – 0.30

Basophil absolute 0.00x 103/µL 0 – 0,1

Carbohydrate Metabolism

Blood Glukose 105,09 mg/dl <200

Electrolyte

Natrium (Na) 134 mEq/L 135-155

Kalium (K) 4.4 mEq/L 3.5-5.5

Klorida (Cl) 101 mEq/L 96-106

Virus

Anti DHF IgM Positive Negative

Anti DHF IgG Negative Negative

Follow Up

Follow Up May 29th 2012

S : Fever (-)

O: Sensorium: compos mentis, temp: 37,4 oC, BP: 130/80 mmHg,

Body weight: 17 kg, BB/TB: 80,75%

Head : Eye: Light reflexes (+/+), isochoric pupillary, palpebra

inferior conjunctival pallor (-/-), Ear/Nose/Mouth: within

normal limit.

Neck : Lymph node enlargement (-).

Thorax : Symmetrical fusiform, retraction epigastrium (-)

HR:86 bpm, reguler, murmur (-)

RR: 28 bpm, reguler, ronchi (-/-)


Abdominal : Soepel, peristaltic (+) Normal, liver and lien were not

palpable

Extremities : Pulse = 86 bpm, regular, adequate

pressure/volume.

Genitalia : Male, within normal limit

A : Dengue Fever

P : - IVFD RL 50 gtt/ minute micro- Paracetamol 3x250 mg- Diet MB 1350 kkal with 35 gram protein


Hemoglobin (Hb) 13.10 g% 11.3 – 14.1





MCV 88.70 fL 81 – 95

MCH 27.20 pg 25 – 29

MCHC 30.20 g% 29 – 31

RDW 14.10 % 11.6 – 14.6

MPV 9.10 Fl 7.2 – 10.0

PCT 0.19 %

PDW 10.5 fL

LED 45 <15


Cell Count :

Neutrofil 75.10 % 37 – 80

Limfosit 15.50 % 20 – 40

Monosit 9.40 % 2 – 8


Basophil 0.000 % 0 – 1

Neutrophil absolute 3.21x 103/µL 2.4 – 7.3




Basophil absolute 0.00x 103/µL 0 – 0,1

Carbohydrate Metabolism

Blood Glukose 105,09 mg/dl <200

Electrolyte

Natrium (Na) 138 mEq/L 135-155

Kalium (K) 4.9 mEq/L 3.5-5.5

Klorida (Cl) 104 mEq/L 96-106

Follow Up

Follow Up May 30th 2012S : Fever (-)

O: Sensorium : Compos Mentis, Temperature = 36.5 0C, BP: 120/80 mmHg

Body Weight: 17 kg, BB/TB: 80,75%Head : Face : macula Eritematous (-) Eye : Light reflexes (+/+), isochoric pupillary, palpebra inferior conjunctival pallor (-/-), Ear/Nose/Mouth: within normal limit

Neck : Lymph node enlargement (-).Thorax : Symmetrical fusiform, retraction epigastrial (-),

HR: 84 bpm regular, murmur (-)

RR: 24 bpm, regular, ronchi (-/-)


Abdominal : Soepel, peristaltic (+) Normal, Liver and Lien were not

palpable,

Extremities : Pulse = 84 bpm, regular, adequate pressure/volume,

warm acral,

Urogenitalia : Male, within normal limit

A : Dengue Fever

P : - IVFD RL 50 gtt/ minute micro- Paracetamol 3x250 mg- Diet MB 1350 kkal with 35 gram protein


Hemoglobin (Hb) 12.60 g% 11.3 – 14.1





MCV 79.30 fL 81 – 95

MCH 23.00 pg 25 – 29

MCHC 33.80 g% 29 – 31

RDW 12.10 % 11.6 – 14.6

MPV 8.20 Fl 7.2 – 10.0

PCT 0.19 %

PDW 10.5 fL

LED 45 <15


Cell Count :

Neutrofil 78.10 % 37 – 80

Limfosit 16.50 % 20 – 40

Monosit 8.40 % 2 – 8


Basophil 0.000 % 0 – 1

Neutrophil absolute 3.21 x 103/µL 2.4 – 7.3




Basophil absolute 0.00 x 103/µL 0 – 0,1

discussion

Theory Cases

Epidemic dengue is a major public health problem in Indonesia, Myanmar, Sri Lanka, Thailand and Timor-Leste which are in the tropical monsoon and equatorial zone where Aedes aegypti is widespread in both urban and rural areas.

Indonesia is a country located on the equatorial zone.

The initial phase is typically characterized by high temperature (≥ 38,50 C) accompanied by headache, vomiting, myalgia, and joint pain, sometimes with a transient macular rash. Children have high fever but are generally less symptomatic than adults during this phase of the illness. Mild hemorrhagic manifestation such as petechiae and bruising, particularly at venipuncture sites and palpable liver are commonly noted. Laboratory finding mild-to-moderate thrombocytopenia and leucopenia, often with a moderate elevation of hepatic aminotransferase levels. This pahse last for 3 to 7 days, after which most patient recover without complication

main complaint of this patient is fever. This occurred since 4 days ago, high fever tipical, temperature get lower after the medicine was given but fever still remain until now. While the first time get fever. vomitting (+) 2 times this morning, volume of vomit is ¼ glass of water. Leucocytes of this patient 2.27 x 103/mm3 and thrombocyte 90x 103

Patients, D, 3-year-old, male, was diagnosed with dengue fever. A symptomatic treatment to has been conducted to this patient. He has been stabilized, and sent home.

summarry

THANK YOU FOR YOUR ATTENTION

ppt dengue hany

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