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Case Presentation. Francine 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

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identifying data
Identifying Data
  • Gem R.
  • 8/M
  • student
  • Roman Catholic
  • Taytay, Rizal
  • Informant: mother, 80% reliability
history of present illness
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 illness1
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
Past Medical History
  • (+) Asthma (1997)
    • Last attack: First quarter of 2011
family history
Family History
  • (+) Asthma – paternal
  • (+) DM – paternal
  • (+) HTN – maternal
birth history
Birth History
  • Born full term
  • NSD
  • 28 year old G2P2
  • Attended by OB
  • No complications
  • Birth weight unrecalled
nutritional history
Nutritional History
  • Breastfed until 2 months
  • Formula Bonna
  • Weaning 6 months
  • No food allergies
  • Prefers chicken, juice
  • Usual diet: soup, rice, chicken
immunization history
Immunization History
  • BCG
  • DPT x 3
  • Polio x 3
  • Measles x 1
  • Influenza
  • No MMR, rotavirus, varicella, Hib, Pneumococcal
developmental history
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
Personal Social History
  • Grade 2 student
  • Likes Math and Sibika
  • Parents work at a cable company
    • Father is a technician
    • Mother is an office employee
  • Up and down house
  • Drinking water: purified
  • Adequate ventilation and lighting
  • Daily garbage collection
review of systems
Review of Systems
  • No 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
Physical Exam
  • Conscious, coherent, not in distress
  • Weight 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 exam1
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 exam2
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 5thICS left midclavicular line, normal rate, regular rhythm, no murmurs
physical exam3
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
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
Differentials
  • Systemic Viral Illness
  • Dengue Fever
  • Urinary Tract Infection
  • Typhoid fever
work up
Work-Up
  • CBC
    • 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
assessment
Assessment
  • Dengue Fever
hospital day 1
Hospital Day 1
  • Day 3 of illness
hospital day 2
Hospital Day 2
  • Day 4 of illness
hospital day 3
Hospital Day 3
  • Day 5 of illness, Day 1 afebrile
hospital day 4
Hospital Day 4
  • Day 6 of illness, Day 2 afebrile
dengue fever
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 pps
Classification: PPS

Fever

Nonspecific symptoms

(+) tourniquet test

Grade 1

+

Spontaneous bleeding

Circulatory failure

Profound shock

transmission
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 Aedesmosquitoes, principally Ae. Aegypti
transmission1
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
slide33

Endothelial cell dysfunction plasma leakage

  • Alterations in megakaryocytopoeisis by infection of human hematopoeitic cells and impaired progenitor cell growth  platelet dysfunction
phases
Phases
  • Febrile Phase
  • Critical Phase
  • Recovery Phase
febrile phase
Febrile Phase
  • Sudden 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 bleeding
    • Petechia and mucosal membrane bleeding --- massive vaginal bleeding and GI bleeding
  • Enlarged and tender liver
  • Earliest abnormality: decreased WBC
critical phase
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 phase1
Critical Phase
  • Plasma leakage: pleural effusion, ascites
    • degree of increase above the baseline hematocrit often reflects the severity of plasma leakage
    • If critical volume is lost  Shock
      • Below normal body temperature
      • progressive organ impairment, metabolic acidosis and disseminated intravascular coagulation
        • Severe hemorrhage – increase in WBC
        • Hepatitis, encephalitis, myocarditis
critical phase2
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 phase
Recovery Phase
  • If 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
Severe Dengue
  • plasma leakage that may lead to shock (dengue shock) and/or fluid accumulation, with or without respiratory distress, and/or
  • severe bleeding, and/or
  • severe organ impairment
severe dengue1
Severe Dengue
  • Progression 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
Diagnosis
  • Fever of 2-7 days duration
  • Any 2 of the following: (WHO – 2 or more)
diagnosis1
Diagnosis
  • DF/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 ELISA
    • Dengue Dot Blot ELISA
    • Dengue Immunochromatography (ICT)
    • Dengue Dipstick ELISA
admission criteria
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
Fluids: Outpatient
  • ORS based on weight
fluids admitted without shock
Fluids: Admitted, without Shock
  • Isotonic solutions (D5LRS, D5NSS, D5 0.9%NaCl)
  • Holiday Segar Method
fluids admitted with shock
Fluids: Admitted, with Shock
  • Isotonic crystalloid (LRS, NSS, 0.9%NaCl)
  • Glucose containing solutions should be avoided to prevent osmotic diuresis
  • Infuse 20ml/kg bolus
    • If with no improvement, repeat 2-3 times; consider inotropic agent
    • If stable, gradually decrease IVF rate
  • Continuous monitoring
  • Oxygen 2-3L/min
blood transfusion
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
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
prevention
Prevention
  • Insect 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