Dengue Fever Report

8/12/2019 Dengue Fever Report

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Dengue Fever



General Data

• A.A.

• 30 year old

• Female

• From Sampaloc, Manila• Married

• Roman Catholic Filipino

• Office clerk

• Admitted for the first time at Ospital ngMaynila Medical Center (OMMC) on February1, 2014



Chief Complaint

Undocumented 4 day fever



History of Present Illness

Patient has no known comorbids and was apparentlywell until…

• 4 days PTAundocumented intermittent fever

temporary relived by Paracetamol 500mg/tab every 4hours

productive cough with yellowish sputum

generalized body pains (myalgia)

weakness

self-medicated with Paracetamol 500mg/tab every 4 hoursand Carbocysteine taken thrice a day

no joint pains, no difficulty of breathing

no consult done




• 3 days PTA

still with above symptoms

muculopapular rashes on the bilateral upper

extremities

No bleeding manifestations

No consult done




• 1 day PTA

still with above symptoms

rashes were now noted to spread to the face,

chest, abdomen, back and lower bilateral

extemities

epigastric pain, nonradiating (4/10)

No nausea nor vomiting, no hematochrezianor black tarry stool

no consult done




• On the day of admission

Patient still with above symptoms

Persistence of fever prompted consult



Past Medical History

• No Hypertension

• No Diabetes Mellitus

• No Bronchial Asthma

• No allergy to food or medication

• No previous history of Dengue fever

• No previous history of hospitalization

• Immunization

– The patient had BCG. Other childhood vaccines unrecalled.

• Childhood illnesses – Mumps

– Measles

– Chicken pox



Family Medical History

• HPN- paternal

• No DM, BA, allergies to food/medications

• 2 siblings which are all apparently healthy



Personal Social History

• Non-smoker

• Non-alcoholic beverage drinker

• Denies illicit drug use• Food preferences

o fatty and salty foods

o 5 glasses of water per day from faucet

o softdrinks

• Household:o lives in 1 room houseo garbage is collected everyday

o With history of dengue fever in the community



Review of Systems

• ConstitutionalNo weight loss. No anorexia

• SkinNo dryness

• HairNo excessive hair loss. No baldness.

• NailsNo pallor. No cyanosis.

• HeadNo dizziness nor lightheadedness. No head injury or

trauma. No syncope. No tenderness.



Review of Systems

• EyesDoes not wear reading glasses. No redness. No excessive

tearing or lacrimation.

• Ears

No loss of hearing. No tinnitus. No earaches. No dischargeor infection.

• Nose and sinusesNo complaints of loss of smell. No discharge or epistaxis.

No itching. No congestion, obstruction, and tenderness.

• Throat (mouth and pharynx)No toothaches. No complaints of loss of taste. No sore

throat. No mouth sores.



Review of Systems

• NeckNo pain or tenderness at back of the neck. No

lumps or masses. No stiffness.

• RespiratoryNo dyspnea . No hemoptysis.

• CardiovascularNo palpitations. No paroxysmal nocturnal

dyspnea. No orthopnea. No angina or cyanosis.

• GastrointestinalDefecates regularly. No constipation, or

hemorrhoids.



Review of Systems

• Renal

No dysuria, nocturia, polyuria, incontence,

retention.

• Genitalia

No itching, pain, discharge, or swelling

• Neurologic

No paralysis, tremors, numbness, seizures, or

memory loss



PHYSICAL EXAMINATION



General Survey

• Patient is cooperative and coherent

• Appears conscious, and is oriented to time and

place

• Preferred a sitting position

• Appeared clean and well-groomed



Vital Signs

• Temperature: 36.2 C axillary, left arm

• Respiratory rate: 20 cpm, regular

• Heart rate: 82 bpm

• Blood Pressure: 110/80

• Weight: 56 kg

• Height: 5’2”



Skin

• Warm to touch.

• Well defined maculopapular rashes on the

face, back, chest and upper and lower

extremities.



HEENT

Head

• No masses or deformities.

Eyes

• The patient does not wear corrective glasses.

• Visual fields are intact.

• Anicteric sclerae, pink palpebral conjunctivae

• Both pupils 3mm constricting to 2mm, equallyround and reactive to light and accommodation.



HEENT

Ears

• Intact hearing.

Nose

• Symmetrical, nasal septum in midline. No masses ordeformities. No bleeding or discharge.

Lips , Mouth and Throat

• No tonsillopharyngeal congestion.

Neck • Trachea in midline, neck is supple, thyroid not

palpable.



Cardiovascular

• Neck viens

– Nondistended

– Carotid pulse is brisk

– No bruits noted



Cardiovascular

Heart

Inspect ion and Palpat ion

• Adynamic precardium

• No observed bulging

• PMI: tapping, 3 cm lateral to midsternal line in

the 5th intercostal space



Cardiovascular

Auscul ta t ion

• Base: S2 greater than S1; physiological

spitting of S2 ; A2 greater than P2

• Apex: S1 greater than S2

• No extra heart sounds or murmurs heard



Chest and Lungs

Inspect ion .

• Thorax is symmetric with no abnormal

retractions on inspiration.

• Transverse diameter > AP diameter

Palpation.

• Good chest expansion.

• Tactile fremitus equal on both lung fields• No palpable masses, tender areas



Chest and Lungs

Percussion

• Both lungs were resonant on percussion overthe posterior intercostal spaces

Auscul ta t ion

• Vesicular breath sounds heard over both lungsat the lower lung fields; bronchovesicular breath

sounds heard over the posterior interscapulararea

• No crackles, wheezes or rhonchi



Gastro-urinary

Inspect ion

• Abdomen is flat and symmetric.

Auscul ta t ion

• Bowel sound: 19 per min at the right lower

quadrant

• No bruits



Gastro-urinary

Percussion

• The abdomen is dull over the left upper

quadrant, and tympanitic over the right upper

quadrant and the rest of abdomen.• Liver span is 5 cm over the midstrenal line and

6 cm over the right midclavicular line.



Gastro-urinary

Palpation

• Abdomen is soft and nontender.

• Liver edge is smooth and palpable at 4 cmbelow the right costal margin in themidclavicular line.

• Liver span is 5 cm over the midstrenal lineand 6 cm over the right midclavicular line.

• No tenderness on kidney punch.

• Patient declined DRE.



Extremities

• Warm

• No edema

• No cyanosis

• Capillary refill: <2 seconds

• No limitation of movement of both left and right

upper and lower extremities



Peripheral vascular

• No varicosities

• No stasis pigmentation or ulcers.

• Pulses (2+ = brisk or normal) and equal onupper and lower extremities



Neurologic

Mental Status

• Patient was conscious, alert, and oriented

to person, time and place.



LaboratoryCBC 1/31 2/1 2/2 (AM) 2/2 (PM) 2/3 (AM) Urinalysis 1/31

WBC 2.9 5.61 5.81 5.65 5.39 Color Dark yellow Neutro 0.60 28 22.6 20.9 41.3 Transparen

cy Sl. Turbid

Lympho 0.37 64 65.1 64.7 46.1 Epithelial

cell Many

Mono 0.03 5 3.8 5.3 6.3 Mucus

thread Few

Eosi 3 6.3 7.7 5.8 Amorphous

urate Few

Baso 2.2 1.4 0.5 WBC 4-6 RBC 5.35 4.71 4.52 4.37 4.29 RBC 0-3 Hgb 14.2 14.3 13.7 13.2 13 Cast Hct 53.5 40.2 39 37 36.1 urobilinoge

n MCV 76.6 85.4 86.3 84.5 84.2 ketone MCH 26.6 30.4 30.3 30.3 30.3 Albumin Trace MCHC 34.7 35.6 35.1 35.8 36 Sugar Negative RDW 13.2 13.2 13.1 SG 1.015 Platelet 170 155 114 124 143 pH 6.0 Positive Rapid Dengue IgG/IgM



SALIENT FEATURES



Salient Features

• General Data

– 30 year old

– Female

• CC

– Undocumented 4 day intermittent fever



Salient Features

• HPI – generalized body pains (myalgia)

– weakness

– maculopapular rashes on face, chest, abdomen,

back and lower bilateral extemities which startedon the upper extremities

– epigastric pain, nonradiating (4/10)

– No difficulty of breathing

– No nausea nor vomiting – No hematochrezia nor black tarry stool

– No bleeding gums



Salient Features

• PMH

– No Hypertension. No Diabetes Mellitus. NoBronchial Asthma. No allergy

– No previous history of hospitalization• FMH

– HPN- paternal

– No DM, BA, allergies to food/medications

• PSH

– Non-smoker. Non-alcoholic beverage drinker



Salient Features

• ROS

– No weight loss. No anorexia

– No pallor. No cyanosis.

– No sore throat.

– No dysuria.



Salient Features

• PE

– cooperative and coherent

– Temperature: 36.2 C axillary, left arm

– Respiratory rate: 20 cpm, regular

– Heart rate: 82 bpm

– Blood Pressure: 110/80



Salient Features

– Well defined maculopapular rashes on theface, back, chest and upper and lowerextremities.

– Anicteric sclerae, pink palpebral conjunctivae

– No tonsillopharyngeal congestion

– Thorax is symmetric with no abnormalretractions on inspiration. Vesicular breath

sounds heard over both lungs at the lowerlung fields; bronchovesicular breath soundsheard over the posterior interscapular area



Salient Features

– Abdomen is flat and symmetric. Bowel

sound: 19 per min. Abdomen is soft and

nontender. – No edema. No cyanosis. Capillary refill: <2

seconds

– Pulses (2+ = brisk or normal) and equal on

upper and lower extremities



Working Impression

• Dengue Fever with Warning signs



Approach to Diagnosis



Approach to Diagnosis

Fever, Myalgia and Rash

Scarlet

Fever

Measles Rubella Meningococcal

Disease

ChikungunyaDengue

Fever



Dengue Fever Rule in Rule out Fever

Myalgia

Weakness

Maculopapular

rashes on face,

chest, abdomen,

back and lower

bilateral extemitieswhich started on the

upper extremities

Epigastric pain

Cannot be ruled out



Chikungunya Rule in Rule out Fever

Myalgia

Weakness

Maculopapular

rashes on face,

chest, abdomen,

back and lower

bilateral extemities Epigastric pain

No joint pains

No hepatomegaly



Measles Rule in Rule out Fever

Myalgia

Maculopapular rash No Koplik spots

Upper respiratory tract

symptoms more

common.

No conjunctivitis.

Maculopapular rash,

predominantly on the

face and ears.



Rubella Rule in Rule out Fever

Myalgia

Maculopapular rash Maculopapular rash,

which usually begins

on the face and

spreads from the head

to the feet.

No lymphadenopathy

(often posterior

cervical). No conjunctivitis.



Meningococcal Disease Rule in Rule out Fever

Myalgia

Maculopapular rash No neck pain and/or

stiffness.

No photophobia.

No altered

consciousness.

No seizures.

No haemorrhagic

rash.



Diagnosis

Dengue Fever with warning signs



Dengue Fever

• Most rapidly spreading mosquito borne-viral disease in theworld.

• It is an all year round disease.

• also known as breakbone fever ,

• Symptoms include fever, headache, muscle and joint pains,

and a characteristic skin rash that is similar to measles• Dengue is transmitted by several species of mosquito within

the genus Aedes, principally A. aegypti .

• The virus has five different types; infection with one typeusually gives lifelong immunity to that type, but only short-

term immunity to the others. Subsequent infection with adifferent type increases the risk of severe complications.



Revised Dengue Clinical Case Management

Guidelines 2011

Case Definition for DENGUE FEVER (DF)Probable Dengue

An acute febrile illness with 2 or more of the following:

Headache

Retro-orbital pain Arthralgia

Rash

Hemorrhagic manifestations

Leukopenia

ANDSupportive serology (a reciprocal HI antibody titer ≥ 1280, a comparable

IgG assay ELISA titer or (+) IgM antibody test on a late or acute

convalescent phase serum specimen.



Revised Dengue Clinical Case Management

Guidelines 2011

NEW

Case Classification and Levels of Severity

Lives in or travels to dengue-endemic area, with fever, plus any two (2) of the following:

Headache

Body malaise

Myalgia Arthralgia

Retro-orbital pain

Anorexia

Nausea

Vomiting

Diarrhea

Flushed skin

Rash (petechial, Hermann's sign)

AND

Laboratory test, at least CBC (leukopenia with or without thrombocytopenia) and /or dengue NS1

antigen test or dengue IgM antibody test (optional).

Confirmed Dengue

Viral culture isolationPCR



Case Definition for DENGUE

HEMORRHAGIC FEVER (DHF)

Case Definition of DENGUE WITH

WARNING SIGNS

The following must all be present:

Fever or history of fever, lasting 2-7

days, occasionally biphasicHemorrhagic tendencies evidenced by

at least one of the following:

(+)Torniquet test

Petechiae, ecchymosis pupura

Bleeding from the mucosa, GIT,

injection sites, or other locations

Hematemesis or melena

Lives in or travels to a dengue-

endemic area, with fever lasting 2-7

days, plus any of the following:

Abdominal pain or tenderness

Persistent vomiting

Clinical signs of fluid accumulation

Mucosal bleeding

Lethargy, restlessness

Liver enlargement

Laboratory: increase in Hematocrit

and/or decreasing platelet count

Confirmed Dengue

Viral culture isolation

PCR



Case Definition for DENGUE

HEMORRHAGIC FEVER (DHF)

Case Definition of DENGUE WITH

WARNING SIGNS

Thrombocytopenia (100,000

cells/mm3 or less)

Evidence of plasma leakage due toincreased vascular permeability,

manifested by at least one of the

following:

A rise in the hematocrit equal to or

greater than 20% above average

for age, sex, and population

A drop in the hematocrit following

volume replacement treatment

equal to or greater than 20%

baseline

Signs of plasma leakage such as

pleural effusion, ascites, and

hypoproteinemia



Case Definition for Dengue Shock

Syndrome (DSS)

Case Definition for SEVERE

DENGUE

All of the four criteria for DHF must be

present, plus evidence of circulatory

failure manifested by:

Rapid and weak pulse, AND

Narrow pulse pressure (<20 mmHg

[2.7kPa])

OR

manifested by:

Hypotension for age, AND

Cold clammy skin and restlessness

Lives in or travels to a dengue-

endemic area with fever of 2-7 days

and any of the above clinicalmanifestations for dengue with or

without warning signs, plus any of the

following:

Severe plasma leakage, leading to:

Shock

Fluid accumulation with

respiratory distress

Severe bleeding

Severe organ impairment

Liver: AST or ALT ≥ 1000

CNS: e.g. seizures, impaired

consciousness

Heart: e.g. myocarditis

Kidneys: e.g. renal failure

Case Definition for Dengue Shock Case Definition for SEVERE



g

Syndrome (DSS) DENGUE

DHF Grade 1

Fever accompanied by non-specific

constitutional signs and symptoms such

as anorexia, vomiting, abdominal pain;the only hemorrhagic manifestation is a

(+) Torniquet test and or easy bruising.

DHF Grade 2

Spontaneous bleeding in addition to

manifestations of grade 1 patients

usually in the form of skin or otherhemorrhages (mucocutaneous, gastro-

intestinal)

DHF Grade 3

Circulatory failure manifested by rapid,

weak pulse and narrowing of pulse

pressure or hypotension, with thepresence of cold clammy skin and

restlessness.

DHF Grade 4

Profound shock with undetectable

blood pressure or pulse



General Guidelines

• Dengue infection is a systemic and

dynamic disease.

• 3 phases of dengue fever:

– Febrile

– Critical

– recovery



D F C iti l h



• Dengue Fever: Critical phase

– Defervescense occurs on day 3-7 of illness,

when the temp drops to 37.5-38C or less andremains below this level.

– Dengue without warning sign: improve after

defervesence

– Dengue with warning sign: deteriorate

Warning Signs

• Abdominal pain or tenderness

• Persistent vomiting

• Clinical signs of fluid accumulation• Mucosal bleeding

• Lethargy, restlessness

• Liver enlargement

• Laboratory: increase in Hematocrit and/or decreasing platelet count



• Some patients may deteriorate to

SEVERE dengue when: plasma leakage

that may lead to shock, severe bleeding.

• Dengue Fever: Recovery Phase



• Dengue Fever: Recovery Phase

– Gradual re-absorption of extravasated fluid

from the intravascular to the extravascular

space (48 to 72 hours)

– Classical rash of “isles of white in the sea of

red”

– WBC count rises soon, platelet count typicallyfollows



MANAGEMENT



1. Overall assessment

o History

o Physical Examination

o Laboratory Investigation

Complete Blood Count with Platelet



pCount

• Leukopenia

– Earliest abnormality in CBC

– Decreases progressively

• Hematocrit – 20% rise from the baseline

– If there is no baseline; Hct>40% in female orHCT>46% in males

• Thrombocytopenia

– Decreases rapidly during late febrile phase or

at defervescence



Other Serologic Tests

• Liver Function Test

– Elevated liver enzymes

– AST elevation>ALT elevation

Laboratory Confirmatory Test



Laboratory Confirmatory Test• Antibody detection

– Heamagglutination Inhibition Test (GOLDSTANDARD)

– Dengue IgM (MOST WIDELY USED)

– Dengue IgG

• Viral isolation (MOST DEFINITIVE TEST)

• Detection of virus genetic material

– Reverse transcriptase PCR

• Detection of Dengue Virus Protein – Nonstructural Protein 1 Antigen

1 O ll t



1. Overall assessment

o History

o Physical Examinationo Laboratory Investigation

2. Diagnosis, Assessment of DiseasePhase, and Severity

3. Management

o Disease Notification

o Management Decision

Sent home (Group A)

In-hospital management (Group B)

Emergency treatment (Group C)



R th li i l t t t



• Reassess the clinical status, repeathematocrit and review infusion rate

accordingly

• Give the minimum IV Fluid volumerequired to maintain good perfusion andurine output of about 0.5ml/kg/hr

• Reduce IV Fluid gradually when the rate of

plasma leakage decreases towards theend of critical phase



Maintenance Requirement



Monitoring

• Patients with warning signs should bemonitored until the at-risk period is over.

• Parameters to be monitored: – Vital signs and peripheral perfusion (1-4 hourly

until patient is out of critical phase) – Urine output (4-6 hourly)

– Hematocrit (before and after fluid replacementtherapy, then 6-12 hourly)

– Blood glucose – Other organ functions (renal profile, liver profile,

coagulation profile)



Discharge Criteria

• All of the following must be present – No fever for 48 hours

– Improvement in clinical status

• General well being• Appetite

• Hemodynamic status

• Urine output

• No respiratory distress – Increasing trend of platelet count

– Stable hematocrit without IV Fluid

• Diet as Tolerated; Avoid dark colored food



• Diet as Tolerated; Avoid dark colored food

• PNSS 1L x 150cc/hr

• Diagnostics requested:

– CBC with PC – Dengue IgG/IgM

– Urinalysis

– Serum Na, K

– BUN, Crea

– 12 L ECG – CBG

– Chest X Ray

• Medications: – Paracetamol 500mg/tab 1tab every 4 hours for T>37.8 C

– ORS sachet 1sachet +1Lwater; to consume 2-3 L/day

– HNBB 10mg/tab 1tab every 8 hours as needed forabdominal pain

Dengue Fever Report

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