THROMBOCYTOPENIA · HEPARIN INDUCED THROMBOCYTOPENIA •A fall in platelet count to
Thrombocytopenia, fever, rash, hypotension · §Must consider Dengue, Malaria, Typhoid,...
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Thrombocytopenia, fever, rash, hypotension Alexander D. Hristov MD University of Wisconsin Hospital and Clinic Internal Medicine PGY 2
Transcript of Thrombocytopenia, fever, rash, hypotension · §Must consider Dengue, Malaria, Typhoid,...
Thrombocytopenia, fever, rash, hypotension
Alexander D. Hristov MD University of Wisconsin Hospital and Clinic
Internal Medicine PGY 2
Case Chief Complaint: Fever, diarrhea, bloody nose, rash
HPI: 38 y/o Indonesian Male • Presented to urgent care w/ 5 days of fever, epistaxis, and
melena. • Recent 2 week trip to Indonesia w/ daughter for family
wedding • Returned 1 week ago
• Hypotensive, light-headed with scattered petechiae and thrombocytopenia (PLT 10).
Social Hx: Born in Indonesia.
Family Hx: Daughter w/ similar symptoms w/o bleeding.
JakartaSerang
Physical Exam BP: 96/59, HR:114,Temp:102.6
• GENERAL: diaphoretic• HEENT: petechiae on palate,
dry mucous membranes, dried blood on nares
• ABD: epigastric tenderness• SKIN: petechiae on LUE and
bilateral LE, +Tourniquet Sign
Differential Diagnosis US Patient •DIC from Sepsis •TTP/HUS •Tick Borne Disease§Babesiosis§Ehrlichiosis
Returning Traveler •Vector Borne Illness
§Malaria§Dengue
•Typhoid •Tick Borne Disease §Scrub Typhus
•Meningococcal Sepsis
Admission Labs
Blood Cultures: PendingStool Cultures: Pending
17.14.5 8
49
132
4.3
96
23
17
>40% bands
1.1798
AST: 138ALT: 61Alk Phos: 55Tbili: 0.4
PTT: 67INR: 1.1LDH: 634Fibrin Monomer: (-) Fibrinogen: 205
Blood Smear:
Hospital Course • Hypotension - fluid responsive. Developed edema • Skin – morbilliform rash developed across trunk, petechiae
resolved• Fever – defervesced• Epistaxis – Resolved without recurrence • Melena – resolved with some residual loose stool• Treated w/ Ceftriaxone for 5 days given concern for typhoid.
• Thrombocytopenia – Improved without transfusion• Plt – 69
• Blood cultures negative • Dengue antibodies IgM and IgG positive after 5 days
Dengue Epidemiology•WHO estimates 50 - 100 million infections yearly.•US reports ~100 cases per year•Most due to returning travelers• Sporadic outbreaks in Florida, Hawaii, and Texas
•Vector Borne Illness • Incubation Period 4-10 days
• Four different strains •DENV 1-4
WHO 2009 Classification Dengue w/o Warning Signs •Nausea, Rash, • Leukopenia,
Dengue w/ Warning Signs • Abdominal pain, •Mucosal Bleeding, • Plasma leak• Thrombocytopenia, High
HCT
Severe Dengue §Shock due to severe
plasma leakage§Severe Bleeding §Organ Failure
Diagnosis •Dengue Serology • anti-DENV IgM and IgG • Real time PCR• Non structural Enzyme ELSIA
(NS1) •During febrile phase (10 days) Serology w/ RT PCR or NS1 is highly specific and sensitive.
In Summary • Returningtravelerw/fever,petechiae,bleedingdiatheses
§Alwaysruleoutsepsis,DIC,TTP/HUS§MustconsiderDengue,Malaria,Typhoid,Rickettsial Diseases§Travelhistoryhelpsguidediagnosis
•Patientsw/priorexposurepresentw/worsesymptoms§Whyhisdaughterhadlessenedresponse
• SupportivetherapyiskeyinDengue
Thank you…Dr. Bennett VogelmanDr. Sean O’NeillDr. Kelly LavinDr. Jessica TischendorfDr. Brian Lewis Dr. Melissa MacDonald
Citations• World Health Organization. Dengue: Guidelines for diagnosis, treatment, prevention
and control, New edition. WHO: Geneva 2009. http://www.who.int/tdr/publications/documents/dengue-diagnosis.pdf?ua=1 (Accessed on December 07, 2016).
• Dengue. (2014, June 09). Retrieved August 20, 2017, from https://www.cdc.gov/dengue/epidemiology/index.html
• Hunsperger, E. A., Muñoz-Jordán, J., Beltran, M., Colón, C., Carrión, J., Vazquez, J., ... & Margolis, H. S. (2016). Performance of dengue diagnostic tests in a single-specimen diagnostic algorithm. The Journal of infectious diseases, 214(6), 836-844.
• World Health Organization, Special Programme for Research, Training in Tropical Diseases, World Health Organization. Department of Control of Neglected Tropical Diseases, World Health Organization. Epidemic, & Pandemic Alert. (2009). Dengue: guidelines for diagnosis, treatment, prevention and control. World Health Organization.
• Kalra, N. L., Joshi, A. B., Dash, A. P., Hilderbrand, A., Sawguanprasitt, B., & Prasittisuk, C. (2011). Comprehensive guidelines for prevention and control of dengue and dengue haemorrhagic fever. India: World Health Organization (WHO) Regional Office for South-East Asia, 75-88.
