Dengue Fever

Presenters: - Okmaronab Febriza (080100375) - Hanidya fazwat (080100381) Supervisor : dr. Lily Irsa, SpA (K)
DEPARTMENT OF PEDIATRICS HAJI ADAM MALIK GENERAL HOSPITAL FACULTY OF MEDICINE UNIVERSITAS SUMATERA UTARA
2012

CASE REPORT

Dengue fever is disease that cause by one of the four serotype of dengue virus (den-1, den-2, den-3, den-4). - Family: flaviviridae - Genus: flavivirus - = 50 nm Dengue fever is transmitted from human to human by the mosquito aedes aegypti.

1980

Spread across the country in Indonesia

EPIDEMIOLOGY

 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

CLINICAL MANIFESTATIONS CRITICAL PHASE

Increasing hemoconcentration, hypoprotein, pleural effusion, ascites Skin bleeding, mucosal bleeding (gastrointestinal or vaginal)

RECOVERY PHASE

Moderate to severe thrombocytopenia

Dengue fever
Acute febrile illnes with two or more of the following manifestation
Headache, Retro-orbital, manifestation, leukopenia Myalgia, Rash, Haemorrhagic

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

Complete Blood Count Haematrocrit Haemoglobin Thrombocyte Leucocyte Bleeding time aPTT PTT

 Virus Isolation

RT-PCR
Detection of antigens IgM/IgG ratio

IgA

DF/DHF Grade DF

Symptoms Fever with two or more of the

Laboratory leukopenia occasionally.

following sign : headache, retroorbital

pain, myalgia, arthralgia

Thrombocytopenia, may be
present,no evidence of plasma loss

DHF

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)

Thrombocytopenia < 100.000, Hct rise 20% Thrombocytopenia < 100.000, Hct rise 20%

DHF

IV

Profound shock with undetectable blood pressure and pulse

Differential Diagnose
chinkungunya Scarlet fever

malaria
leptospirosis Thypoid and typhus Influenza measles

 Bed rest

Adequate Nutrition
Symptomatic :
Oral fluids sent home Intravena fluids Paracetamol

High fever, < 7 days Malaise, no ARI Emergency signs (+)

Shock Seizure Encephalopath y Bleeding

Emergency signs (-)

Tourniquet test

Positive Leucocyte < 4.000/uL

Negative

Inpatient

Normal leucocyte

One day observation Observe for 24 hours Symptoms & lab+ Thrombocyte <

Outpatient Control until fever(-) Advice the parent

100.000/uL + Rise of Ht > 10%

Fever persist > 3 days Check Hb, Ht, leucocyte & thrombocyte
18

 Fluid Drink 2 litre/day to prevent dehydration Mineral water, juice, oralit Symptomatic Give antipiretic if high fever or history of febrile seizure occured. Suggestion is paracetamol. Asetosal & ibuprofen are contraindicated Diazepam Domperidon 1 mg/kgBB, 3 dose, 1-2 days H2 blocker (ranitidine, cimetidine) Antibiotic is not given Steroid is not effective
19

Able to drink

Unable to drink Vomit

Infuse D5%:NaCl 0,9% = 3:1 Maintenance drips Check Hb, Ht, thrombocyte every 6-12 hours Evaluate the symptoms & lab Signs of shock Diuresis Bleeding Hb, Ht, thrombocyte every 6-12 hours

Drink 2 L/day Paracetamol Anticonvulsive, if necessary

Discharge

Improve

Worsen

Change to RL D5%
20

Improveme nt agitated Not

Strong pulse Stable BP Ht decrease Diuresis 1 ml/kg/hour Fluid decrease to 5 ml/kg/hour

Initial fluid 6 8 ml/kg/hour RLD5% or RAD5%

No Improvement

Monitor the vital signs Hb, Ht, thrombocyte every 6-12 hours Agitated Respiratory distress HR increase Ht increase Pulse pressure < 20mmHg Diuresis <1 ml/kg/hr
Fluid increase to 10-15 ml/kg/hour Evaluate in 12-24 hours Treatment of DSS Unable vital signs
21

3 ml/kg/hour Stop in 24-48 hours

SHOC K

O2 2-4 L/min Isotonic fluid 20 ml/kg/hour RL/RA/NS in 30 min Evaluate in 30 minute, has the shock resolved? Yes No Continue the RL + Kolloid + Correct acidosis Evaluate in 1 hour Ht Not resolved Increase Kolloid No improvement
22

Adjust the fluid Monitor

Shock has resolved

Stable

Decrease Transfusion Inotropic

Stop the fluid not more than 48 hours after the shock has resolved

23

 Environment

-drain the tub or water reservoirs at least once a week -replace or drain the vase -bury the cans Biological -use of larvae-eating fish Chemical -fogging using malathion and fenthion or abate powder in water reservoirs

Central nervous system

Liver failure and renal failure

encephalopat hy

Intracranial bleeding

 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 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 History of previous medication

: cough : Paracetamol

Physical Examination :
Presence Status :

Compos Mentis, Temperature : 38,2C, 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: typhus measles, 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 11.60 g% 4.40 x 106/mm3 2.27 x 103/mm3 42.90 % 90 x 103/mm3 70.30 fL 20.00 pg 33.20 g% 14.10 % 9.20 Fl 0.19 % 10.5 fL

Normal Value 11.3 14.1 4.40 4.48 4.5 13.5 37 41 217 497 81 95 25 29 29 31 11.6 14.6 7.2 10.0

Complete Blood Count :

Hemoglobin (Hb) Erytrocyte (RBC) Leukocyte (WBC) Hematocrite Trombocyte (PLT) MCV MCH MCHC RDW MPV PCT PDW

Test (28-05-2012) Cell Count : Neutrofil Limfosit Monosit Eosinophil Basophil

Results

Normal Value

75.10 % 15.50 % 9.40 % 0.00 % 0.000 %

37 80 20 40 28 16 01

Neutrophil absolute
Limfosit absolute Monosit absolute Eosinophil absolute Basophil absolute

3.21x 103/L
0.00 x 103/L 0.40 x 103/L 0.10 x 103/L 0.00x 103/L

2.4 7.3
1.7 5.1 0.2 0.5 0.10 0.30 0 0,1

Carbohydrate Metabolism

Blood Glukose Electrolyte

Natrium (Na) Kalium (K) Klorida (Cl)

105,09 mg/dl
134 mEq/L 4.4 mEq/L 101 mEq/L

<200
135-155 3.5-5.5 96-106

Virus Anti DHF IgM Anti DHF IgG Positive Negative 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 (-/-)

Follow Up May 29th 2012

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

Test (29-05-2012) Complete Blood Count : Hemoglobin (Hb) Erytrocyte (RBC) Leukocyte (WBC)

Results 13.10 g% 4.50 x 106/mm3 6.27 x 103/mm3

Normal Value 11.3 14.1 4.40 4.48 4.5 13.5

Hematocrite
Trombocyte (PLT) MCV

38.50 %
152 x 103/mm3 88.70 fL

37 41
217 497 81 95

MCH
MCHC RDW MPV PCT PDW LED

27.20 pg
30.20 g% 14.10 % 9.10 Fl 0.19 % 10.5 fL 45

25 29
29 31 11.6 14.6 7.2 10.0

<15

Test (29-05-2012) Cell Count : Neutrofil Limfosit Monosit Eosinophil Basophil

Results

Normal Value

75.10 % 15.50 % 9.40 % 0.00 % 0.000 %

37 80 20 40 28 16 01

Neutrophil absolute
Limfosit absolute Monosit absolute Eosinophil absolute Basophil absolute

3.21x 103/L
0.00 x 103/L 0.40 x 103/L 0.00 x 103/L 0.00x 103/L

2.4 7.3
1.7 5.1 0.2 0.5 0.10 0.30 0 0,1

Carbohydrate Metabolism

Blood Glukose Electrolyte

Natrium (Na) Kalium (K) Klorida (Cl)

105,09 mg/dl 138 mEq/L

4.9 mEq/L 104 mEq/L

<200
135-155 3.5-5.5 96-106

Follow Up
Follow Up May 30th 2012

S : 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 (-/-)

Follow Up May 30th 2012 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

Test (30-05-2012)
Complete Blood Count : Hemoglobin (Hb) Erytrocyte (RBC) Leukocyte (WBC) Hematocrite Trombocyte (PLT) MCV MCH MCHC RDW MPV PCT

Results
12.60 g% 4.43 x 106/mm3 8.5 x 103/mm3 38.70 % 207 x 103/mm3 79.30 fL 23.00 pg 33.80 g% 12.10 % 8.20 Fl 0.19 %

Normal Value
11.3 14.1 4.40 4.48 4.5 13.5 37 41 217 497 81 95 25 29 29 31 11.6 14.6 7.2 10.0

PDW
LED

10.5 fL
45 <15

Test (28-05-2012) Cell Count : Neutrofil Limfosit Monosit Eosinophil Basophil

Results

Normal Value

78.10 % 16.50 % 8.40 % 1.00 % 0.000 %

37 80 20 40 28 16 01

Neutrophil absolute
Limfosit absolute Monosit absolute Eosinophil absolute Basophil absolute

3.21 x 103/L
2.00 x 103/L 0.40 x 103/L 0.00 x 103/L 0.00 x 103/L

2.4 7.3
1.7 5.1 0.2 0.5 0.10 0.30 0 0,1

Theory

Cases

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

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-tomoderate 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 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.