Case Report DENGUE SHOCK SYNDROME (DSS)

Supervisor: dr.Hj.Silvia Triratna Sp.A (K)

Presented by: Arinanda Kurniawan Irwansyah Roza Maulindra

I.Identification
Name : An. R. P (, 8 y.o) Weight : 50 kg Height : 147 cm Religion : Islam Adress : Palembang Admitted hospital : 20 April 2010

II. Anamnesis
Problem Identification: -Main Problem: fever -Problem: cold in extremities

History of the disease

5 days before admission, patient got high fever, acute, continously, no chill, no sweat. Cough(+), flu(+), pain when swelling(-) . Headache(+), myalgia(+), athralgia(+), pain on occular dorsal (-). Ptechie(-), epistaksis (-), gum bleeding(-). Nausea (-), vomitting (-). Urination and defecation normal. Parents bring the patients to Benteng hospital and hospitalized 2 days but fever still occur. Patient decided to back home.

 1 day before admission patient still got fever, brought to pediatrician, nausea (+), vomiting (+), frequency 2x/day, that containt eaten and drunk by him. Patient reffered to RSK Charitas. 3 hours before admission, each extremities are cold and moist. The patient manage with IVFD challange RL 1kolf and reffered to RSMH, hospitalized in PICU.

Past history of the disease History of malaria (-) History of travelling to endemic area of malaria (-) Typhoid history (-).
Family history No history of the same disease

History of pregnancy and birth: GPA : G3P3A0 Partus and gravid complication : (-) Gravida : Aterm Partus : Spontan Delivered : Sp. OG Weight : 3400gram Height : 52 cm Apgar score :9

 Riwayat Makanan: Breast Feeding : 0-12 months PASI : birth-now poridge+cow milk : 6-8 month Rice : 1 year-now Meat, chicken, egg, fish vegetables and fruits Milk 2 gelas/hari interpretation: good in quality and quantity

Imunitation history: BCG : (+) DPT : DPT I, II, III Polio : Polio I, II, III Hepatitis B : Hepatitis B I, II, III Campak : (+) interpretation : complete Developmental history: lying : 4 month crawl : 7 month sit : 6 month stand : 12 month walk : 18 month interpretation : normal motoric developmental

 Social and economic history

good in social and economic status

III. Physical Examination

General examination Consiousness : Compos Mentis Blood pressure : 110/70 mmHg pulse : filiformis HR : 105x/m RR : 30x/m Temperature : 36,5 0C General appearance: severe illness weight : 50 kg height : 147 cm Anemic : Sianosis : Ikteric : oedema anasarca : nutritioanla status : weight/age = 50/26 x 100% = 192,3 % height/age = 147/128 x 100% = 114,8 % weight/height = 50/38 x 100% = 131,5 % interpretation : obese

Specific Examination:
Skin: turgor normal, venektasis (-), ptechiae (-) Kepala: normocephali
Head circumference Fontanella Hair : 53 cm : closed : black, straight, not easy to pull

Mata: konjungtiva anemis (-), sklera ikteric (-) light reflex +/+ normal, round shape pupil, isochor, diamater 3 mm Noose : Secret (-), nafas cuping hidung (-/-) Eye : Secret (-) Mouth : Stomatitis angularis (-), atrophy tounge (-), dry mouth (+), sianosis circum oral (-), typhoid tongue (-) Pharynx : Hiperemis (-), tonsil T1-T1 Neck : increasing in jugular vein (+), hipertrophy of lymph node (-)

Neurologic Examination

III. Supporting Exam

Blood exam: (20 April 2010) Hb : 16,3 g/dl Ht : 46 vol % Leukocyte : 8800/mm3 LED : 2 mm/hours Trombocyte : 46.000/mm3 Diff. count : 0/1/1/63/31/0 BSS : 117 mg/dL IgG dengue: (-) IgM dengue: (-) Intrepretation: trombocytopenia

How to diagnose
DD:
Dengue Shock Syndrome Post Resusitation Shock Hipoglicemia

Working Diagnose:
Dengue Shock Syndrome post resucitation

Management
Manage Shock PICU (17.00) - IVDF RL 20gtt/min makro - Ranitidin Inj. 2x50mg 1 ampul - Oksigenasi (O2 2 L/menit) Follow up vital sign every 15 min and balance record Penatalaksanaan lanjutan Oxigen Shortness of breath IVFD RL 10 cc/ kg weight/hours = 380 cc/30min Observe vital sign, sign of bleeding, and diuresis Balance per 6 hours Temp. curve per 6 hours Hb, Ht dan thrombocyte per 6 hours -next 30 min: hemacell IV10 cc/kgBB/30menit 380cc/30menit -next 30 min :RL IV 4 cc/kgBB/hours

Refference
Dengue Hemorrhagic Fever: Definition: acute febrile diseases which occur in the tropics, can be lifethreatening, and are caused by four closely related virus serotypes of the genus Flavivirus, family Flaviviridae Etiology: Dengue virus (DENV), a mosquito-borne flavivirus

Dengue Shock Syndrome

DHF grade III/IV with failure in circulation such as tight pulse pressure (<20mmHg), or hipotension or cold and moist extremities, anxiety.

Pathogenesis:

How to diagnose: Anamnesis: fever, bladder problem, constant headaches, eye pain, severe dizziness and loss of appetite. bleeding from mucosa, gingiva, injection sites vomiting blood, or bloody diarrhea Px : positive tourniquet test, spontaneous bruising
Supporting Exam: Thrombocytopenia (<100,000 platelets per mm or estimated as less than 3 platelets per high power field) Evidence of plasma leakage (hematocrit more than 20% higher than expected, or drop in hematocrit of 20% or more from baseline following IV fluid, pleural effusion, ascites, hypoproteinemia) Dengue shock syndrome is defined as dengue hemorrhagic fever plus: Weak rapid pulse, Narrow pulse pressure (less than 20 mm Hg) Cold, clammy skin and restlessness.

Management DSS 1. Oxygen 2-4L/min 2. Crystaloid IV RL/NaCl 0.9% 10-20ml/kgBW challange/ for 30 minutes. evaluation shock status Improvement: IV line change10ml/kgBW/hours evaluation: if stabil condition IV line 5ml/kgBW/hour, IV 3 ml/kgBW/hours, inf. Uppnot more than 48hours after shock No improvement: IV line 15-20ml/kgBW/hours+colloid 10ml/kgBW/hours evaluation 1 hours: if show improvement back to management of stabil condition, if no improvement continoue colloid IV 10-20ml/kgBW

Case Analysis
Anamnesis: Fever for 5 days, acute, continuously, athralgia infection Nausea and vomiting renjatan Cough and flu infection Cold and clammy extremities on 5th days Normal urination and defecation rule out UTI History of malaria (-) rule out malaria Interpretation suspected viral infection, dengue fever, shock condition

Physical Exam: After resuscitation, TD=100/80, pulse= 148, filliformis, RR= 25, temp=36.9C, extremities cold
Next 30min TD=110/80, pulse 138, RR=26, temp=35,8. Extremities became warm improvement

Interpretation: shock show good improvement post resuscitation

 Supporting Exam Before referred to RSMH= Ht: 53%, Th: 24.000 RSMH, Ht:46%, Th: 46.000, Hb:16,3, BSS: 117mg/dL, leu: 10.900 Day 5: IgM (-), IgG(-) Day 6: IgM (-), IgG(+) Interpretation: DHF

Management
1. Oxygen 2-4L/min 2. Crystaloid IV RL/NaCl 0.9% 1020ml/kgBW challenge/ for 30 minutes. evaluation shock status Improvement: IV line change10ml/kgBW/hours evaluation: stabile condition IV line 4ml/kgBW/hour, IV 3 ml/kgBW/hours, inf. Upp.

Prognosis
Quo at functional: dubia at bonam Quo at vitam: Bonam

Thank You