Case Report Dhf

Case Report – Dengue Hemorrhagic Fever

CASE

I. PATIENT IDENTITY

Name : F.S.K

Age : 53 y.o

Sex : Female

Date of Admission: 7 March 2010

II. ANAMNESIS (AUTOANAMNESIS & ALLOANAMNESIS, 11 MARCH 2010)

Chief Complaint

Fever

Present Illness

The patient came to Siloam Kebon Jeruk Hospital with a chief complaint of fever

since 3 days before hospital admission. The fever is continuosly. The patient also

complains of weakness, loss of appetite, nausea without vomiting, and numbness

in both legs. The patient has no problem on urinating and defecation. According

to the patient, she experience no features of cough or flu. The patient has not

been travelling out of town and none of her neighbours or family member suffer

from the same sickness. The patient admits that she consumed panadol for her

fever with no effect. She also had Diabetes Mellitus since 5 years ago, and is on

medication glucovance 2.5 mg twice daily (morning and afternoon).

Past Medical History

The patient was previously hospitalized in the Siloam Kebon Jeruk Hospital on

2009 with complaint of numbness and treated by the neurologist. The patient

deny any kind of surgery and has no history of allergies to any type of drugs or

food.

Clinical Clerkship of Internal Medicine Division

Pelita Harapan University – Siloam Hospital Kebon Jeruk

1 March – 9 May 2010

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Family History

None of this patient’s family member is experiencing this sort of sickness. Her

uncle also has Diabetes Mellitus. No family member has a history of hypertension

and heart disease.

Social history

This Patient comes from a middle economical family. There is no history of

smoking and alcoholic drinks.

III. PHYSICAL EXAMINATION (11 MARCH 2010)

General State : Moderately ill

Consciousness : Compos Mentis

GCS : E4M6V5

Blood pressure : 100/60

Pulse : 82 x/minute

Temperature : 37.5 oC

Respiration : 22 x/minute

Skin

Warm and dry, turgor is adequate, color is normal.

There is no icterus, petechia, purpura, rash, or unusual pigmentation noted.

Head

Normocephaly and no sign of traumatic; no lesions noted.

Hair short and black, the face is symmetrical, no edema.

Eyes

Eyelids ptosis (-), exopthalmos (-), laceration (-).

cornea is without lesion, no secret.

conjunctiva anemic (-), Sclera icterus (-),




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pupils are equal, measuring approximately 3 mm-3 mm in diameter, round,

reactive to light; direct light reflex (+,+), indirect light reflex (+,+).

Extraocular movements are conjugated, no signs of Nystagmus or strabismus.

Ears

Normal in appearance, auditory canal appear clean and without lesion,

hearing is adequate, pain upon tragus’s pressure (-)

Nose

Septum appears to be within normal limits and without deviation. Nasal mucosa

appear pink without any abnormal discharge. No nasal polyp or other lesion are

noted, frontal and maxillary sinuses are nontender.

Mouth

Lips are symmetris; no cyanosis or pallor. Surface is rather dry.

Buccal mucosa is normal in appearance.

Tounge

symmetrical in shape, shows no lesions or tremor,

movement is free in every direction.

Throat

Pharyngeal mucosa is pink and does not reveal any lesion, exudates, erythema,

or evidence of tonsils inflammation.

Gag reflex is intact. Uvula is centered.

Neck

Neck is symmetry. Full range of motion is present. There is no evidence of

tracheal deviation or neck lymphadenopathy. Thyroid gland is in normal size, it’s

palpation does not reveal any nodule or masses.




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Thorax

-inspection :Symmetrical, normal intercostals space, no enlargement nor

shrinkage, no venectation, no tumor. Movement is

accordingly to respiration. Apical impulse not visible.

-Palpation : No signs of mass, tactil fremitus equal bilaterally.

-Percussion : Lung fields are resonant throughout.

Lung – Liver border : right midclavicular line ICS V

-auscultation Lung : vesicular breath sound, ronchi (-/-), wheezing (-/-)

Heart : S1S2 are regular, murmur (-), gallop (-).

Abdomen

-Inspection :Abdominal wall is symmetric, normal size and contour. There

are no vein dilatations.

Abdominal wall moves accordingly to respiration.

-Palpation :Abdominal wall is supple, no abdominal distention or

masses. Pain on epigastric pressure is present, no pain on

other abdominal field.

Liver : not palpable.

Spleen : not palpable

Kidney : No CVA tenderness

-Percussion : Tympanic on all four abdominal quadrants.

-Auscultation : Normoactive bowel sounds.

Extremity

Both hands and feet are normal in size and shape

Acrals are warm, no sign of cyanotic

No edema on all four extremities

No tremor on all four extremities




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Anogenitalia

Not examined.

IV. SUPPORTIVE

Laboratorium test ( 7 March 2010 )

Complete Blood Count

Hemoglobin 12.8 g/dL 13 – 18

Leukocyte count 6.3 103/µL 4.0 – 10.0

Diff. Leukocyte Count

Basofil 0 % 0 - 1

Eosinofil 5 % 0 - 4

Band 0 % 2 – 6

Segmented 64 % 50 – 70

Lymphocyte 28 % 20 – 40

Monocyte 3 % 2 – 8

ESR 13 Mm 0 – 15

Erythrocyte 4.06 106/µL 4.5 – 6.2

Hematocrite 36.5 % 40 – 54

MCH 89.9 fL 81 – 96

MCV 31.5 Pg 27 – 36

MCHC 35.1 g/L 31.0 – 37.0

Platelet 197 103/µL 150 - 400

Chemistry

Blood Gluc. 2pp morning 239 mg/dL 60 - 140

Blood Gluc. 2pp

afternoon

250 mg/dL 60 - 140

Blood Gluc. 2pp evening 265 mg/dL 60 – 140

SGOT 23 U/L 11 - 42

SGPT 58 U/L 10 – 65




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Ureum 13 mg/dL 10 – 40

Kreatinin 0.50 mg/dL 0.00 – 1.20

Natrium 136 mmol/L 135 – 145

Pottasium 3.3 mmol/L 3.5 – 5.1

Chlorida 99 mmol/L 98 - 107

Hematologi (08/03/10)

malaria No malaria parasite found

Serologi (08/03/10)

S. Typhi O Negative

S. Typhi H Negative

S. Paratyphi AO Negative

S. paratyphii AH Negative

S. paratyphii BO Negative

S. paratyphii BH (+) 1/320

S. paratyphii CO Negative

S. paratyphii CH Negative

Anti dengue IgG Negative

Anti dengue IgM Negative

Hematologi (11/03/10)

Hb 10.1 g/dL

Leucocyte 6.4 10^3/µL

Hematocrite 29.7 %

Platelet 140 10^3/µL




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Blood Chemistry (11/03/10)

Fasting Blood Glucose 175 mg/dL

Blood Gluc. 2pp morning 276 mg/dL

Blood gluc. 2pp afternoon 257 mg/dL

Blood gluc. 2pp evening 121 mg/dL

Serologi (11/03/10)

Anti dengue IgG Positive

Anti dengue IgM Positive

Laboratory Observation

Date Haemoglobin Haematocrite Platelet Leucocyte

7/3 12.8 36.5 197 6.3

10/3 10.8 31 160 8.9

11/3 10.1 29.7 140 5.1

12/3 9.6 28.4 147 5.1

Blood Glucose Observation

7/3 9/3 10/3 11/3

Fasting blood glucose 294 133 175

Blood gluc. 2pp morning 239 233 252 276

Blood gluc. 2pp

afternoon

250 228 342 257

Blood gluc. 2pp evening 265 190 271 121

V. RESUME




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A patient, female, 53 y.o., came to Siloam Kebon Jeruk hospital with a chief

complaint of fever since 3 days before hospital admission. The fever is continuosly.

The patient also complains of weakness, loss of appetite, nausea without vomiting,

and numbness in both legs. The patient has no problem on urinating and defecation.

According to the patient, she experience no features of cough or flu. The patient has

not been travelling out of town and none of her neighbours or family member suffer

from the same sickness. The patient admits that she consumed panadol for her fever

with no effect. She also had Diabetes Mellitus since 5 years ago, and is on

medication glucovance 2.5 mg twice daily (morning and afternoon).

Physical examination showed relatively stable hemodynamic with blood pressure

: 100/60, pulse : 82 x/min, temperature : 37.5 0C, respiratory : 22x/min. Lips looked

dried, present of pain on epigastric pressure.

Significant features found on laboratory test are; Haemoglobin 10,1 g/dL;

Haematocrite 28.7%; platelet count : 140.000/μl, The daily curve on blood glucose

shown hyperglycemic, on serologic test shown that antidengue IgM and IgG are

positive.

VI. WORKING DIAGNOSIS

1. Dengue Haemorrhagic Fever (DHF)

2. DM type II

3. Polyneuropathy diabeticum

1. Dengue Haemorrhagic Fever (DHF)

DHF is diagnosed based on findings during anamnesis, physical examination &

laboratory finding such as :

1. Fever since 3 days before admission

2. GIT symptoms (nauseous)

3. Lab ↓ platelet 147.000/μl

Anti dengue IgM (+)




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Differential Diagnosis :

1. Typhoid fever

Theraphy :

a. Medication:

ORAL: Paracetamol (Sumagesic ® 500mg, 3 x 1)

IV: Pantoprazole (Pantozol® 40mg IV, 1 x 1)

Ondansetron (Narfoz® 4 mg IV, 3 x 1)

FLUID: Ringer Asering 30 drops per minute.

b. Nonmedication:

Bedrest

2. Diabetes mellitus tipe II

Diabetes Mellitus is diagnosed based on findings during anamnesis, laboratory

finding such as :

The patient having Diabetes Mellitus since 5 years ago and consume

glucovance 25 mg twice daily.

Fasting Blood glucose 175 mg/dL

Blood Glucose 2pp in the morning 276 mg/dL

Blood glucose 2pp in the afternoon 257 mg/dL

Theraphy :

1. Medication:

ORAL : Glimepiride (Amaryl® 1mg 1x1)

SC : insulin (actrapid® 3x8 U)

2. Non medication :

Education & motivation to exercise

Control the food with low glucose




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3. Polyneurophaty diabeticum

Polyneuropathy diabeticum is diagnosed based on findings during anamnesis,

physical examination such as :

Hipestesia and parastesi

Theraphy :

1. Medication:

ORAL : Anti neuropathy pain (Lyrica® 75 mg 1x1)

Nootropik&neurotonik (Arcalion® 200mg 2x1)

IV : Mecobalamin (Methycobal® 1x1)

2. Non medication :

fisioterapi

VII. PROGNOSIS

Ad vitam : dubia ad bonam

Ad functionam : dubia ad bonam

Ad sanationam : dubia ad bonam




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DENGUE HAEMORRHAGIC FEVER

Dengue is a mosquito-borne infection that in recent decades has become a major

international public health concern. Dengue is found in tropical and sub-tropical regions

around the world, predominantly in urban and semi-urban areas.

Dengue haemorrhagic fever (DHF), a potentially lethal complication, was first

recognized in the 1950s during dengue epidemics in the Philippines and Thailand. Today

DHF affects most Asian countries and has become a leading cause of hospitalization and

death among children in the region.

There are four distinct, but closely related, viruses that cause dengue. Recovery from

infection by one provides lifelong immunity against that virus but confers only partial and

transient protection against subsequent infection by the other three viruses. There is good

evidence that sequential infection increases the risk of developing DHF.

Global burden of dengue

The incidence of dengue has grown dramatically around the world in recent decades.

Some 2.5 billion people – two fifths of the world's population – are now at risk from dengue.

WHO currently estimates there may be 50 million dengue infections worldwide every year.

In 2007 alone, there were more than 890 000 reported cases of dengue in the Americas, of

which 26 000 cases were DHF.

The disease is now endemic in more than 100 countries in Africa, the Americas, the

Eastern Mediterranean, South-east Asia and the Western Pacific. South-east Asia and the

Western Pacific are the most seriously affected. Before 1970 only nine countries had

experienced DHF epidemics, a number that had increased more than four-fold by 1995.

Not only is the number of cases increasing as the disease is spreading to new areas, but

explosive outbreaks are occurring. In 2007, Venezuela reported over 80 000 cases, including

more than 6 000 cases of DHF.

Some other statistics:




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During epidemics of dengue, infection rates among those who have not been

previously exposed to the virus are often 40% to 50%, but can reach 80% to 90%.

An estimated 500 000 people with DHF require hospitalization each year, a very large

proportion of whom are children. About 2.5% of those affected die.

Without proper treatment, DHF fatality rates can exceed 20%. Wider access to

medical care from health providers with knowledge about DHF - physicians and

nurses who recognize its symptoms and know how to treat its effects - can reduce

death rates to less than 1%.

The spread of dengue is attributed to expanding geographic distribution of the four dengue

viruses and their mosquito vectors, the most important of which is the predominantly urban

species Aedes aegypti. A rapid rise in urban mosquito populations is bringing ever greater

numbers of people into contact with this vector, especially in areas that are favourable for

mosquito breeding, e.g. where household water storage is common and where solid waste

disposal services are inadequate.

Transmission

Dengue viruses are transmitted to humans through

the bites of infective female Aedes mosquitoes. Mosquitoes

generally acquire the virus while feeding on the blood of an

infected person. After virus incubation for eight to 10 days,

an infected mosquito is capable, during probing and blood

feeding, of transmitting the virus for the rest of its life.

Infected female mosquitoes may also transmit the virus to

their offspring by transovarial (via the eggs) transmission, but the role of this in sustaining

transmission of the virus to humans has not yet been defined.

Infected humans are the main carriers and multipliers of the virus, serving as a

source of the virus for uninfected mosquitoes. The virus circulates in the blood of infected

humans for two to seven days, at approximately the same time that they have a fever;

Aedes mosquitoes may acquire the virus when they feed on an individual during this period.




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WHO/TDR/Stammers


Some studies have shown that monkeys in some parts of the world play a similar role in

transmission.

Characteristics

Dengue fever is a severe, flu-like illness that affects infants, young children and

adults, but seldom causes death.

The clinical features of dengue fever vary according to the age of the patient. Infants

and young children may have a fever with rash. Older children and adults may have either a

mild fever or the classical incapacitating disease with abrupt onset and high fever, severe

headache, pain behind the eyes, muscle and joint pains, and rash.

Dengue haemorrhagic fever (DHF) is a potentially deadly complication that is

characterized by high fever, often with enlargement of the liver, and in severe cases

circulatory failure. The illness often begins with a sudden rise in temperature accompanied

by facial flush and other flu-like symptoms. The fever usually continues for two to seven

days and can be as high as 41°C, possibly with convulsions and other complications.

In moderate DHF cases, all signs and symptoms abate after the fever subsides. In

severe cases, the patient's condition may suddenly deteriorate after a few days of fever; the

temperature drops, followed by signs of circulatory failure, and the patient may rapidly go

into a critical state of shock and die within 12 to 24 hours, or quickly recover following

appropriate medical treatment (see below).

Treatment

There is no specific treatment for dengue fever.

For DHF, medical care by physicians and nurses experienced with the effects and

progression of the complicating haemorrhagic fever can frequently save lives - decreasing

mortality rates from more than 20% to less than 1%. Maintenance of the patient's

circulating fluid volume is the central feature of DHF care.




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Immunization

There is no vaccine to protect against dengue. Although progress is underway,

developing a vaccine against the disease - in either its mild or severe form - is challenging.

With four closely related viruses that can cause the disease, the vaccine must

immunize against all four types to be effective.

There is limited understanding of how the disease typically behaves and how the

virus interacts with the immune system.

There is a lack of laboratory animal models available to test immune responses to

potential vaccines.

Despite these challenges, two vaccine candidates have advanced to evaluation in human

subjects in countries with endemic disease, and several potential vaccines are in earlier

stages of development. WHO provides technical advice and guidance to countries and

private partners to support vaccine research and evaluation.

Prevention and control

At present, the only method of controlling or preventing dengue virus transmission is

to combat the vector mosquitoes.

In Asia and the Americas, Aedes aegypti breeds primarily in man-made containers

like earthenware jars, metal drums and concrete cisterns used for domestic water storage,

as well as discarded plastic food containers, used automobile tyres and other items that

collect rainwater. In Africa the mosquito also breeds extensively in natural habitats such as

tree holes, and leaves that gather to form "cups" and catch

water.

In recent years, Aedes albopictus, a secondary

dengue vector in Asia, has become established in the United

States, several Latin American and Caribbean countries, parts

of Europe and Africa. The rapid geographic spread of this

species is largely attributed to the international trade in used tyres, a breeding habitat.




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WHO/TDR/Crump


Vector control is implemented using environmental management and chemical

methods. Proper solid waste disposal and improved water storage practices, including

covering containers to prevent access by egg-laying female mosquitoes are among methods

that are encouraged through community-based programmes.

The application of appropriate insecticides to larval habitats, particularly those that

are useful in households, e.g. water storage vessels, prevents mosquito breeding for several

weeks but must be re-applied periodically. Small, mosquito-eating fish and copepods (tiny

crustaceans) have also been used with some success.

During outbreaks, emergency vector control measures can also include broad

application of insecticides as space sprays using portable or truck-mounted machines or

even aircraft. However, the mosquito-killing effect is transient, variable in its effectiveness

because the aerosol droplets may not penetrate indoors to microhabitats where adult

mosquitoes are sequestered, and the procedure is costly and operationally difficult. Regular

monitoring of the vectors' susceptibility to widely used insecticides is necessary to ensure

the appropriate choice of chemicals. Active monitoring and surveillance of the natural

mosquito population should accompany control efforts to determine programme

effectiveness.




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Bibliography

1. Fauci, Braunwald, Kasper, Hauser, Longo, Jameson, Loscalzo. Harrison’s Principles of

Internal Medicine 17th edition.2008.USA:McGraw-Hill

2. Suhendro, Nainggolan L, Chen K, Pohan HT. Demam Berdarah Dengue. Dalam

Sudoyo AW, Setiyohadi B, Alwi I, Simadibrata MK, Setiati S, editor : Buku Ajar Ilmu

Penyakit Dalam edisi 4 jilid 3.2006.Jakarta:Fakultas Kedokteran Universitas

Indonesia. Hal 1709-13.

3. WHO. Dengue Haemorrhagic Fever.

http://www.who.int/mediacentre/factsheets/fs117/en/index.html




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http://www.who.int/mediacentre/factsheets/fs117/en/index.html

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