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 Informant: Grandfa ther (80% reliabilit y)

Dengue Case1..Final

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Informant: Grandfather (80% reliability)

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General Data

G.E., 6 years old,F, Filipino, Catholic, born on

May 18,2005 from Bulanao, Tabuk, Kalinga,

was admitted for the 1st time at CVMC on

July 26, 2011.

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Chief complaint

epigastric pain

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History of Present Illness

4 days PTA (+) intemittent fever39o and loss of appetite

no consultations

3 days PTA (+) high-grade fever consult a private physician- Cefalexin 2

tbsp OD and Paracetamol 1tbsp every

4 hours

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� 1 day PTA (+) chocolate-colored,

formed stool, (-) petichialrashes

� Few hrs PTA persistence of previous

conditions, (+) epigatric pain brought to AGH refered to

CVMC

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Past Medical History

� At5 years old (August 2010) firsthospitalization for 7 days at Almora Genaral

Hospital

� Diagnosis: dengue fever, no bleeding� (-)previous accident or operations

� (-) allergies to food and drugs.

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Personal and Social History

� the younger of 2 siblings

� parents are overseas workers

 ± mother a domestic helper

 ±father is a driver

� lives with her grandparents and her sibling

� one-storey concrete-type house with 3bedrooms, well ventilated

� source of water for drinking and for generaluse is a pump well. Drinking water is boiled.

 

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Family History

� With family history of Asthma (paternal side)

� (-) hx of hypertansion, DM, cancer, heart

disease, blood disorder

 

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Growth and Development

A. Prenatal History-Unknown prenatal history

� B. Natal History

Born to a 20-year old G2P2 (2002) mothervia NSD

assisted by a traditional birth attendant at home

She was active, pinkish and had good cry.

No immediate complications noted

Birth weight unknown.

 

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� C. Postnatal history

� Unknown postnatal history

� D. Developmental Milestones

At 6 years old:

-fine motor: can copy diamond

-receptive language: follow 3-step command-expressive language: names colors and repeatssentences

-personal-social development: ties shoelaces and

dresses without assistance, plays games,

 

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� E.Feeding History

� The patient was breastfed from birth.

Unknown duration.

� F. Immunization History

� Unkown immunization history.

 

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REVIEW OF SYSTEMS

�Integumentary: (-) purplish or violaceous

red discoloration, (-)easy bruising, no

pruritus

CNS/HEE

NT: (-)seizures, (-) loss of consciousness, (-) eye redness, (-) sore

throat

� Cardiorespiratory: (+) non-productive cough,

(-) hemoptysis, (-) orthopnea, (-)chest

pain, (-) palpitations

 

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�GIT: (-) diarrhea nor constipation,

(-)hematochezia, no nausea,�GUT: (-) hematuria, (-) lumbar pains, (-)

oliguria

� Musculoskeletal: (-) myalgia�Hematologic System: (+)bleeding tendencies

�Endocrine System: (-) chills, (-) night

sweating, (-) weight loss

 

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PHYSICAL EXAM

awake, conscious and coherent, appearedweak, well-nourished and not in cardio-

respiratory distress.

� Vital signs:

CR: 68 bpm

RR: 28 cpm

BP: 90/60 mmHg

Temp.: 37.4 C

� Weight: 25 kg

 

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� Skin: (-) rashes

(-) flushing nor purplish discoloration of skin

(-) bruises nor ecchymoses

(-) petechiae

(-) hematoma

(+) with good skin turgor� HEENT:

normocephalic

(-) frontal/retro-orbital tenderness

(-) conjunctival injection(-) anicteric sclerae

 

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(-)naso-aural discharge,

(-) moist lips and oral mucosa(-) circumoral cyanosis

(-) neck vein engorgement

(-) cervical lymphadenopathy� Chest and Lungs:

Symmetrical chest expansion, with clear

breath sounds

 

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� Heart:

Adynamic precordium, PMI at 4th ICS

LMCL, normal rate, regular rhythm, no

murmurs

� Abdomen:

Globular abdomen, normoactive bowel

sounds, with epigastric tenderness, no

organomegaly

 

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� Genitalia: Grossly female

� Extremities: No gross deformities, no

edema, no clubbing, pinkish nail beds,capillary refill time is 3 seconds, full and equal

pulses, cold extremities.

 

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NEUROLOGIC EXAM

Mental Status: Awake, conscious and coherent,oriented to 3 spheres

Cranial Nerves:

CN I: can identify odor

CN II: pupils equally reactive to light

CN III, CN IV, and CN VI: able to track examinersface/moving object

CN V: (+) corneal reflexCN VII: facial symmetry

CN VIII: can hear

 

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CN IX, X: midline uvula

CN XI: shoulder symmetry

CNX: no tongue deviation

Motor: grade 5/5 on all four extramities

Sensory: all fours 100%

Meningeal signs:

(-) Nuchal rigidity

Autonomics:

No abnormal sweat patterns, no urinary/bowelincontinence

Pathologic Reflex:(-) Babinski reflex

 

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SALIENT FEATURES

� intermittent fever

� melena

�epigastric pain

� cold extremities

� previous hospitalization diagnosed with

dengue� loss of appetite

 

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� IMPRESSION

Dengue Hemorrhagic Fever, Grade 33

 

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DIFFERENTIAL DIAGNOSES

Malaria :

� An infection of RBCs with Plasmodium species,

transmitted by bite of female Anophelesmosquito.

Rule in Rule out

Fever (-) regular, high-grade fever

(40-41 deg Celsius)

Anorexia (-) febrile paroxysms

Residence is an endemic

for malaria

 

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Influenza :

� A common respiratory infection transmittedvia the respiratory route caused by Influenza

viruses A, B, C, from the group of 

Orthomyxoviruses.

Rule in Rule out

Fever High grade fever

cough (-) Sore throatAnorexia (-) Chills

Melena

 

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Typhoid f ever:

� A clinical syndrome of constitutionalsymptoms caused by Salmonella typhi , a gram

negative bacterium.

Rule in Rule out

Fever intermittent fever

Abdominal pain Febrile episodes lasted

<10 daysAnorexia Melena

(-) Rose spots

 

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DISCUSSION:

 

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DENGUE VIRUS

� - an arbovirus of the Flaviviridae family

� - transmitted by daytime-biting female, gravid

anophelene mosquitoes, more commonly theAedes aegypti species.

� - has 4 serotypes DENV 1, 2, 3, 4

 

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Replication and Transmission of 

De

ngue

 Vi

rus

1.The virus is inoculated into humans with the

mosquito saliva

2.localizes and replicates (local lymph nodesand liver)

3.released and spreads through the blood to

infect (WBC an lymphatic tissues)4.circulates in the blood

 

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1.mosquito ingests blood containing the virus

2.replicates in the mosquito midgut, the ovaries,

nerve tissue and fat body then escapes intothe body cavity, and later infects the salivary

glands.

3.The virus replicates in the salivary glands andwhen the mosquito bites another human, the

cycle continues.

 

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DENGUE HEMORRHAGIC FEVER

� a severe, often fatal, febrile disease

characterized by :

�capillary permeability� abnormalities of hemostasis

�severe cases a protein-losing shock syndrome

(dengue shock syndrome).

 

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EPIDEMIOLOGY

� TheWHO says some 2.5 billion people, two

fifths of the world's population, are now at

risk from dengue and estimates that there

may be 50 million cases of dengue infection

worldwide every year. The disease is now

endemic in more than 100 countries.

 

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RISK FACTORS

Virus strain: DHF can occur in primary

infection with certain genetic strains of virus

Pre-existing anti-dengue antibody, eithercaused by previous infection or to maternal

antibodies passed to infants

Host genetics - whites may be at greater risk,and blacks at lower risk.

 

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Age - in Southeast Asia, children are most

affected, in the Americas, all age- groups are

affected; higher risk in secondary infectionsHigher risk in locations with two or more

serotypes circulating simultaneously at high

levels� (hyperendemic transmission in tropics of 

Asia and America).

 

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Pathogenesis of DHF

Dengue Virus

Liver

Coagul at i on Defec t 

Complement Ac t iv at i on+ Cytok ines

Lymphoid &  pl asmacells

M acr ophages

Bleeding

 

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Pathogenesis of DHF

Coagul at i on

defec t 

Complement Ac t iv at i on

+ Pr operdin

C3bac t iv at i on of 

K alili k rein-k inin

C3a, C5aanaphy l atox in

Injure pl at elet 

Thr omboc ytopeni a Ext r av asat i on Hemoc oncent r at i on

H ypot ensi onBleeding

Int r av ascul ar C l ot 

Shoc k 

Liver injur y 

T issue death

 Acid osis

Increasev ascul ar 

 per meabili ty 

 

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CLINICAL MANIFESTATIONS

� Incubation Period: 1-7 days

 

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Dengue Fever

�Variable and influenced by age of patient

�Infants and young children: undifferentiated

or characterized by:� fever for 15 days,

� pharyngeal inflammation,

� rhinitis, and

� mild cough

 

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�Older children and adults:

� sudden onset of fever (39.4 41.1°C)

� frontal or retro-orbital pain particularly on

pressure

� transient, macular, generalized rash that blanches

under pressure may be seen during the 1st 24 48

hr of fever.� Occasionally, severe back pain precedes the fever

(back-break fever)

 

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� pulse rate may be slow relative to the degree of 

fever

� Myalgia and arthralgia with increasing severity

� nausea and vomiting from 2nd to 6th days of fever

� generalized lymphadenopathy, cutaneous

hyperesthesia or hyperalgesia, taste aberrations,

and pronounced anorexia

 

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� generalized, morbilliform, maculopapular rash

that spares the palms and soles (12 days after

defervescence) and disappears in 15 days;

desquamation may occur.

� body temperature, which has previously

decreased to normal, may become slightly

elevated and demonstrate the characteristic

biphasic temperature pattern.

 

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Dengue Hemorrhagic Fever

�1st phase (mild)

� abrupt onset of fever, malaise, vomiting,

headache, anorexia, and cough

� followed after 25 days by rapid clinical

deterioration and collapse

 

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�2nd phase

� cold, clammy extremities, a warm trunk, flushed

face, diaphoresis, restlessness, irritability, and

mid-epigastric pain

� scattered petechiae on the forehead and

extremities

� easy bruising and bleeding at sites of venipuncture

are common� macular or maculopapular rash may appear

 

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� circumoral and peripheral cyanosis

� Respirations are rapid and often labored.

� pulse is weak, rapid, and thready and the heart

sounds faint.

� The liver may enlarge to 4 6 cm below the costal

margin and is usually firm and somewhat tender.

 

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� Approximately 2030% of cases of dengue

hemorrhagic fever are complicated by shock(dengue shock syndrome).

� <10%: gross ecchymosis or gastrointestinal

bleeding, usually after a period of uncorrectedshock.

� temperature may return to normal before or

during the stage of shock.

� Bradycardia and ventricular extrasystoles are

common during convalescence.

 

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WHO Criteria for Dengue 

Hemorrhagic Fever

� Fever, or recent history of acute fever

� Hemorrhagic manifestations Skin hemorrhages:

y petechiae, purpura, ecchymoses

Gingival bleeding

Nasal bleeding

Gastrointestinal bleeding:

y hematemesis, melena, hematochezia

Hematuria

 

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�Low platelet count (100,000/mm3 or

less)

�Objective evidence of leaky capillaries:Elevated hematocrit (20% or more over

baseline)

Low albuminPleural effusion (by CXR) or other effusions

 

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Classif ication of DHF according to

severity

o Grade 1 Fever accompanied by non specific

constitutional symptoms.

- (+) tourniquet test

o Grade II grade I + spontaneous bleeding (skin

and/or other hemorrhages)

o Grade III circulatory failure manifested by rapid and

weak pulse, narrowing pulse pressure (< 20 mmHg)or hypotension, (+) cold clammy skin, restlessness

� Grade IV profound shock with undetectable blood

pressure and pulse

 

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Danger Signs in Dengue 

Hemorrhagic Fever

�Abdominal pain - intense and sustained

�Persistent vomiting

�Abrupt change from fever to hypothermia,with sweating and prostration

�Change in the mental status of the patient,

going to be restlessness or somnolence.�All of these are signs of impending shock and

should alert clinicians that the patient needs

close observation and fluids. 

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Dengue Shock Syndrome: WHO

Criteria

� Signs and symptoms of DHF plus evidence of 

circulatory failure manifested indirectly by all of 

the following:� Rapid and weak pulse

� Narrow pulse pressure (< 20 mm Hg) OR

hypotension for age

� Cold, clammy skin and altered mental status

� Frank shock is direct evidence of circulatory failure

 

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LABORATORY TESTS

�Clinical laboratory tests

� CBC

�WBC (pancytopenia at 3-4 days of illness, neutropenia

in latter stage)�platelets (<100,000 platelets per mm³),

�haematocrit (20% or more from baseline following IV

fluid)

� Albumin(renal impairment� Liver function tests (hepatomegaly)

� Urinecheck for microscopic hematuria

 

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� Dengue-specific tests

� Virus isolation

� Serology

� Immunoglobulin M enzyme linked immunoassay,

or IgM ELISA (basic test for serologic diagnosis)

� Platelia Dengue (NS1 antigen test): made by Bio-

Rad Laboratories and Pasteur Institute, introducedin 2006, allows rapid detection before antibodies

appear the first day of fever.

 

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TREATMENT

�Timely supportive therapy:

�mainstay of treatment

�to tackle circulatory shock due to

hemoconcentration and bleeding

�Close monitoring of vital signs in the critical

period (up to 2 days after defervescence - the

departure or subsiding of a fever) is critical.

 

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�Oral rehydration therapy:

�to prevent dehydration in moderate to severe

cases

�Supplementation with intravenous fluids may be

necessary if the patient is unable to maintain oral

intake.

 

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�fluids for rapid volume expansion include:

�normal saline

�Ringers lactate or Ringers acetate not to be used in

cases of acidosis�5% glucose solution diluted in 1:2 or 1:1 normal saline

�Plasma, plasma substitutes (dextran 40) or 5% albumin

(50 g/L)

�FFP-

 

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�Platelet transfusion

� if the platelet level drops significantly (below

20,000) or if there is significant bleeding (melena),

<50,000

 

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�Aspirin and non-steroidal anti-inflammatorydrugs should be avoided as these drugs may

worsen the bleeding tendency associated with

some of these infections. Patients may receiveparacetamol, ranitidine, celecoxib

preparations to deal with these symptoms if 

dengue is suspected.�Rest and increase of fluids

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CRITERIA FOR DISCHARGING 

INPATIENTS:

Absence of fever for at least 24h without use

of antipyretics or cryotherapy

Return of appetite

Visible clinical improvement

Good urine output

 

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Stable hematocrit

Passing of at least 2 days after recovery from

shock

No respiratory distress from pleural effusionor ascites

Platelet count of more than 50,000 per mm3

 

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PREVENTION

�There is no tested and approved vaccine for

the dengue flavivirus. There are many ongoing

vaccine development programs. Change the water of water storage containers

every alternate days.

Over turn buckets and containers when not inuse (do not let the rain water or other froms

of water to get stagnant).

 

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Check and remove stagnant water from open

 jars, tires, dump holes, coconut shells andcanvas used for covering goods.

Dispose of unwanted article left in outdoor

areas.Ensure good house keeping. Clean room and

check for any stagnant water daily.

Use screens on doors and windows, use of baygon is also advisable.