DENGUE Janice Louie

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DENGUEHemorrhagic Fever

Grupo ni Louie

IntroductionPhilippine Hemorrhagic fever was first reported in 1953. In 1958, hemorrhagic fever became a notifiable disease in the country and was later reclassified as Dengue Hemorrhagic fever. Dengue cases usually peaks in the months of July to November and lowest during the month of February to April

Etiologic AgentDengue virus types 1, 2, 3 and 4

Source of infectionImmediate source is a vector mosquito the

, Aedes

Aegypti or the common household mosquito.The infected person

Mode of TransmissionMosquito bite (

Aedes Aegypti)

Incubation PeriodUncertain, Probably 6

days to one

week.Period of CommunicabilityUnknown. Presumed to be on the first week of illness when virus is still present in the blood.

Susceptibility

are are susceptible susceptible

Both sexes Both sexes are equally are equally affected. All person affected. All personPeak age affected Peak age affected 5-9 years of age. 5-9 years of age.

Age groups Age groups predominantly affected predominantly affected are the preschool are the preschool

and school age and school age. .

Occurrence is sporadic throughout the year. Epidemic usually occur during the rainy season as June

November. Peak months are September and October.immunity may be temporary but usually permanent.

Susceptibility is universal. Acquired

Early Symptoms

Malaise

Fever HeadacheVomiting

Muscle and joint aches

Decrease appetite

Acute phase symptoms include the following:

Shock-like stateSweaty (diaphoretic)Cold, clammy extremities

Restlessness followed by:Worsening of earlier Symptoms

Petechiae Ecchymosis Generalized rash

Stages of Clinical Presentation

Febrile ToxicConvalescent

Stages of Clinical Presentation

Febrile

First 4 days (DOH) Abrupt onset of high fever > 39-40 degrees Headache Malaise Nausea and Vomiting Muscle pain

Stages of Clinical Presentation Flushing which may be Febrile accompanied by conjunctival infection and epistaxis may be observed Hepatomegalyis is Hepatomegaly at a later period commonlyfound found commonlyand liver is and liver is usually soft and usually soft and tender tender

Sometimes abdominal pain

Stages of Clinical PresentationThrombocytopenia and Thrombocytopenia and rising hematocrit due to rising hematocrit due to plasma leakage are plasma leakage are usually detectable usually detectable before the onset of before the onset of Toxic stage Toxic stage

Stages of Clinical Presentation 5-7th days An abrupt fall to normal or subnormal levels of Severe abdominal Severe abdominal temperature pain, frequent pain, frequent and varying degrees of bleeding from GI bleeding from GI circulatory disturbance (hematemesis, (hematemesis, will develop melena may occur) may occur) melena (like unstable BP, narrow pulse pressure and shock)

Toxic

Stages of Clinical Presentation

ConvalescentThe rash in dengue is The rash in dengue is called "Herman's rash". called "Herman's rash". It appears on the upper It appears on the upper and lower extremities, and lower extremities, purplish or violaceous red purplish or violaceous red with blanched areas about with blanched areas about 1 cm or less in size. 1 cm or less in size.

Recovery stage Appetite regained BP stable Generalize flushing Hermans sign

Categories of DHFCategory I Category II Category III Category IVCategory II plus Category III plus Circulatory profound failure shock with Cold clammy skin undetectable Weak thready pulse and pulse blood Narrow pulse pressure pressure ( less than 20mm/Hg) Hypotension Restlessness History or Category I plus Presence presence of of one or more Danger fever 2-7 days Signs (especially duration, with a defervescence) (+) tourniquet Restlessness test or presenceChanges in sensorium of skin flushing Cold, clammy skin or petechial Sudden onset of rash abdominal pain Difficulty of breathing Circumoral cyanosis Seizures Spontaneous bleeding (gum bleeding, epistaxis, rashes, petechiae)

Clinical Diagnosis of DHF is base on four major characteristic manifestations Sustained high fever, lasting 2-7 days Hemorrhagic tendencies such as positive torniquet test, petechiae, epistaxis, bleeding GI tract, injection sites Thrombocytopenia ( < 100,000 platelets/mm3 ) Evidence of plasma leakage

Clinical Diagnosis of DHF is base on four major characteristic manifestations Evidence of plasma leakage because of increased vascular permeability Increase in hematocrit greater than 20% above average for age, sex and population Pleural effusion, ascites and hypoproteinemia Decrease in hematocrit following volume replacement treatment greater than 20% of baseline

Pathophysiology

VasculopathyA positive tourniquet test indicating the increased capillary fragility is found in the early febrile stage. It may be a direct effect of dengue virus as it appears in the first few days of illness during the viremic phase.

Tourniquet test (capillary fragility test or Tourniquet test (capillary fragility test or Rumpel Leads test) a presumptive test Rumpel Leads test) a presumptive test which is positive in the presence of more which is positive in the presence of more than 20 petechiae within an inch square, than 20 petechiae within an inch square, after 5 minutes of test after 5 minutes of test

Thrombocytopenia and platelet dysfunction.Patients with DHF usually have platelet counts less than 100 x 109/L. Thrombocytopenia is most prominent during the toxic stage. The mechanisms of thrombocytopenia include decreased platelet production and increased peripheral destruction.

Platelet dysfunctionPD as evidenced by the absence ofadenosine diphosphate (ADP) release, was initially demonstrated in patients with DHF during the convalescent stage. The platelet dysfunction might be the result of exhaustion from platelet activation triggered by immune complexes containing dengue antigen.

Coagulopathy clotting disorder During the acute febrile stage, mild prolongation of the prothrombin time and partial thromboplastin time, as well as reduced fibrinogen levels.

There are four distinct, but closely related, viruses that cause dengue DEN 1, DEN 2, DEN 3 and DEN 4.Recovery from infection by one provides lifelong immunity against that serotype but confers only partial and transient protection against subsequent infection by the other three. There is good evidence that sequential infection increases the risk of more serious disease resulting in DHF.

Medical Treatment Symptomatic and supportive relief Rapid replacement of Fluids (most important treatment) like oresol and IV Start IVF using D5LRS or D5 0.9NaCl or plain LRS Give fresh whole blood at 1-ml/KBW if there is significant blood loss or if hematocrit continues to fall despite fluid resuscitation

Medical Treatment Give fresh whole blood at 1-ml/KBW if here is significant blood loss or if hematocrit continues to fall despite fluid resuscitation Give platelets when platelet count is below 150,000/uL or if there is significant blood loss and platelet count is below 150,000/uL, or there is continuous bleeding and hematocrit remains normal.

Outlook (Prognosis) With early and aggressive care, most patients recover from dengue hemorrhagic fever. However, half of untreated patients who go into shock do not survive

Comprehensive Health History Patient X is 2 years and 9 months old a male toddler born and raised from South Cotabato Informant: Patients mother Reliability: 100% Patient: Patient X Birthday: November 10, 2005 Nationality : Filipino Address: 271B, 61D, PA. South Cotabato Type of Admission: Direct from ER Attending Physician: Dr. X Final Diagnosis: Dengue Hemorrhagic Fever II Ward: Pediatric Ward Hx: This is a case of a 3 year-old male with DHF II Chief complaint: Fever HPI: 10 hours PTA - (+) high grade fever, vomiting for several hours Patient History Patient X is a toddler, admitted into the hospital around 5:00 am carried by his mother. He is born healthy, under normal spontaneous vaginal delivery without any body-marks or observable congenital birth defects. He has completed his immunization program for the following vaccines: BCG, DPT, OPV, MEASLES and HEPA-B. Patient X being the youngest of three 3 siblings, stays with her mother most of time at home. This is his first time to contact a serious illness since his birth. Most of the time he frequently catch common colds and slight to moderate fever but not of a high grade fever. The night prior to his admission to the hospital, patient X is feverish and it worsens in the wee hours of the morning. Patient is irritable, crying and has vomited for about three times.

Physical AssessmentCATEGORY General Appearance Vital Signs FINDINGS The patient looks weak and with eyebags. Temperature: 40.5 Respiration: 30 cpm Pulse Rate: 110 Blood Pressure: 90/40 Upon inspection, the patient was noted to have flushed skin color The patients natural hair color is black. Soft and shiny. Upon inspection the skull is symmetrically aligned. No signs of lesions. Eyes and eyebrows are symmetrically aligned with equal distribution of hair on both eyebrows. PERRLA The color of both ears is the same with the facial skin and is symmetrically aligned. No ear discharge is noted. The external nose is symmetric and straight same color as with the facial skin. There is no nasal flaring. No obstruction in both nasal cavities Appears to be a little bit dry but not bluish or cyanotic. No lesions, cracks or warts are present The patient can move his head freely, no nodules palpated in the cervical area Normal respiration, symmetrical chest expansio