Case presentationDengue Shock Syndrome

By: AntonEmmaYokita

Pembimbing: Dr. dr. Yulia Iriani, SpA

PAEDIATRIC DEPARTEMENTRSUP DR MOHAMMAD HOESIN PALEMBANG MEDICAL FACULTY UNIVERSITY OF SRIWIJAYA

IDENTIFICATION

Annisa binti Hamid4 years and 5 monthsJl. Mataram No.39 Kertapati PalembangIndonesiaIslam04 November 2012, 10.30 WIB IKA B/High Care Unit

Anamnesis (Alloanamnesis with patients mother and father, 04 November 2012)Chief ComplaintCool extremities 1 day before admissionOther ComplaintHigh fever which suddenly spiked up since 6 days before admission.

History of Present Illness+ 6 days before admission High fever (+)Shivering (-)Convulsions (-)Cough/common cold (-) Headache (+)Muscle ache (+)Retro orbital pain (+)Joint pain (+)Abdominal pain (-) decreased appetite (+) excessive sweating at night (-)drastic decreased BW (-) Nausea(-), vomiting(-), Black color stool (-), petechial rash (-), epistaxis (-), gum bleeding (-)Went to local government clinic, diagnosed as flu/common cold and given 2 type of medication PCT syrup and another white color syrupHowever, there was no respons to medication

Cont+ 5 days before admission High fever (+), shivering (-), convulsions (-), cough and common cold (-), headache (+), retro orbital pain (+), joint pain (+)Abdominal pain (-), decreased appetite (+), excessive sweating at night (-), drastic decreased BW (-) Nausea(-), vomiting(-), Black color stool (-), petechial rash (-), epistaxis (-), gum bleeding (-)Taken to midwife given 3 types of medicationsYet, no further respons to the medication

+ 5 days before admission fever weak cool extremitiesepistaxis (-), gum bleeding (-) and black color stool(+)- Taken to peadiatrician, diagnosed as DHF, referred to RS Bari, admitted for 1 day and given 7 kolf+ 1 hour before admission WeakCool extremities ( occurred again) referred to RSMHAdmitted in High care unit (HCU) RSMH Palembang

Medical HistoryNo other diseases.No recent visit to endemic places.

Family HistoryNo family members suffers from any diseasesBirth Details G2P1A0, aterm, spontaneously delivered, by midwife, BW after birth = 3,2kg, No fever and PROM (-)

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Immunization StatusBCG (+), Scar (-)DPT I (+), DPT II (+), DPT III (+)Polio I, II, III, IV (+)Hepatitis B I, II, III (+)Varicella zoster (+) Complete immunization statusDevelopmental DataRevert : 3 months Lying down flat : 4 monthsCrawling : 6 months Standing : 10 monthsWalking : 11 monthsNormal physical development

Feeding HistoryBreastfeeding: (-)Formula milk: 0-2 yearsMilk porridge: 3 months-2 yearsRice porridge : 8 months 15 monthsRice : 15 months -now

Family History Mr.Hamid, 27yrs, SMA Mrs.Hamid,25 yrs, Entrepreneur Housewife

patient Social Economic StatusWell to do

Physical Examination(04 November 2012)

compos mentisBP: 80/P mmHgPulse : filiformisRR: 32 x/menitTemperature : 36,2CBody weight : 14 kg Body Height: 98 cm Nutritional Status : BW/U = 82,3%;BH/U = 94,2% ;BW/BH = 93,93 %Good nutritional status

Specific ExaminationSkin : Ptechiae (-) Head : normocephaly, flushing (-)Eye : Conjunctiva -/-, icteric sclera -/- edema palpebra (+) Ears: Secretion (-)Nose: Nasal flare (-), secretion (-), epistaxis (-) Larynx: Hyperemic pharynx(-), tonsil T1-T1 Teeth and mouth: Rhagaden (-), gum bleeding(-)Neck: Elevated JVP(-), lymph nodes enlargement(-)

Thorax Lungs : Symmetric, retraction (-), sonor, vesicular (+) normal, ronchi(-), wheezing (-) Cor : HR= 82 x/min, regular, murmur (-), gallop (-) AbdomenDistended, liver and lien not palpable, timpanic, shifting dullness (+), bowel sound (+)Extremities : Cool (+), edema(-), cyanosis (-) CRT < 2 sec

Neurologic StatusMotoric and sensoric functionNo abnormalitiesNn Craniales No abnormalitiesMeningeal signs Negative

Routine Blood Check(04-11-12)RS BariHb: 10,7 g/dlHt: 33 vol%Thrombocyte : 22.000/mm3Routine Blood Check(04-11-12)RSMHHb : 12,1 g/dlHt : 36 vol%Trombocyte : 21.000/mm3

Laboratory Findings

Additional ExaminationNS-1IgM and IgG anti dengue

ResumeGirl, 4 years 8 months old, admitted on 4th November 2012 at 10.20 A.M. with chief complaint of cold extremities, high fever since 6 days and black colored stool since 1 day. Since 6 days, patient had a high fever, headache, retro orbital pain, joint pain, and decreased appetite. Thus, patient was brought to a local government clinic, and diagnosed with a flu/common cold and given 2 types of medication : PCT syrup and another white color syrup. But yet, the temperature didnt go down.Since 5 days, patient still has a fever, headache, retro orbital pain, joint pain, and decreased appetite. She was taken to midwife and given 3 types of medication. No respond to the medication.Since 1 day, patient seems to be weak, the extremities have become cold and her stool was black in color and she was brought to a pediatrician. It was diagnosed as DHF, she was referred to RS Bari, admitted there for 1 day and given 7 kolf.

One hour before admission, patients extremities became cold again, and patient was referred to RSMH.Physical examination: 80/P mmHg,filiformis, RR32x/menit, Temperature 36,2C, shifting dullness (+), cool extremities (+)Laboratory findings:(04-11-12)RS BariHb : 10,7 g/dlHt : 33 vol%Thrombocyte : 22.000/mm3(04-11-12)RSMHHb : 12,1 g/dlHt : 36 vol%Thrombocyte : 21.000/mm3

Differential DiagnosisDengue Shock SyndromeTyphoid FeverMalariaIdiopatic Thrombocytopenia Purpura

Working DiagnosisDengue Shock Syndrome

BP : 90/60 mmHg, Pulse: 72 times/min. O2 2 L/minute

Rapid plasma replacement RL 140 cc and koloid 140 cc in 30 minutes.

30 minutesAdmitted in High care unit (HCU) RSMH PalembangRL140 cc/hour Shock resolved IVFD RL 98 cc/Hour

Treatment (Emergency Room)

(High Care Unit)Bed restIVFD RL 7 cc/kgBW/Hour = 98 cc/hour, gtt 24x/minutes NGT Check for bleeding Check Hb, Ht, Platelet every 8 HoursCheck diuresis every hourObserve vital sign every 15 minutes and signs of fever and bleeding

Treatment (cont)

PrognosisQuo ad vitam: bonamQuo ad functionam : bonam

Follow Up (4-11-2012)BSS : 103 mg/dl

TimeBP (mmHg)HR (x/min)RR(x/min)Temp.(oC)Water Balance 15.00100/601273236,615.00-16.00I: 140 cc O : 24 cc IWL : 16,6 B: + 99,4 D: 1,71RL7cc/kgBW/Hour = 98 cc/Hour 24 gtt/min (macro)15.15100/601143436,815.30101/601113437,115.45101/601163637,016.00101/601163436,816.00-17.00I: 98 cc O : 20 cc IWL : 16,6 B: + 61,4 D: 1,4RL7cc/kgBW/Hour = 98 cc/Hour 24 gtt/min (macro)16.15120/601183436,716.30120/601163036,816.45120/601203037,017.00120/601113236,817.00-18.00I : 98 cc O : 34 cc IWL : 16,6 B: + 47,4 D: 2,4RL 7cc/kgBW/Hour = 98 cc/Hour 24 gtt/min (macro)

18.00-19.00I : 98 ccO : 29 cc IWL : 16,6 B: + 52,4 D: 2,0RL 7cc/kgBW/Hour = 98 cc/Hour 24 gtt/min (macro)18.00120/601103636,219.00120/601103636,2

Working diagnosis : Dengue Shock SyndromeTreatment : Bedrest IVFD RL 7cc/kgBW/Hour Routine blood check / 12 hoursDiuresis / 2 hours

Morning (Bari hosp)Evening (RSMH)Hb: 10,7 g/dlHb: 12,1 g/dl

Ht: 33 vol%Ht: 36 vol%

Thrombocyte : 22.000/mm3Thrombocyte: 21.000/mm3

Follow Up (5th-11-2012)

Problem : Abdominal PainVital Sign Sens: Compos mentisBP: 80/50 mmHgPulse: 94 x/minuteRR: 32 x/minuteTemp: 36, 8oC

Working diagnose :Dengue Shock Syndrome

TreatmentBedrestIVFD RL 4cc/kgBW/hour 14 gtt/microRanitidine injection 2 x 14 mg (IV)Water balance and diuresis every 6 hours Observe vital signs every 3 hoursObserve the Temperature every 6 hoursRoutine blood check every 12 hoursGastric lavage

Water Balance23.00-01.00I: 140 ccO : 50 ccIWL : 33,2B: + 56,8D: 1,7 cc/kgBW/hourRL 5cc/kgBW/hour = 98 cc/hour01.00-03.00I: 140 ccO : 100 ccIWL : 33,2B: + 6,8D: 3,5 cc/kgBW/hourRL 5 cc/kgBW/hour = 98 cc/hour 03.00-05.00I : 140 ccO : 70 ccIWL : 33,2B: + 36,8D: 2,5 cc/kgBW/hourRL 5cc/kgBW/Hour

Morning 06.00Evening 18.00 Hb: 10, 7 g/dl Hb: 11,6 g/dl Ht: 32 vol%Ht: 34 vol%Thrombocyte : 24.000/mm3Trombocyte : 53.000/mm3

Follow Up (6th-11-2012)Problem : Blood in NGT (+)Vital SignsSens: Compos MentisBP: 80/60 mmHgPulse: 96 x/minuteRR: 32 x/minuteTemp: 36, 4oC

Working diagnosis: Dengue Shock Syndrome, 48 hours after the shock resolved.TreatmentBedrest IVFD RL 4cc/kgBW/hour 24 gtt/min (makro)Ranitidine injection 2 x 14 mg (IV)Paracetamol 140mg (If needed)Pro IgG dan IgM

Patient was moved to the normal ward.

Water Balance06.00-12.00I : 650 ccO : 600 ccIWL : 33,2B: + 16,8D: 7,1 cc/kgBW/hour12.00-18.00I : 66 ccO : 500 ccIWL : 75B: - 500D: 2,98 cc/kgBW/hour18.00-24.00I : 250 ccO : 450 ccIWL : 75B: + 125D: 1,49 cc/kgBW/hour24.00-06.00I : 50 ccO : 250 ccIWL : 75B: -275D: 2,98 cc/kgBW/hour

Morning 06.00Evening 18.00Hb: 11,5 g/dlHb: 11,7 g/dl Ht: 42 vol%Ht: 35 vol%Thrombocyte: 93,000/mm3Thrombocyte: 142,000/ mm3

Case Analysis

AnamnesisMain prob: Cool extremities 1 day before admissionAdd. Prob: High fever which suddenly spiked up 6 days before admission.

Common causes of fever in children : Dengue hemorrhagic FeverTyphoid FeverMalariaUrinary Tract Infection (UTI)Acute tonsilopharyngitisAcute otitis media

Typhoid FeverFever more than 7 daysRemittent type of feverPhysical exam :typhoid tongue and rhagadenAnorexia, usually followed by diarrhea or constipation.

Fever caused by acute tonsilopharyngitis and acute otitis mediaPain during ingestion (-), tonsil T1-T1 non hyperemic , pharynx non hyperemicThere was no history of otalgia or otorrhea

MalariaPeriodic type of feverUsually accompanied with shivering and sweatingType of fever is associated with the specific plasmodium. Plasmodium vivax/ ovale/ Plasmodium malariae/Plasmodium falciparum

Fever caused by UTIIn this patient there were no complaints of dysuria, back pain, urinary urgency, hematuria, or foul smelling urine.

Dengue hemorrhagic fever(WHO 2009)

Acute fever usually occurs for 2 7 days.One sign or more of the following manifestations : tourniquet test (+), ecchymosis, purpura, petecchie, mucosal bleeding, hematemesis, melena, gastrointestinal tract symptoms.Thrombocytopenia ( 100.000 cells/ mm3)Evidence of plasma leakage, by following:Increase of Ht 20% from normal,Decrease of Ht 20% after fluid resuscitation,pleural effusion, ascites, or hypoproteinemia.

Meanwhile in this patientAll of the WHO criteria are fullfilled

1. The patient had an acute and intermittent type of fever, for 5 days, and she was in plasma leakage phase, by the time she got to the emergency department, causing her to relapse into shock (hands and feet were cold)

Besides that, she also had other sign of DHF : myalgia, athralgia, retro-orbital pain, headache, anorexia, and stomach pain

2. The patient had spontaneous bleeding: melena and blood in NGT (+)3. The routine blood examination showed platelet count was : 22.000/mm3 (thrombocytopenia).4. The patient had ascites (shifting dullness (+).

What about the patients DHF grade?

By the time she got to Emergency :General app : looked severely illSens : somnolenceBP : 80/palpationPulse : filiform, weakRR : 40x/minuteTemp : 38,6CCold and pale extremities

Grade III : Pulse is fast and weak, BP < 20 mm Hg and cold extremities

Guideline in treating grade III DHF

Rudini1. Pathophysiology of ascites (shifting dullness)?2. Calculating formula for 7 kolf in BARI hosp?3. Changing thrombocyte in two lab results (BARI hosp vs RSMH) ?4. Hypocalcemia and hyponatremia in this patient? How to manage this condition?

YamaIf there is fluid overload in shock patient (esp. in dengue shck synd), what should we do?Re-adjusting the fluid resusscitationDiuretic is not recommended

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