Download ppt - DENGUE Janice Louie

DENGUEDENGUEHemorrhagic FeverHemorrhagic Fever

Grupo ni Louie

Introduction

Philippine 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

Source of infection

Immediate source is a vector mosquito,the Aedes Aegypti or the common household mosquito.

The infected person

Etiologic AgentDengue virus types 1, 2, 3 and 4

Mode of Transmission

Mosquito bite (Aedes Aegypti)

Incubation Period

Uncertain, 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.

SusceptibilityBoth sexes are equally

affected.

Both sexes are equally

affected. Peak age affected 5-9 years of age.

Peak age affected 5-9 years of age.

All person are

susceptible

All person are

susceptible

Age groups predominantly affected

are the preschool and school age.

Age groups predominantly affected

are the preschool 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.

Susceptibility is universal. Acquired

immunity may be temporary but usually permanent.

Early Symptoms

FeverFever HeadacheHeadache

Muscle and joint achesMuscle and joint aches

MalaiseMalaiseDecrease appetiteDecrease appetite

VomitingVomiting

Restlessness followed by:Worsening of earlier

Symptoms

Petechiae Ecchymosis

Generalized rash

Acute phase symptoms include the following:

Shock-like state Sweaty (diaphoretic)

Cold, clammy extremities

Stages of Clinical Presentation

ToxicFebrile

Convalescent


• First 4 days (DOH)

• Abrupt onset of high fever > 39-40 degrees

• Headache

• Malaise

• Nausea and Vomiting

• Muscle pain

Febrile


• Flushing which may be accompanied by conjunctival infection and epistaxis may be observed at a later period

• Sometimes abdominal pain

Febrile

Hepatomegaly is commonly found and liver is usually soft and tender

Hepatomegaly is commonly found and liver is usually soft and tender


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

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


• 5-7th days• An abrupt fall to normal or

subnormal levels of temperature

• and varying degrees of circulatory disturbance will develop – (like unstable BP, narrow

pulse pressure and shock)

ToxicSevere abdominal pain, frequent bleeding from GI (hematemesis, melena may occur)

Severe abdominal pain, frequent bleeding from GI (hematemesis, melena may occur)


• Recovery stage

• Appetite regained

• BP stable

• Generalize flushing

• “Herman’s sign”

Convalescent

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

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

Category I

Category II Category III Category IV

History or presence of fever 2-7 days duration, with a (+) tourniquet test or presence of skin flushing or petechial rash

Category I plus Presence of one or more Danger Signs (especially defervescence)

RestlessnessChanges in sensoriumCold, clammy skinSudden onset of

abdominal painDifficulty of breathingCircumoral cyanosisSeizuresSpontaneous bleeding

(gum bleeding, epistaxis, rashes, petechiae)

Category II plus Circulatory failure

Cold clammy skinWeak thready

pulseNarrow pulse

pressure ( less than 20mm/Hg)

HypotensionRestlessness

Category III plus profound shock with undetectable pulse and blood pressure

Categories of DHF

• 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

Clinical Diagnosis of DHF is base on four major characteristic manifestations

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

Tourniquet test (capillary fragility test or Rumpel Leads test) a presumptive test which is positive in the presence of more than 20 petechiae within an inch square, 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 dysfunction PD as evidenced by the absence of adenosine 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: Patient’s 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 FINDINGS

General Appearance The patient looks weak and with eyebags.

Vital Signs Temperature: 40.5Respiration: 30 cpmPulse Rate: 110Blood Pressure: 90/40

Skin Upon inspection, the patient was noted to have flushed skin color

Hair The patient’s natural hair color is black. Soft and shiny.

Head/skull Upon inspection the skull is symmetrically aligned. No signs of lesions.

Eyes Eyes and eyebrows are symmetrically aligned with equal distribution of hair on both eyebrows.

PERRLA

Ears The color of both ears is the same with the facial skin and is symmetrically aligned. No ear discharge is noted.

Nose 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

Lips Appears to be a little bit dry but not bluish or cyanotic. No lesions, cracks or warts are present

Neck The patient can move his head freely, no nodules palpated in the cervical area

Thorax/Lung Normal respiration, symmetrical chest expansion, clear breath sounds, negative retraction.

Heart/Cardiovascular Normal cardiac rate, symmetrical peripheral pulse noted.

Abdomen Normal bowel sound. Soft non tender abdomen

Muscoloskeletal Motor @ 4/5 upper and lower extremitiesBoth appear to be symmetric

Mental Status Conscious and oriented

Laboratory Exams Day 1 Day 3 Day 4 Normal Values

Hematology Resut

Hemoglobin 13.6 14.313.0 - 18.0 Cms

%

Hematocrit 0.41 0.43 0.40 - 0.54 Vol%

RBC 4.7 5 4.5 - 6.5x10 L

WBC 4.7 8.2 4.5 - 5.2x10 L

Segmenters 0.80 0.36 0.50 - 0.70

Lymphocytes 0.20 0.64 0.20 - 0.40

Platelet 138 190 150 - 350

Summary of Lab Results

Summary of Lab ResultsLaboratory Exams Day 1 Day 3 Day 4 Normal Values

Urinalysis

Physical Appearance

Colory Yellow Yellow

TransparencySlightly Hazy Clear

Reaction pH 6.0 4.6 - 8.0

Specific Gravity 1.03 1.010 - 1.035

Sugar Negative Absent

Protein Negative Absent

Microscopic

Pus Cell 0-3 Absent

RBC 0-1 0 - 5

Epithelial Cells Occasional

Protein Negative Absent

Crystal

Amorphous urates Positive

Amorphous Phosphate Blank

Summary of Lab Results

Laboratory Exams Day 1 Day 3 Day 4Normal

Values

Fecalysis

Color Yellow

Consistency Soft

Typhidot

IgG Positive

IgM Negative

Course in the ward Day 1In day 1, a 3-year old male patient carried by his mother was admitted with a chief complaint of fever. Ten hours prior to consultation, the patient had a high grade fever and vomiting for several hours according to the mother. The patient had a high grade fever of 40.5 0C and BP: 90/40. Diet as tolerated was ordered. Upon assessment the patient is positive for tonsillopharyngitis. . Anti-biotics was also part of his medication to treat his tonsilopharyngitis. Ampicillin testing was done and had negative result. At 1000H, patient had a febrile seizure with temperature 41.80C, Paracetamol was given. Stool examination was requested and the fecalysis result was normal, the stool was soft, yellow colored stool. At 0100H, the patient experienced chills with temperature of 38.80C. Paracetamol was given, patient’s temperature went down to 370C.

Course in the ward Day 2 & 3

In day 2, the patient is slightly febrile with temperature of 37.60C. The mother was instructed to continue TSB and increase fluid intake.

In day 3, the patient is still febrile, Paracetamol via IV was given. Doctor ordered for typhidot. The typhidot result were the following: IgG positive and IgM negative. The patient is negative on typhoid fever.

Course in the ward Day 4In day 4, a significant drop in his temperature was noted, as low as 36.8 oC which is a sign that the patient is entering into the toxic stage of Dengue Fever. This state of defervescence, is a period where the number of patient’s platelet is at its lowest. It is at this time where his attending physician ordered another Laboratory request for CBC and PC to check if Patient X’s platelet count is below the normal range of 150,000 to 350,000 /L, which is referred to as thrombocytopenia. Hemoglobin, hematocrit, RBC WBC and Platelet count are within normal limits. Segmenters are slightly decrease with the value of 0.36 which is below the normal value of 0.50-0.70. After the significant drop of the client’s temperature, Patient X temperature were elevated again for eight hours, a normal phenomenon for a DHF patient before entering into the convalescent stage. The patient had general rashes with itchiness.

Course in the ward Day 5 & 6

In day 5, the patient is afebrile and positive for Herman’s sign.

In day 6, the patient is afebrile and still positive for Herman’s sign. Additional medication was ordered Ascorbic acid with dosage of 100mg/5mL to be taken 1 tsp everyday. Diagnosis of Dengue Hemorrhagic Fever II was resolved. The patient was discharged.

Drug Study

Please refer to hardcopy provided

NCP

Please refer to hardcopy provided

From : Grupo ni Louie