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Case Presentation

Case Presentation. Francine Lu. Identifying Data. Gem R. 8/M student Roman Catholic Taytay , Rizal Informant: mother, 80% reliability. Chief Complaint. Fever. History of Present Illness. Fever ( Tmax 39.4), remittent Generalized body weakness Fronto -temporal headache, 7/10

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Case Presentation

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  1. Case Presentation Francine Lu

  2. Identifying Data • Gem R. • 8/M • student • Roman Catholic • Taytay, Rizal • Informant: mother, 80% reliability

  3. Chief Complaint • Fever

  4. History of Present Illness • Fever (Tmax 39.4), remittent • Generalized body weakness • Fronto-temporal headache, 7/10 • Paracetamol, unrecalled dose, provided some relief • No rash, no gum bleeding, no epistaxis 2 days PTA

  5. History of Present Illness • On/off abdominal pain, 5/10, epigastric and periumbilical, crampy, nonradiating • Vomiting of recently ingested food, 2 episodes, non bloody • Still with fever, no signs of bleeding • Consult at ER 1 day PTA Admission

  6. Past Medical History • (+) Asthma (1997) • Last attack: First quarter of 2011

  7. Family History • (+) Asthma – paternal • (+) DM – paternal • (+) HTN – maternal

  8. Birth History • Born full term • NSD • 28 year old G2P2 • Attended by OB • No complications • Birth weight unrecalled

  9. Nutritional History • Breastfed until 2 months • Formula Bonna • Weaning 6 months • No food allergies • Prefers chicken, juice • Usual diet: soup, rice, chicken

  10. Immunization History • BCG • DPT x 3 • Polio x 3 • Measles x 1 • Influenza • No MMR, rotavirus, varicella, Hib, Pneumococcal

  11. Developmental History • Can write fairly well at 6 • Can count to ten at 5 • Can add and subtract at 6 • Dresses self completely at 6 • Backward heel to toe walk at 6 • Language

  12. Personal Social History • Grade 2 student • Likes Math and Sibika • Parents work at a cable company • Father is a technician • Mother is an office employee • Up and down house • Drinking water: purified • Adequate ventilation and lighting • Daily garbage collection

  13. Review of Systems • No weight loss; with good appetite • No pruritus or skin lesions • No eye or ear discharge, no epistaxis, no colds • No bleeding gums, no dysphagia • No cough, dyspnea or hemoptysis • No cyanosis or pallor • No change in bowel movements or jaundice, no hematochezia or melena • No change in bladder habits • No limping, swelling of the extremities

  14. Physical Exam • Conscious, coherent, not in distress • Weight 35.1kg (z=2) • Height 140 cm (z=2) • BMI 17.9 (normal for age) • Vitals • BP 120/80, HR 90, RR 24, T 38.2 • Skin: warm, flushed, no active lesions, no pallor or cyanosis

  15. Physical Exam • Head normocephalic, atraumatic • Eyes: pink palpebral conjunctivae, anicteric sclerae, no discharge • Ears: patent ear canal, intact TM, no discharge • Nose: no alar flaring, midline septum, no nasal discharge, no bleeding • Oropharyngeal cavity: no tonsillopharyngeal congestion, no lesions, no bleeding

  16. Physical Exam • Neck: no CLAD • Chest/Lungs: Equal chest expansion, resonant on all lung fields, no retractions, clear breath sounds • Cardiovascular: Adynamic precordium, apex beat 5thICS left midclavicular line, normal rate, regular rhythm, no murmurs

  17. Physical Exam • Abdomen: flat, normoactive bowel sounds, tympanitic, (+) epigastric tenderness, no palpable masses. Liver edge palpable 1 cm below right subcostal margin. No obliteration of Traube space. No CVA tenderness. • DRE and Genitalia: not assessed • Extremities: full and equal pulses, CRT<2s, no edema, no clubbing, no cyanosis • Musculoskeletal: no gross deformities

  18. Salient Features • 8 year old male • Remittent fever of 2 days duration • Generalized body weakness • Fronto-temporal headache, 7/10 • On/off abdominal pain, 5/10, epigastric and periumbilical, crampy, nonradiating • Vomiting of recently ingested food, 2 episodes, non bloody • Flushed skin, (+) epigastric tenderness

  19. Differentials • Systemic Viral Illness • Dengue Fever • Urinary Tract Infection • Typhoid fever

  20. Work-Up • CBC • Hgb: 137 [115-145] • Hct 0.39 [33-43] • WBC 11.40 [4-12] • Neut 0.60 [54-62] • Lym 0.36 [25-33] • Mono 0.04 [3-7] • Plt 302 [150-400] • Dengue NS-1: Positive

  21. Assessment • Dengue Fever

  22. Course in the Wards

  23. Hospital Day 1 • Day 3 of illness

  24. Hospital Day 2 • Day 4 of illness

  25. Hospital Day 3 • Day 5 of illness, Day 1 afebrile

  26. Hospital Day 4 • Day 6 of illness, Day 2 afebrile

  27. Discussion

  28. Dengue Fever • Dengue is the most rapidly spreading mosquito-borne viral disease in the world • estimated 50 million dengue infections occur annually • approximately 2.5 billion people live in dengue endemic countries

  29. Classification: WHO

  30. Classification: PPS Fever Nonspecific symptoms (+) tourniquet test Grade 1 + Spontaneous bleeding Circulatory failure Profound shock

  31. Transmission • single-stranded RNA virus comprising four distinct serotypes (DEN-1 to -4) • genus Flavivirus, family Flaviviridae • genotypes of DEN-2 and DEN-3 are frequently associated with severe disease • transmitted to humans through the bites of infected Aedesmosquitoes, principally Ae. Aegypti

  32. Transmission • Incubation period 4-10 days • virus enters via the skin while an infected mosquito is taking a bloodmeal • acute phase: virus is present in the blood and its clearance from this compartment generally coincides with defervescence

  33. Endothelial cell dysfunction plasma leakage • Alterations in megakaryocytopoeisis by infection of human hematopoeitic cells and impaired progenitor cell growth  platelet dysfunction

  34. Phases • Febrile Phase • Critical Phase • Recovery Phase

  35. Febrile Phase • Sudden onset of high grade fever • Lasts 2-7 days • Facial flushing, skin erythema, generalized bodyache, myalgia, arthralgia, headache, sore throat, injected pharynx, conjunctival injection, Anorexia, nausea, vomiting • From mild to massive bleeding • Petechia and mucosal membrane bleeding --- massive vaginal bleeding and GI bleeding • Enlarged and tender liver • Earliest abnormality: decreased WBC

  36. Critical Phase • Time of defervescence; Days 3-7 • Increase in capillary permeability paralleling with increasing hematocrit • period of clinically significant plasma leakage usually lasts 24–48 hours. • Progressive leukopenia followed by a rapid decrease in platelet count usually precedes plasma leakage. • No increase in capillary permeability: will improve • Otherwise: may become worse as a result of lost plasma volume

  37. Critical Phase • Plasma leakage: pleural effusion, ascites • degree of increase above the baseline hematocrit often reflects the severity of plasma leakage • If critical volume is lost  Shock • Below normal body temperature • progressive organ impairment, metabolic acidosis and disseminated intravascular coagulation • Severe hemorrhage – increase in WBC • Hepatitis, encephalitis, myocarditis

  38. Critical Phase • If with improvement after defervescence = non-severe dengue • If defervescence does not occur, take CBC to guide the onset of critical phase and plasma leakage • If with deterioration = dengue with warning signs • will probably recover with early intravenous rehydration • Some will deteriorate to severe dengue

  39. Recovery Phase • If patient survives 24-48h critical phase  gradual reabsorption of extravascular compartment fluid in the following 48-72 h • Better, good appetite, no GI symptoms, hemodynamic status stable, diuresis ensues • Rash: “isles of white in the sea of red” • Pruritus, bradycardia, ECG changes • HCT stabilizes or may be lower (dilutional) • WBC rises soon after defervescence; Platelets recover later • Excessive IVF: pleural eff, ascites, pulmo edema, CHF

  40. Severe Dengue • plasma leakage that may lead to shock (dengue shock) and/or fluid accumulation, with or without respiratory distress, and/or • severe bleeding, and/or • severe organ impairment

  41. Severe Dengue • Progression of vascular permeability  worsening hypovolemia  shock • Usually around the time of defervescence, usu day 4 or 5 (d 3-7) • Preceded by warning signs • Initially: tachycardia, peripheral vasoconstriction with reduced skin perfusion -- cold extremities and delayed capillary refill time • Narrowed pulse pressure, as peripheral vascular resistance increases • Decompensation – both pressures disappear abruptly

  42. Diagnosis • Fever of 2-7 days duration • Any 2 of the following: (WHO – 2 or more)

  43. Diagnosis • DF/DHF suspected  do CBC and actual platelet count • Done daily to determine hemoconcentration and thrombocytopenia • PT and PTT not routinely done • NS1 antigen test useful for rapid early diagnosis (Day 1-4) • Other serological tests not routinely done; but best results obtained starting on Day 5 of illness • Dengue IgM and IgG ELISA • Dengue Dot Blot ELISA • Dengue Immunochromatography (ICT) • Dengue Dipstick ELISA

  44. Admission Criteria • Shock • Spontaneous bleeding • Danger signs: inability to drink or feed, vomits everything, convulsions, lethargy, unconsciousness, no urine output for 6-8 hours • Increased vascular permeability: hematocrit, serous effusion, hypoproteinemia • Abdominal pain

  45. Fluids: Outpatient • ORS based on weight

  46. Fluids: Admitted, without Shock • Isotonic solutions (D5LRS, D5NSS, D5 0.9%NaCl) • Holiday Segar Method

  47. Fluids: Admitted, with Shock • Isotonic crystalloid (LRS, NSS, 0.9%NaCl) • Glucose containing solutions should be avoided to prevent osmotic diuresis • Infuse 20ml/kg bolus • If with no improvement, repeat 2-3 times; consider inotropic agent • If stable, gradually decrease IVF rate • Continuous monitoring • Oxygen 2-3L/min

  48. Blood Transfusion • Fresh whole blood/whole blood if with significant bleeding (hematemesis, hematochezia) • If with DIC, blood component therapy (CP, FFP, Plt) • Preventive transfusion has no role in DHF

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