dengue case1..final
TRANSCRIPT
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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.