DENGUE

Hemorrhagic 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

Etiologic Agent
Dengue virus types 1, 2, 3 and 4

Source of infection
Immediate source is a vector mosquito the

, Aedes

Aegypti or the common household mosquito.

The infected person

Mode of Transmission
Mosquito bite (

Aedes Aegypti)

Incubation Period
Uncertain, Probably 6

days to one

week.
Period of Communicability
Unknown. 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 person
Peak 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 Headache
Vomiting

Muscle and joint aches

Decrease appetite

Acute phase symptoms include the following:

Shock-like state
Sweaty (diaphoretic)
Cold, clammy extremities

Restlessness followed by:

Worsening of earlier Symptoms

Petechiae Ecchymosis Generalized rash

Stages of Clinical Presentation

Febrile Toxic
Convalescent

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 commonly
and liver is and liver is usually soft and usually soft and tender tender

Sometimes abdominal pain

Stages of Clinical Presentation

Thrombocytopenia 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

Convalescent
The 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 DHF
Category I Category II Category III Category IV
Category 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

Vasculopathy
A 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 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: 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 Assessment
CATEGORY 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 expansion, clear breath sounds, negative retraction. Normal cardiac rate, symmetrical peripheral pulse noted. Normal bowel sound. Soft non tender abdomen Motor @ 4/5 upper and lower extremities Both appear to be symmetric Conscious and oriented

Skin Hair Head/skull Eyes

Ears Nose

Lips Neck Thorax/Lung Heart/Cardiovascular Abdomen Muscoloskeletal Mental Status

Summary of Lab Results

Laboratory Exams Hematology Resut Hemoglobin Hematocrit RBC WBC Segmenters Lymphocytes Platelet 13.6 0.41 4.7 4.7 0.80 0.20 138 14.3 13.0 - 18.0 Cms% 0.43 0.40 - 0.54 Vol% 5 8.2 0.36 0.64 190 4.5 - 6.5x10 L 4.5 - 5.2x10 L 0.50 - 0.70 0.20 - 0.40 150 - 350 Day 1 Day 3 Day 4 Normal Values

Summary of Lab Results

Laboratory Exams Urinalysis Physical Appearance Colory Transparency Reaction pH Specific Gravity Sugar Protein Microscopic Pus Cell RBC Epithelial Cells Protein Crystal Amorphous urates Amorphous Phosphate Positive Blank 0-3 0-1 Occasional Negative Absent Absent 0-5 Negative Negative Yellow Slightly Hazy 6.0 1.03 Yellow Clear 4.6 - 8.0 1.010 - 1.035 Absent Absent Day 1 Day 3 Day 4 Normal Values

Summary of Lab Results

Laboratory Exams Fecalysis Color Consistency Typhidot IgG IgM Positive Negative Yellow Soft Day 1 Day 3 Day 4 Normal Values

Course in the ward

Day 1

In 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, patients 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 4

In 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 patients 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 Xs 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 clients 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 Hermans sign. In day 6, the patient is afebrile and still positive for Hermans 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
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From : Grupo ni Louie