Dhf Case Presentation Dyta

7/23/2019 Dhf Case Presentation Dyta

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Dengue Hemorrhagic Fever grade Iwith

Right Pleural Efusion and AscitesSupervised by dr! "linar #arpaung$ Sp!A

%reated by Amiradyta #aharti&a '()*+(*(((),- Departemen of Pediatrics

Clerkship of Clinical Pediatrics Hospital Bhayangkara Tk. I Raden SaidSukanto Facult of edicine !ni"ersit of Pelita Hara an



IDE/0I01 2F 0HE PA0IE/0

-ame R+

Age 3 years 4 months

5ender #ale

Address 6l! Alsa7ah 5g! H! #u8tar R0(9:(; /o! *$ %ilang8ap

/ationality

Indonesian

Religion #oslem

Education <



IDE/0I01 2F 0HE PA0IE/0=SPARE/0S

Father other

/ame #r! > #rs! E

Age 3+ years old ;, years old

Address 6l! Alsa7ah 5g! H!

#u8tar R0 (9:(; /o! *$%ilang8ap

6l! Alsa7ah 5g! H!

#u8tar R0 (9:(; /o! *$%ilang8ap

/ationality

Indonesian Indonesian

Religion #oslem #oslem

Education Senior High School 6unior High School2ccupation

Private Employee Housewi?e



HIS02R1 0A@I/5

Anamnesis was done with alloanamnesismethod with the patient=s mother on thedate o? admission$ 6une +4th +(*3!

%hie? complaint Fever since 3 days be?oreadmission to the hospital

Additional complaint body ?eels sore$ pain in

the stomach



HIS02R1 2F PRESE/0 I/ESS

0he patient had ?ever since 3 days be?ore admission! 0he ?ever was sudden and instantly went to the hightemperature$ but it was never measured! 0he ?ever wascontinuous throughout the day! 0he patient was alsoo?ten shivering! History o? sei&ure was denied!

Since the onset o? illness$ the patient also complainedabout sore all over his body$ and also he ?elt pain in theupper<middle area o? the abdomen! 0he pain was sharp$continuous$ and not migrating to the other part o? the

body! He ?elt nausea but there isn=t any vomiting! 0hepatient=s appetite had decreased since the onset o?illness



0he patient had no complain about urination! 0hepatient hadn=t de?ecated since the onset o? the illness!History o? nosebleeds$ gum bleeding$ red spots on thes8ins was denied!

; days be?ore admission the patient went to the

physician in the clinic! 0he patient had been givenparacetamol and some antibiotics$ but there was nosigni7cant improvement regard the patient=s symptoms!

0he ?ever only relieved ?or several hours when the

patient too8 paracetamol$ and the body temperaturewould rise again!



+ days be?ore admission the mother gave ibupro?en tothe patient and the body temperature was declined! 0hepatient had gained his appetite$ and the patient was

able to do his activities again! At night the ?everreturned suddenly and the patient too8 some ibupro?en!Several hours be?ore admission the body temperaturewas declined in the morning and the patient went to thenearest Pus8esmas to get his blood tested!



HIS02R1 2F PAS0 I/ESSES

Pharingitis/ Tonsilitis +

Bronchiolitis -

Pneumonia -

Morbili/Measles -

Pertusis -

Varicella -

Diphtheria -

Malaria -

Polio -

Enteritis -

Bacilarry Dysentery -

Dysentery Amoeba -

Typhoid -

Worm -

urgery -

Brain !oncussion -

"racture -

Drug #eaction -

Dengue "e$er/Dengue

%emorrhagic "e$er

-

%ospitali&ed -



#20HER=S PRE5/A/%1 HIS02R1

• Antenatal %are #other chec8ups her pregnancyto the health center 'midwi?e:obstetrician- everymonth! /o problem during pregnancy and the?etus in the womb was healthy!

• Disease during pregnancy no history o? problemsand diseases during pregnancy!

• Drugs ta8en #others get vitamins everyantenatal care!



>IR0H HIS02R1

• abor Pasar Rebo Hospital

• >irth attendants 2bstetrician

• #ode o? delivery %aesarean delivery

• 5estation ;) wee8s

• Fetal membrane %lear

• In?ant state Healthy

• >irth weight 3 8g

• >ody length 39 cm

• According to the mother$ the baby started to cry andthe babyBs s8in is red! /o congenital de?ects!



P2S0 /A0A HIS02R1

• 0he baby and the mother was eCaminedby the midwi?e

• 0he health state o? the in?ant Healthy



HIS02R1 2F DEE2P#E/0

• First dentition ) months

• Psychomotor development

– Smile + months

–Slant 3 months

– Prone 3 months

– Sitting ) months

– %rawling 9 months

– Standing months

– al8ing *( months

• %onclusion good motor developmental status



HIS02R1 2F EA0I/5

• >reast mil8 ?rom birth until + years old!

• Formula mil8 ?rom + years old until now$but rarelyG only * glass each time$ +<;

times a wee8!• Fruits and vegetables apple$ banana$

spinach

•

Solid ?ood rice$ chic8en$ 7sh$ meat$ andsome other vegetables



I##"/IA0I2/ HIS02R1

'mmuni&ation "re(uency Time

B!) 1 times 1 month

%epatitis B 3 times 0, 1, 6 month

DPT 4 times 2, 4, 6, 18 month

Polio 4 times 2, 4, 6, 18 monthMM# 1 times 15 months



FA#I1 HIS02R1

• Family data

'n*ormation "ather Mother

umber o* marriage 1 1

Age at marriage 33 years old 27 years old

tate o* health Healthy Healthy



• #ode o? reproduction

0he patient is the second child o? twosiblingsumber o* children Age )ender

, 8 years old Female

4 years 5 months Male

Father 0he patient=s ?ather is 3+ years old! 0he patient=s

?ather is healthy and has no history o? the disease! /ohistory o? drug or ?ood allergies!#other 0he patient=s mother is ;, years old! 0hepatient=s mother is healthy and has no history o? thedisease! /o history o? drug or ?ood allergies!



HIS02R1 2F DISEASE I/ 20HER FA#I1#E#>ERS:AR2"/D 0HE H2"SE

Family members 0he patient=s older sibling has ust recovered ?rom ?ever illness J * wee8 be?orethe patient admitted to the hospital!

Around the house ?or the past * month therewere + children whose admitted to the hospitalbecause o? dengue hemorrhagic ?ever!



PH1SI%A EKA#I/A0I2/ '6une +4th$ +(*3-

enerali/ed status5eneral appearance moderatelyillAwareness compos mentis

0ital signs

5%S E3:#,:4Heart rate ***C:minRespiratory rate ;)C:min>lood pressure *((:)(mmHg

0emperature ;9$+(

%'aCilla-AnthropometricDataeight *3 8gHeight *(( cm



/utritionalStatus

• /utritional Status based/%HS '/ational %enter ?orHealth Statistics- year +(((

• Interpretation based onLokarya AntropometriDepkes 1974 dan Puslitbang

Gizi 1978

• FA 'eight ?or Age- *3:*)C *((L M 9+$;L

• HFA 'Height ?or Age-*((:*(4 C *((L M 4$+;L

• FH 'eight ?or Height-*3:*, C *((L M 9)$4L

• Conclusion: nutritionstatus of the patient isgood.



S1S0E#I% PH1SI%AEKA#I/A0I2/

S8in

%olor 0ones$ not pale$ nocyanosis$ no petechiae

0urgor normal

Head Shape and si&e /ormocephali$

no de?ormityarge ?ontanel %losedHair blac8$ not easy to repeal$eNuitable distribution

Eyes

Pupil Iso8orPupil reOeC :Eyes movement node?ormity%onungtiva Anemis <:<S8lera Icterus <:<Sun8en eyelids <:<

Ears

%erumen < 0ympanic membrane Intact :

/ose Shape /ormal

Septum Deviation '<-Secrete /o secrete#ucosa Hyperemia <:<

#outh and throatips pale '<-$ cyanosis '<-$

dry '<- 0eeth caries '<- 0ongue clear$ tremor '<-PharynC hyperemia '<-

0onsils 0+:0+

/ 8



/ec8 0yroid enlargement'<-

0rachea In the middle

ymph nodes /ec8 lymph nodes no

enlargementACilla lymph nodes noenlargement

0horaCungs

Inspection Symmetric in a static state and dynamic$suprasternalretractions '<-$ intercostal retractions '<-$ ictus cordis is notvisible

Palpation ictus cordis palpable in the ?ourth intercostalsspace o? the

le?t linea midclavicularis$ tactile ?remitus are symmetrical

Percusion sonor in both lung 7elds• 0op border o? heart I%S II linea le?t parasternalis• e?t border o? heart I%S I linea le?t midclavicula• Right border o? heart I%S I linea right parasternalisAuscultation >reath soundesicular breath sounds$ no rhon8i$ no whee&ingHeart sound First and second heart sounds regular$ murmur '<-$gallop'<-



AbdomenInspection %onveC$ epigastric retraction '<-$ there is no a

widening o? the veins$ no spider nevi!Palpation Supple% tenderness in right upper1uadrant and

epigastrium% li"er is palpa2le 34 &cm 2elo5costal margin$

abdominal mass '<-$ 8idney ballotenment '<-Percussion 0he entire 7eld o? tympanic abdomen$ shi?ting

dullness '<-

Auscultation >owel sound '- 4 times : minutes ertebrae 0here=s no scoliosis$ 8yphosis$ and lordosis$ donot

loo8 any mass along the line o? the vertebral5enitalia %overing the labia maora labia minora

Anus Hole intact$ does not seem that out o? themass o?

the anusECtremities arm$ capillary re7ll time Q+ seconds$in?usion sets

mounted on the le?t hand



/E"R225I%AEKA#I/A0I2/•

#eningeal signs – /ec8 stifness '<-

– >rud&ins8i I maneuver '<-

– >rud&ins8i II maneuver '<-

– @ernig maneuver '<-

• Physiological ReOeC

– >iceps ReOeC normoreOeC:normoreOeC

– 0riceps ReOeC normoreOeC:normoreOeC

– Patellar ReOeC normoreOeC:normoreOeC

– Achilles ReOeC normoreOeC:normoreOeC

• Pathological ReOec

– Hofmann<0rommerReOeC <:<

– >abins8i ReOeC <:<

– 2ppenheim ReOeC <:<

– Schae?er ReOeC <:< – %haddoc8 ReOeC <:<

– 5ordon ReOeC <:<



I/ES0I5A0I2/ '6une +4th$ +(*3-

• From Pus8esmas %iracas'morning-%ematology #esults ormal Value

%emoglobin 15,9 g/d 13-16 g/d

%ematocrit .0 40-48!

1eu2ocytes 7"700/# 5-10"000/#

Thrombocytes 345666/u1 150"000-40"000/#

Erythrocytes 5,8 millions/# 4,5-5,5 millions/#



• From Pus8esmas %iracas

• From Polri Hospital

6idal Serology Results

Salmonella 0yphi 2 <

Salmonella Paratyphi A2 <

Salmonella Paratyphi >2 <

Salmonella Paratyphi %2 <

Salmonella 0yphi H <

Salmonella Paratyphi AH <

Salmonella Paratyphi >H <

Salmonella Paratyphi %H <

Hematology Results -ormal 0alue

Hemoglobin *4$+ g:d *;<*, g:d

Hematocrit ))7 3(<39L

eu8ocytes !,((:u 4<*(!(((:u

0hrombocytes &8.'''9u: *4(!(((<3(!(((:u

Erythrocytes 4$9, millions:u 3$4<4$4 millions:u



I/ES0I5A0I2/S '6une +,th$ +(*3-

7rinalysis #esults ormal Value

!olour $ello%

!learness &lear

#eaction / p% 6 5 ' 8"5

peci*ic gra$ity 1,025 1000 ' 1,030

Protein - (egati)e

Bilirubin - (egati)e

)lucose - (egati)e

8etones * (egati)e

Blood / %b - (egati)e

itrite - (egati)e

7robilinogen 0"1 0"1 ' 1,0 +

1eu2ocytes - (egati)e



ediment

1eu2ocytes 0-1 / ield o )ie% -

Erythrocytes 0-1 / ield o )ie% -

Epithelial cells * / ield o )ie% -

!ylinder - -

!rystal - -

etc5 - -



F;C;S

Macroscopic

o !olor 1ellow

o !onsistency So?t

o Mucus <

o Blood <

Microscopic

o

1eu2ocytes *<;:7eld o? view 4

o Eritrocytes (<+:7eld o? view <

Worm egg

o Ascaris p <

o Anchilostoma p <

o Trichiuris p <

o 9:yuris p <



2R@I/5 DIA5/2SIS

• Dengue Hemorrhagic Fever gradeI



#A/A5E#E/0

• Parenteral in?usion Ringer actate #aintenance 'Holiday<Segaar-*+(( ml

*(L because o? DHF *+( ml 0otal parenteral Ouid:+3 hours(=&' ml (> dpm

• Inection o? itamin @ ;C* ampul

• Paracetamol ;C4((mg 'i? ?everpresents-

• Isprinol ;C4ml



PR25/2SIS

• uo ad vitam dubia adbonam

• uo ad ?unctionam bonam

•

uo ad sanationam bonam



Follow "p



0he 7rst day o? hospitali&ation$ 4th day o? sic8ness 6une +4th +(*3

S Fe"er% Body feels sore% -ausea% 2ut no "omit% Pain a2o"e the um2ilical

2 5eneral condition moderately ill

Awareness %ompos mentis

ital Signs

>lood pressure *((:)( mmHg

Heart rate *** times:minute$ strong$ ?ull$ regular

Respiratory Rate ;) times:minute

0emperature =>%&? C

Abdominal ECamination

. Inspection Flat$ epigastric retraction '<-

. Palpation Supple$ tenderness @3A in right upper 1uadran and epigastrium$ li"er is

palpa2le & cm 2elo5 costal margin$ abdominal mass '<-

. Percusion 0ympanic$ shi?ting dullness '<-

Auscultation >owel sounds 9 times : minutes



InvestigationFrom Pus8esmas %iracas 'morning-

From Polri Hospital


Hemoglo2in 15,9 g/d 13-16 g/d

Hematocrit )87 40-48!

:eukocytes 7"700/# 5-10"000/#

Throm2ocytes $B.'''9u: 150"000-40"000/#

;rythrocytes 5,8 millions/# 4,5-5,5 millions/#


Salmonella Typhi -

Salmonella Paratyphi + -

Salmonella Paratyphi B -

Salmonella Paratyphi C -

Salmonella Typhi H -

Salmonella Paratyphi +H -

Salmonella Paratyphi BH -

Salmonella Paratyphi CH -



Hematocrit )&7 40-48!

:eukocytes 5"300/# 5-10"000/#

Throm2ocytes )).'''9u: 150"000-40"000/#




A Dengue Hemorrhagic Fever grade I

P Parenteral in?usion Ringer actate *9 dpm

Paracetamol ;C4((mg 'i? ?ever presents-

Isprinol ;C4ml



0he +nd day o? hospitali&ation$ ,th day o? sic8ness$ 6une +,th +(*3

S >ody ?eels sore$ Pain above the umbilical



ital Signs


Heart rate *() times:minute$ strong$ ?ull$ regular

Respiratory Rate ;, times:minute

0emperature ;)$4 %


. Inspection Flat$ epigastric retraction '<-

. Palpation Supple$ tenderness @3A in right upper 1uadran and epigastrium$ li"er is

palpa2le & cm 2elo5 costal margin$ abdominal mass '<-

. Percusion 0ympanic$ shi?ting dullness '<-

Auscultation >owel sounds *+ times : minutes



(,!3+

*9!+(

%ematology #esults ormal Value


%ematocrit ..0 40-48!

1eu2ocytes 9"600/# 5-10"000/#

Thrombocytes 5666/u1 150"000-40"000/#


%ematology #esults ormal Value


%ematocrit 38! 40-48!

1eu2ocytes 10"800/# 5-10"000/#

Thrombocytes ;5666/u1 150"000-40"000/#




!rinalysis Results -ormal 0alue

Colour $ello%

Clearness &lear

Reaction 9 pH 6 5 ' 8"5

Specic gra"ity 1,025 1000 ' 1,030

Protein - (egati)e

Biliru2in - (egati)e

lucose - (egati)e

Eetones * (egati)e

Blood 9 H2 - (egati)e

-itrite - (egati)e

!ro2ilinogen 0"1 0"1 ' 1,0 +

:eukocytes - (egati)e

Sediment

:eukocytes 0-1 / ield o )ie% -

;rythrocytes 0-1 / ield o )ie% -

;pithelial cells * / ield o )ie% -

Cylinder - -

Crystal - -

etc. - -



ST:

Macroscopic

o !olor 1ellow

o !onsistency So?t

o Mucus <

o Blood <

Microscopic

o 1eu2ocytes *<;:7eld o? view 4

o Eritrocytes (<+:7eld o? view <

Worm egg

o Ascaris p <

o

Anchilostoma p <

o Trichiuris p <

o 9:yuris p <



A Dengue Hemorrhagic Fever grade I

P Parenteral in?usion Ringer actate *9 dpm


Isprinol ;C4ml



0he ;rd day o? hospitali&ation$ )th day o? illness$ 6une +)th +(*3

S Pain above the umbilical$ >ody ?eels sore



ital Signs


Heart rate **9 times:minute$ strong$ ?ull$ regular

Respiratory Rate +) times:minute

0emperature ;,$4 %

0horaC ECamination

. Inspection Symmetric in a static state and dynamic$ suprasternal retractions '<-$ intercostal

retractions '<-$ ictus cordis is not visible!

. Palpation ictus cordis palpable in the ?ourth intercostal space o? the le?t linea

mid8lavi8ularis

. Percusion Sonor on both lung 7elds

. Auscultaion Decrease "esicular 2reath sound on lo5er right lung elds$ no

whee&ing$ no rhonchi$ 7rst and second heart sounds regular$ murmur '<-$ gallop '<-




Abdominal ECaminationInspection loo8s distended$ epigastric retractionPalpation Supple$ tenderness @3A in right upper 1uadran and epigastrium$li"er is palpa2le & cm 2elo5 costal margin$ abdominal mass '<-Percusion 0ympanic$ shifting dullness @3AAuscultation >owel sounds *( times : minutes

S8in mild rash in the trun8

Investigation#orning

A?ternoon



Hematocrit 38! 40-48!

:eukocytes 12"800/# 5-10"000/#

Throm2ocytes =).'''9u: 150"000-40"000/#





:eukocytes ((.)''9u: 5-10"000/#

Throm2ocytes =).'''9u: 150"000-40"000/#


Clinical chemistry

+l2umin =%( g9d: 3,5-5,2 g/d



0horaC K<ray RDInterpretationSinus:diaphragm is normal#ediastinum isn=t widenedHeart is hard to assessed

Pulmonary right pleura is widened$no active lesion is seen/o abnormalities in the bone Conclusion right pleural eGusion

A Dengue Hemorrhagic Fever grade I with right pleural efusion and ascites

P Parenteral in?usion Ringer actate , dpm

Inection o? itamin @ ;C*ampul


Isprinol ;C4ml

0iral Immunoserology

+nti Dengue Ig 9

Ig

Results -ormal 0alue

+nti Dengue Ig (egati)e (egati)e

+nti Dengue Ig Positi"e (egati)e



0he 3th day o? hospitali&ation$ 9th day o? illness$ 6une +9th +(*3

S Pain in the upper abdomen



ital Signs


Heart rate *(( times:minute$ strong$ ?ull$ regular

Respiratory Rate +3 times:minute

0emperature ;, %

0horaC ECamination



. Palpation ictus cordis palpable in the ?ourth intercostal space o? the le?t linea mid8lavi8ularis


. Auscultaion Decrease vesicular breath sound on lower right lung 7elds$ no whee&ing$ no

rhonchi$ 7rst and second heart sounds regular$ murmur '<-$ gallop '<-




Abdominal ECaminationInspection epigastric retraction '<- $ loo8s distendedPalpation Supple$ tenderness @3A in right upper 1uadrant and epigastrium$li"er is palpa2le & cm 2elo5 costal margin$ abdominal mass '<-Percusion 0ympanic$ shi?ting dullness '-Auscultation >owel sounds 9 times : minutes

Investigation#orning

A?ternoon




:eukocytes ((.$''9u: 5-10"000/#

Throm2ocytes ,.'''9u: 150"000-40"000/#





:eukocytes 15"500/# 5-10"000/#

Throm2ocytes ,,.'''9u: 150"000-40"000/#






Isprinol ;C4ml


Salmonella Typhi -

Salmonella Paratyphi + -

Salmonella Paratyphi B -

Salmonella Paratyphi C -

Salmonella Typhi H -

Salmonella Paratyphi +H -

Salmonella Paratyphi BH -

Salmonella Paratyphi CH *1/80



0he 4th day o? hospitali&ation$ th day o? illnes$ 6une +th +(*3

S <

2 5eneral condition mildly ill


ital Signs

>lood pressure **(:)( mmHg

Heart rate ( times:minute$ strong$ ?ull$ regular

Respiratory Rate +( times:minute

0emperature ;,$4 %

0horaC ECamination



. Palpation ictus cordis palpable in the ?ourth intercostal space o? the le?t linea

mid8lavi8ularis


. Auscultaion esicular breath sounds in both lung 7elds$ no whee&ing$ no rhonchi$ 7rst and

second heart sounds regular$ murmur '<-$ gallop '<-




Abdominal ECaminationInspection epigastric retraction '<- $ loo8s OatPalpation Supple$ tenderness '<-$ $ li"er is palpa2le & cm2elo5 costal margin$ abdominal mass '<-Percusion 0ympanic$ shi?ting dullness '<-

Auscultation >owel sounds times : minutes

Investigation

A Dengue Hemorrhagic Fever grade I with right pleural efusion and ascites re7nement



Isprinol ;C4ml




:eukocytes 13"400/# 5-10"000/#

Throm2ocytes 110"000/# 150"000-40"000/#


h d ? h i li i



0he ,th day o? hospitali&ation$ *(th day o? illness$ 6une ;(th +(*3

S <

2 5eneral condition wellAwareness %ompos mentisital Signs>lood pressure *((:)( mmHgHeart rate *(, times:minute$ strong$ ?ull$ regularRespiratory Rate +, times:minute

0emperature ;)$; %

Investigation


P 2bservation




:eukocytes 9"800/# 5-10"000/#

Throm2ocytes 211"000/# 150"000-40"000/#




Hematology #une &Bth

@morningA

#une &Bth

@afternoonA

#une &,th

@morningA

#une &,th

@afternoonA

#une &8th

@morningA

Hemoglo2in 15,9 14,5 15,2 13,3 13,2

Hematocrit 47 42 44 38 38

:eukocytes 7"700 5"300 9"600 10"800 12"800

Throm2ocytes 95"000 44"000 27"000 32"000 34"000

;rythrocytes 5,8 5,65 5,86 4,93 4,90

Hematology #une &8th

@afternoonA

#une &>th

@morningA

#une &>th

@afternoonA

#une

&$th

#une

='th

-ormal 0alue

Hemoglo2in 12,7 12,5 12,4 12,9 11,9 13-16 g/d

Hematocrit 37 36 35 36 35 40-48!

:eukocytes 11"400 11"900 15"500 13"400 9"800 5-10"000/#

Throm2ocytes 34"000 56"000 66"000 110"000 211"000 150"000-

40"000/#

;rythrocytes 4,68 4,64 4,64 4,62 4,39 4,5-5,5

millions/#



SPE%IA %2/0R2 IS0

Date Time

Input utputBalance

@mlADiuresis

I0FD @mlA ;at% Drink@mlA

!rineutput@mlA

I6: @mlA

6une +,th$+(*3

9pm '6une+4th-<,am

43( ;4( 3((

;**+4(9 T+;4( M*49

,$+:8g:hour,am<*(am +*, *(( ;+4

*(am<3pm ;+3 +(( ,)4

3pm<**pm ;)9 3(( 4(

6une +)th$+(*3

**pm<,am ;)9 4(( ,((

;**+,,3 T+;(( M;,3

4$9:8g:hour

,am<*(am +*, 9(( ,((

*(am<3pm ;+3 44( 9((

3pm<9pm +*, 3(( ;((

6une +9th$+(*3

9pm<)am 43 *((( *(((

;**+)( T+*)( M9((

4$)3:8g:hour

)am<**am +*, 4(( )4(

**am<,pm +)( ;(( 3+(

,pm<**pm ( < <



Date Time

Input utputBalance@mlA

DiuresisI0FD @mlA

;at% Drink@mlA

!rineutput@mlA

I6: @mlA

6une +th$+(*3

**pm<,am *+, +(( 4((

;**)+ < )((M +

($,;:8g:hour

,am<*+pm *(9

*+pm<,pm *(9 +4( +((

6une ;(th$+(*3

,pm<am +)( *;(( *+(( ;***4)( T*+(( M;)(

4$)ml:8g:hour



iterature Review

Dengue Hemorrhagic Fever



DEFI/I0I2/

Dengue ?ever is a benign syndrome caused by severalarthropod<borne viruses and characteri&ed by biphasic?ever$ myalgia or arthralgia$ rash$ leu8openia and

lymphadenopathy!Dengue hemorrhagic ?ever 'DHF- is a severe$ o?ten ?atal$?ebrile disease caused by dengue viruses characteri&ed

by abnormalities o? hemostasis and capillary permeabilitythat leads$ in severe cases$ to a protein<losing shoc8

syndrome 'dengue shoc8 syndrome$ DSS-!

Dengue and dengue hemorrhagic ?ever 'DHF- are causedby one o? ?our closely related$ but antigenically distinct$

virus serotypes 'DE/<*$ DE/<+$ DE/< ;$ and DE/<3-$ o? thegenus Flaiirus!



EPIDE#I2251

• Estimation 4( million in?ections per yearin *(( countries

• First time appeared in Asia 0hailand$ *4(

and 7rst time appeared in Indonesia*,!

• In +(()the number o? dengue incidencein ESA was increased about *9L and the

morbidity was *4L higher than in +(()!



E0I2251• Dengue and DHF are caused by one o? ?our virus serotypes

dengue virus 'DE/-!• In Indonesiaall serotypes are ?ound and DE/ ; is the most

common one

Flavivirus has spherical shape with a lipid envelopeG the particles are

approCimately 4( nm in diameter! 0he dengue virus genome is**$,33 nucleotides in length!

0he Oavivirus structural protein genes encoding the nucleocaprid orcore protein '%-$ a membrane<associated protein '#-$ an envelopeprotein 'E-$ and seven non<structural protein '/S- genes! Among

non<structural proteins$ envelope glycoprotein$ /S*$ is o? diagnosticand pathological importance!

In?ection with one dengue serotype provides li?elongi i h i b h i i



immunity to that virus$ but there is no cross<protectiveimmunity to the other serotypes! 0hus$ persons living inan area o? endemic dengue can be in?ected with three$

and probably ?our$ dengue serotypes during their li?etime!

Aedes aegypti and Aedes albopictus are the two mostimportant vectors o? dengue! A! aegypti$ the principalvector$ is a small$ blac8<and<white$ highly domesticated

tropical mosNuito that pre?ers to lay its eggs in arti7cialcontainers commonly ?ound in and around homes$ ?oreCample$ Oower vases$ old automobile tires$ buc8ets thatcollect rainwater$ and trash in general!

Aedes aegypti originates ?rom A?rica$ but now is spreading worldwideand become the most common dengue virus transmitter in the world!Aedes albopictus originates ?rom South East Asia$ estern Paci7c$and Indian 2cean!



PA0H2PH1SI2251

• Several theoriesG the most common oneSecondary4infection or immuneenhancement hypothesis.

• patients eCperiencing a second in?ectionwith a heterologous dengue virus serotypehave a signi7cantly higher ris8 ?ordeveloping DHF and DSS!

PreeCisting AA% bound to and the virus is not



gheterologous dengueantibody recogni&esthe in?ecting virus and?orms an antigen4

anti2ody comple

internali&ed byimmunoglobulin Fcreceptors on the cellmembrane o?

leu8ocytes$especiallymacrophages

neutrali&ed andis ?ree toreplicate onceinside the

macrophage

Prior in?ection'Antibody<

dependentenhancement'ADE-- enhancesthe infection andreplication o?dengue virus incells o? themononuclear celllineage

produce and secrete"asoacti"emediators@cytokines%complementsA inresponse to dengue

in?ection

increasedvascularpermeability

Hypo"olemiaand shock

Endothelial cells dys?unction disruption in the ?unction o? endothelial



y pglycocalyC!

lycocalyC ?unctions as a molecular sieve Selectively restricting moleculeswithin plasma according to their

si&e$ charge$ and shape

Albumin and protein lossProteinuria andhypoalbuminemi

a

5lycocalyC hasheparan sul?ate

Dengue virus and/S* bind toheparan sul?ate

5lycocalyC loss its?unction

Increase heparan sul?ate in urine has beendetected in severe dengue cases



0hrombocytopenia

Early bone marrow suppression

Increased peripheral destruction o?platelets during the ?ebrile and earlyconvalescent phase

*! Dengue produces transient suppression o? hematopoiesis via directin?ection or macrophage inOammatory protein *<alpha

+! Dengue virus binds to platelets in the presence o? virus<speci7c antibody

#echanism o? coagulopathy un8nown



#echanisms o? liver inury in dengue may be due to

• direct efects o? the virus or host immuneresponse on liver cells

• circulatory compromise• metabolic acidosis and:or hypoCia caused by

hypotension• locali&ed vascular lea8age inside the liver!

0he predominant 7ndings in these studies weremicrovesicular steatosis and small ?oci o?hepatocellular necrosis in addition to the presence

o? councilman bodies$ @upfer cell hyperplasia andmononuclear cell in7ltrates at the portal tract!



%I/I%A #A/IFES0A0I2/"ndiferentiated fe"er

0he people who got in?ected by dengue virus may develop a simple ?everthat can=t be distinguished ?rom other viral in?ections 'atypical symptoms-!#aculopapular rashes may accompany the ?ever or may appear duringde?ervescence! "pper respiratory and gastrointestinal symptoms arecommon!

Dengue Fe"erDengue ?ever 'DF- is most common in older children$ adolescents and adults!It is generally an acute ?ebrile illness$ and sometimes biphasic ?ever withsevere headache$ myalgias$ arthralgias$ rashes$ leucopenia andthrombocytopenia may also be observed! Severe headache$ muscle and ointand bone pains 'brea8<bone ?ever-$ particularly in adults! 2ccasionally

unusual haemorrhage such as gastrointestinal bleeding$ hypermenorrhea andmassive epistaCis occur!



Dengue Hemorrhagic FeverDHF is characteri&ed by the acute onset of high fe"er! 0here arecommon haemorrhagic diatheses such as positive tourniNuet test

'00-$ petechiae$ easy bruising and:or 5I haemorrhage in severecases! >y the end o? the ?ebrile phase$ there is a tendency to develophypovolemic shoc8 'dengue shoc8 syndrome- due to plasma lea8age!

0he presence o? preceding 5arning signs such as persistent"omiting% a2dominal pain% lethargy or restlessness% or

irrita2ility and oliguria are important ?or intervention to preventshoc8! +2normal haemostasis and plasma leakage are the mainpathophysiological hallmar8s o? DHF! Throm2ocytopenia andrising haematocrit9haemoconcentration are constant 7ndingsbe?ore the subsidence o? ?ever: onset o? shoc8!



Febrile Phase

• High temperature 'U;9!4%- accompanied byheadache$ vomiting$ myalgia$ and oint pain$sometimes with a transient macular rash!

• AnoreCia$ nausea and vomiting• Petechiae$ mucosal membrane bleeding and bruising$

palpable liver are commonly noted• aboratory 7ndings mild<to<moderate

thrombocytopenia and leu8openia• asts ;<) days



%ritical Phase

• De?ervescence 'day ;<) illness-

• Increase in capillary permeability hemoconcentration$ hypoproteinemia$ pleuralefusions$ and ascites

• %linically signi7cant plasma lea8age +3<39hours

• Hemorrhagic mani?estation in children isn=tclinically signi7cant$ associates with pro?ound

and prolonged shoc8• #oderate<to<severe thrombocytopenia

• oo8ing ?or 5arning signs



Recovery:%onvalescent Phase

• ascular permeability is bac8 to normala?ter 39<)+ hours a?ter critical phase

• Rapid improvement o? patient=s

symptomsG stabili&ation o? vital signs• Second rash may appear$ might be

generali&ed pruritus

• %aution o? administration o? intravenous

Ouids



Investigations

0he ?ollowing laboratory tests are available to diagnosedengue ?ever and DHF• irus isolation serotypic:genotypic characteri&ation• iral nucleic acid detection R0<P%R• iral antigen detection /S*• Immunological response based tests Ig# and Ig5

antibody assaysG #A%<EISA$ Ig5:Ig# ratio$ #A% EISA$haemaglutination inhibition test$ complement 7Cationtest$ neutrali&ation test

• Analysis ?or hematological parameters

i ib d i di id l



• Primary antibody response individualwho are not immune to dengue

• Secondary immune response previous dengue in?ection

• Primary in?ection slow and low<titreantibody response

Immunoglobulin 'Ig-# antibodies are the7rst isotype to appear$ by day =* ofillness in 4(L o? hospitali&ed patientsand by day ,T*( o? illness in ;TL o?cases! 0he Ig le"els peak & 5eeks a?ter the onset o? ?ever and then

generally decline to undetectable levelsover the neCt +T; months

Dengue<speci7c Ig5 is detectable at lowtitre at the end o? the 7rst wee8 o? illnessand slowly increases

Secondary in?ection



Secondary in?ection

• high levels o? Ig5antibodies that aredetectable even in theacute phase and risedramatically over the?ollowing + wee8s!

• as Ig# levels aresigni7cantly lower in

secondary denguein?ections$ ?alse<negative test results ?ordengue<speci7c Ig#have been reported

during secondaryin?ections!

• Following a denguein?ection$ Ig5 can beli?elong$ which

complicates the



#A/A5E#E/0 A/D 0REA0#E/0

• /o speci7c therapy is available at thepresent time ?or symptomatic denguein?ections! Efective treatment relies on

good supportive care$ with particularemphasis on Ouid therapy andmanagement o? bleeding complications

Indications ?or I Ouid in critical period o? DHFi d t l O id i t 8 iti i ti t



• inadeNuate oral Ouid inta8e or vomiting in patient• hematocrit continues to rise *(L<+(L despite oral

rehydration•

impending shoc8:warning signs! 0he ?ollowing parameters should be monitored• eneral condition% appetite% "omiting% 2leeding and

other signs and symptoms!• Peripheral perfusion•

0ital signs must be chec8ed e"ery &*) hours in non<shoc8 patients and *T+ hours in shoc8 patients!

• Serial haematocrit must be chec8ed e"ery four to sihours in stable cases!

• !rine output 'amount o? urine- should be recorded! During

this period the amount o? urine output should be a2out '.ml9kg9h 'this should be based on the ideal body weight-!



5eneral principles o? Ouid therapy in DHF• Isotonic crystalloid solutions should be used throughout

the critical period • Hyper4oncotic colloid solutions @osmolarity of J=''

msm9lA such as deCtran 3( or starch solutions may be used inpatients with massive plasma lea8age$ and those not responding

to the minimum volume o? crystalloid!• + "olume of a2out maintenance 37 dehydration should

be given to maintain a intravascular volume and circulation!• 0he duration o? I Ouid therapy not eCceed +3<39 hours ?or

shoc8 patients

the duration o? intravenous Ouid therapy

not more than ,( to)+ hours ?or nonshoc8• In obese patients$ the ideal body weight should be used as a

guide to calculate the Ouid volume

#anaging DHF 5rade I and II



#anaging DHF 5rade I and IIwithout Shoc8

• the Ouid allowance 'oral I- is aboutmaintenance '?or one day- 4L de7cit'oral and I Ouid together-$ to beadministered over 39 hours!

• 0he rate o? I replacement should beadusted according to the rate o? plasmaloss$ guided by the clinical condition$ vital

signs$ urine output and haematocrit levels!• Antipyretic such as paracetamol can be

given

i d



#anaging DHF 5rade III

• #ost cases o? DSS will respond to *( ml:8g inchildren over one hour or by bolus$ i?necessary!

• be?ore reducing the rate o? I replacement

the clinical condition$ vital signs$ urine outputand haematocrit levels should be chec8ed toensure clinical improvement! It must becontinued ?or a minimum duration o? +3 hoursand discontinued by ;, to 39 hours



# i DHF 5 d I



#anaging DHF 5rade I*( ml:8g o? bolus Ouid be given as soon as possible$ within *(<*4

minutes

%ontinuing I Ouidas in 5rade ;

Repeat *( ml:8g bolus and obtain labresults to be corrected

"rgent blood trans?usion should beconsidered as the neCt step 'a?terreviewing the pre< resuscitation H%0-and ?ollowed up by closer monitoring$e!g! continuous bladder

catheteri&ation$ central venouscatheteri&ation or arterial lines!

/ot reversiblerestored

# t ? % l



#anagement o? %onvalescence

• %onvalescence can be recogni&ed by the improvement inclinical parameters$ appetite and general well<being!

• Haemodynamic state such as good peripheral per?usion andstable vital signs should be observed!

• Decrease o? H%0 to baseline or below and dieresis are usually

observed!• Intra"enous Kuid should 2e discontinued.

• In those patients with massive efusion and ascites$hypervolemia may occur and diuretic therapy may benecessary to prevent pulmonary oedema!

• Bradycardia is commonly found and reNuires intensemonitoring ?or possible rare complications such as heart bloc8or ventricular premature contraction 'P%-!

• %onvalescence rash is ?ound in +(LT;(L o? patients!

Si ? R



Signs o? Recovery

• Stable pulse$ blood pressure and breathingrate!

• /ormal temperature!

• /o evidence o? eCternal or internal bleeding!

• Return o? appetite!

• /o vomiting$ no abdominal pain!

• 5ood urinary output!

• Stable haematocrit at baseline level!• %onvalescent conOuent petechiae rash or

itching$ especially on the eCtremities!

% it i ? Di h i P ti t



%riteria ?or Discharging Patients

• Absence o? ?ever ?or at least +3 hours without the use o?anti<?ever therapy!

• Return o? appetite!

• isible clinical improvement!

• Satis?actory urine output!

• A minimum o? +T; days have elapsed a?ter recovery ?romshoc8!

• /o respiratory distress ?rom pleural efusion and no ascites!

• Platelet count o? more than 4( (((:mm;! I? not$ patients

can be recommended to avoid traumatic activities ?or atleast *T+ wee8s ?or platelet count to become normal! Inmost uncomplicated cases$ platelet rises to normal within ;T4 days!

REFERE/%ES



REFERE/%ES

•

5ubler D6$ %lar8 55! Dengue:dengue hemorrhagic ?ever the emergence o? a global health problem! Emerg In?ectDis! *4 Apr<6unG *'+- 44T4)!

• 6agadish8umar @$ 6ain P$ et al! Hepatic Involvement in Dengue Fever in %hildren! Iran 6 Pediatr! 6un +(*+G ++'+- +;*T+;,

• Smith DR$ @ha8poor A! Involvement o? the liver in dengue in?ections! #olecular Pathology aboratory$ Institute o?#olecular >iosciences$ #ahidol "niversity$ 0hailand Dengue >ulletin T olume ;;$ +(($ p! )4<9,

• 5u&man #5$ Halstead S>$ Artsob H$ et al! Dengue a continuing global threat! /ature Reviews #icrobiology $ S)<S*, V doi*(!*(;9:nrmicro+3,(

• H2 SEAR2! %omprehensive 5uidelines ?or Prevention and %ontrol o? Dengue and Dengue Haemorrhagic Fever'Revised and ECpanded Edition-! +(**! Pub H2 http::apps!searo!who!int:pdsWdocs:>3)4*!pd?

• Simmons$ %ameron P!$ et!al! Dengue! /ew England 6ournal #edicine! /E6# ;,,G*4 #assachussets #edicalSociety+(*+

• Hadinegoro S!R!H$ Satari H!I! Demam "erdara# Dengue$ /as8ah eng8ap$ Pelatihan bagi Pelatih Do8ter SpesialisAna8 X Do8ter Spesialis Penya8it Dalam dalam 0atala8sana @asus D>D! 6a8arta >alai Penerbit Fa8ultas @edo8teran"niversitas Indonesia! +((4!

• Halstead$ Scott >! Dengue! 0ropical #edicine Science and Practice ol!4! Imperial %ollage Press ondon

• Standar Pelayanan #edis Demam >erdarah Dengue$ >u8u Aar I8atan Do8ter Ana8 Indonesia! 6a8arta! +((!

• H2! Dengue 5uidelines ?or Diagnosis$ 0reatment$ Prevention$ and %ontrol! +((!

•

@aryana IP5$ et al! 0he value o? Ig5 to Ig# ratio in predicting secondary dengue in?ection! Paediatrica Indonesianavol 3,$ no! 4<,G+((,Gp **;<**)

• H2! Handboo8 ?or %linical #anagement o? Dengue! +(*+!

• @aryanti #R$ Hadinegoro SR! Perubahan Epidemiologi Demam >erdarah Dengue di Indonesia! Sari Pediatri$ ol!*(G,G+((Gp!3+3<3;+

• ei$ H1 et al! Immunopathogenesis o? Dengue irus In?ection! 6 >iomed Sci +((*G9;))T;99

http://apps.searo.who.int/pds_docs/B4751.pdf

http://apps.searo.who.int/pds_docs/B4751.pdf

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