This document contains 4 case histories of patients with dengue fever: 1. A 24-year-old male who was monitored and showed improving lab values before being discharged when afebrile for 48 hours with a platelet count over 50,000. 2. A 33-year-old shocked lady who was aggressively given fluids and showed improving vital signs without further intervention. 3. A 30-year-old male who was over-loaded with fluids in the private hospital and developed pleural effusions and ascites, but recovered with dextran and diuretics. 4. A 10-year-old boy who presented in profound shock and required aggressive fluid resuscitation including blood

1. 4. Case Histories
Dengue Expert Advisory Group

2. CASE HISTORY 1
24 yr old male came to the OPD with H/O fever for
1 day. Had myalgia, and severe headache. No
vomiting.
O/E Flushed skin, good hydration, pulse 80/min,
BP 110/80. No abnormality was detected on
examination.
He was sent home by the OPD doctor advising
him
• to drink - the amount, type of fluid
• to take paracetamol in correct dose
• to have rest.

3. • He was also advised to come back on the 4th
day of the illness with CBC.
• He came back on 4th day, still febrile, had
nausea. Pulse 80/min, BP 110/80.
• CBC on D-3
• WBC – 3800 Hct – 38.8 Plt – 120,000

4. IN PATIENT MANAGEMENT
• FBC and Haematocrit monitored
• Fluid intake and output monitored
IV fluids – 1500 ml with 1000 ml orally per
day
given. Total – 2500 ml/d
Domperidone and PCM sos
• Vital signs monitored

5. CASE HISTORY 1 CONTD.
3 4 5 6 6 7 8 9
WBC 3.8 2.8 4.1 10 9.9 10 8.3 5.5
HCT 38.8 40.5 44.5 48.5 43.9 42.8 39.7 40
PLT 120 80 21 6 9 9 19 57

6. MANAGEMENT CONTD.
• Symptomatic management continued
• Monitoring continued.
• Fluid increased with rise of PCV
• No clinical deterioration. Had small right sided
pleural effusion. No specific management done.
• Patient improved i.e.. General condition, appetite.
Fever settled.
• Patient was discharged home once the plt count
was >50,000 & Afebrile for 48 hrs

7. LESSONS LEARNED:
• Doing a CBC from 3rd day is better.
• Often only symptomatic management is
adequate.
• If there is no active bleeding, there is no place
for platelet transfusion even if the platelet count
is low.
• No place for steroids or FFP.

8. CASE – 2: THE SHOCKED LADY
• A 33 yr old lady, a mother of a 5 month old baby,
was admitted with a H/O fever for 5 days.
• On admission – pulse 100/min, BP 100/90,
CRFT- 3 secs, R/pleural effusion +
05.09.11 07.09.11
Platelets 181,000 52,000
HCT 33.8 40.6

9. FLUID ALLOCATION FOR SHOCKED
PATIENT
53
105
51
104
140 49
103
47
102
120 45
101
43
100
100 41
99
39
98
80 37
35
60
1 2 3 4 5 6 7
1 2
3
M + 5%
24-36 hrs
10 ml/kg
7-5 ml/kg
5-3 ml/kg
3-1 ml/kg
KVO

10. FLUID GIVEN DURING 1ST 24 HRS
0
100
200
300
400
500
600
2pm
3pm
4ppm
5pm
pm
7pm
8pm
9pm
10pm
11pm
12mn
1am
2am
3am
4am
5am
6am
7am
8am
9am
10am
11am
12n
Time
Series1
3
8
3
6
3
5
3
5
3
5
3
8
3
4
3
5
3
5
Total volume given for first 24 hrs – 3600 ml

11. • IV calcium gluconate given 6 hrly.
• Amount of fluid reduced to 75ml/hr and then
50ml/hr and then stopped.
• PCV remained stable
• Blood pressure, pulse, CRFT and UOP
maintained.
• No further interventions were necessary.

12. LESSONS LEARNED:
Treat both
 impending shock (prolonged CRFT, narrow
pulse pressure, severe postural drop of BP,
hypotension)
Full blown shock (BP un-recordable)
AGRESSIVELY and PPOMPTLY.
With crystalloid bolus and gradual reduction of
fluid.
If PCV is low, give blood.
May need dextran later.

13. CASE 3: OVER-LOADING IS EASY !
• A 30 yr old male with DHF was referred (at a
private hospital) on 14th Sep.
• Admitted on 12th at 5 pm & transferred to ICU on
13th at 6 pm.
11.09.11 12.09.11 13.09.11
HCT 40.8 41.2 48.0
PLATELET 112,000 58,000 12,000

14. OVER-LOADING IS EASY !
• Fluid given for 24 hrs = 4150 ml.
• Now the patient has got B/L pleural effusions and
ascites.

15. OVERLOADED PATIENT:
• PCV increased to 52
• Pulse pressure narrowed to 20 with a postural drop
of 30 in SBP.
• Dextran 500 ml given over one hour with 10 mg
of frusemide
• Pulse pressure improved.
• Good UOP.
• Patient recovered without any further intervention

16. LESSONS LEARNED:
• Fluid overload can occur un-intentionally.
• Patients should be told how much and what to
drink
• Dextran is useful in fluid overloaded patients
• Frusemide in small doses is very effective

17. DEXTRAN 40
• Preferred colloid in DHF
• Mechanism of Action - Produces plasma volume
expansion by virtue of its highly colloidal starch
structure, similar to albumin
• Given as a bolus in DHF– 250 ml over 30 mins or
500 ml over 1 hr. Not as a slow infusion.
• Recommended maximum – 1500 ml for 24 hrs.
• Should not be used in a dehydrated patients who
present with shock and high HCT until the
hydration is corrected with crystalloids.

18. CASE HISTORY: DELAY COSTS !
 Mrs. R
 53 year old female
 Diabetic and hypertensive
 Admitted on 08/06/2011 11.05 pm
 D3 of fever
 On admission
Pulse 88/min, BP 120/80,(110/80)
CRFT < 2 sec, Liver 2 cm, tender.
WBC – 1600 N – 43%
Hb – 13.7 PCV – 42 platelet – 40,000

19. SHO seen 09/06/2011 at 4 am.
• Patient C/O dizziness
• No bleeding manifestations
• CVS - PR – 104
BP – 130/90 supine
100/80 sitting
• CRFT - < 2sec
• Tender hepatomegaly
• R/S pleural effusion
• PCV - 46

20. • Critical period 4.00am 09/06/2011 to
4.00 am 11/09/2011
• From 4.00 am to 9.00 am 100ml/hr
• Bolus of N. saline 500ml at9.00am
• After that 150ml/hr x 3hrs
100ml/hr x 39 hrs

21. PCV 46 49.7 48 46 46 47 32? 40 40
39
Pul p 40 20 30 30 30 30 30 30 30 25 30 40
0
100
200
300
400
500
600
1 5 9 13 17 21 25 29 33 37 41 45
fluid intake
CRFT <2 <2 <2 <2 <2 <2 <2 >2

22. • Critical period over at 4 am on 11.06.11.
• By end of critical period 5350ml fluid given
• Blood ordered at 6.30 am
• Admitted to ICU 9.25 am
• On admission to ICU
PR- 120/min BP 110/90 mmhg
Pt dyspnoec, with oxygen SPO2- 96% RR - 38
• Blood 2 pints received at 10.40am!! After 4 hrs
10 pm
10.06.11
4 am
11.06.11
5 am
11.06.11
PCV 39 33 32

23. 1st 24 hours after critical
period
PCV 33 32 28 26 39 39 38 35 31 39
42 45 46
0
50
100
150
200
250
300
350
400
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
oral
dextran
blood
crystalloid

24. • Patient developed shock on 11/06/2011 evening
with impalpable peripheral pulses and cold
extremities
• Femoral CVP catheter inserted.
• Patient developed respiratory distress and was
intubated on 12/06/2011 at 6.30am
WBC PLATELET
11.06.11 9000 32,000
12.06.11 7200 40,000

25. 2nd 24 hours after critical period
12/06/11
PCV 41 35 32 35 41 31 33 37 37 37 36 35 37 37
37 37
0
100
200
300
400
500
600
700
800
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
tetra
crys
blood
FFp
dextran

26. 2ND 24 HOURS AFTER CRITICAL
PERIOD 12/06/11
• Inspite of blood and fluid boluses, patient was
going into shock repeatedly.
• Decided to aspirate the R pleural effusion
• Activated factor VII two vials given
• Pleural effusion aspirated.

29. •1600 ML OF BLOOD ASPIRATED.
PERIPHERAL CIRCULATION RETURNED
IN THE MIDWAY OF ASPIRATION.

30. 3RD 24 HOURS AFTER CRITICAL PHASE 13/06/11
PCV 37 37 37 37 38 40 39 38 40 39 39 38 38 39 34 35 37 40 43 41 41
40 40 39
0
50
100
150
200
250
300
350
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
blood
dextran
crystalloid

31. • R/S pleural aspiration repeated 14/06/2011
1300ml blood aspirated
• Patient extubated on
16/06/2011
• R/S Intercostal tube inserted due to persistant
haemothorax on 17/06/2011
1070ml drained.

33. • Throughout clotting profile – normal
• Slight elevation of liver enzymes
• Renal functions – low K+
• Low Serum calcium – i.v calcium gluconate
given
• Good glycaemic control on insulin
• CRP – 67- 225 – 162 -16
• Patient respiratory secretions culture - MRSA
• Pleural fluid culture and blood cultures – sterile
• Treated with antibiotics + chest physiotherapy

34. CASE PROFOUND SHOCK
A 10 year old boy presented at E/S
C/O
•Fever ---05 days
high grade, continuous with body aches
• Melina ---01 day
two episodes and
one episode of hematochezia
• Altered conscious level --1 hour

35. • Unwell looking GCS 12/15 A febrile
• Pulse Feeble BP un recordable
• Cold clammy skin
• CRT>2sec
• Abdomen tender, Liver 3cm blcm and tender
TT + ve
• USG abdomen pericholic fluid
• Pelvic ascites
O/E

36. Management
 Fluid resuscitation with crystalloid
 Push with N/saline 20ml /kg
 Repeat with 10 ml/kg
 Dextran 40 10ml/kg over 1 hour
 Pulses palpable but tachycardia
 Crystalloids continued

37. Day 5 Day 5
TLC 8,000 7,600
Platelets 10,000 9,000
Hct 28 35
 Blood Transfusion
• Crystalloids
• 18 hours later developed tachycardia
• Narrowed pulse pressure
• Amount of fluids increased

38. Day 6 Day 7
TLC
Plt 8,000 7,000 7,000 7,500 8,000
Hct 38 39 30 36 35
 Packed Cells Transfusion
 Crystalloids gradually tapered

39. CASE
• A six year old girl presented in emergency with
C/O:
• Fever ---04 days
high grade continuous with body aches
• Epistaxis ---01 day
3 episodes
• Vomiting --- 01 day
2-3 episodes
• Fit-----half hour
1 episode, Generalized tonic / colonic

40. ON EXAMIANTION
Lethargic , but arouse able child SOMI -Ve
PR- 80/min, BP- 100/80mmHg, Temp- 100F,
Abdomen mildly tender
Liver palpable 2 cm below costal margin
TT +VE
No clinical and radiological evidence of pleural
effusion
Ultrasound abdomen showed no free fluid
TLC 3,500 Plts 80,000 Hct 36% BSR
20mg/dl

41. INITIAL MANAGEMENT
• BSR corrected
• Maintenance fluid (Oral + I/V)
• Vitals’ Monitoring 4 Hourly

42. ON DAY 5
•Pulse rate 95/min
•Blood pressure 100/75
•Liver palpable 3 cm BCM and tender
•Ultrasound abdomen showed gall bladder wall
edema and mild pelvis ascites

43. Day 5
TLC 2,000 2,500 3,000
Platelets 20,000 15,000 14,000
Hct 35 40 38
 Crystalloids continued

44. ON DAY 6 (AFTER NOON)
• Pulse rate 120/min
• Blood pressure 100/85
Day 6
TLC 3500 3,500 4,000
Platelets 14,000 12,000 10,000
Hct 36 38 48
 Crystalloid bolus with 10 ml / kg
Tapered gradually