Vasculopathy and innate immunity as the first immunopathogenesis dengue and become a future research base on cases

1. EMERGENCY ROOM NIGHT SHIFT
CASE REPORT
Dengue with vasculopathy
On Wednesday, 2ND SEPTEMBER 2015
GP on duty:
dr. Wulan
dr. Nita
Supervisior : dr Soroy Lardo SpPD
FINASIM (Divisi Tropik dan Infeksi
Departemen Penyakit Dalam)
Coass on duty:
Ardian
Ajeng
Universitas Kristen Jakarta (UKRIDA)
Indonesia Army Central Hospital Gatot Soebroto

2. PATIENT RECAPITULATION
Mr. B , 22 y.o , dengue hemorrhage fever
Ms. T , 24 y.o , dyspepsia
Mrs. E , 45 y.o , GERD
Mr. P , 78 y.o , susp. Hepatitis B
Mrs. S , 57 y.o, ca mammae
Mr. P, 67 y.o , GEA +low intake
Mrs. V , 55 y.o, gastritis
Mrs W, 44 y.o, SIDA + low intake

3. Patient’s Identity
• Name : BP
• MR no : 81 30 39
• Sex : male
• Age : 22 years old
• Religion : Christian
• Marital status : single
• Ethnic : Javanese
• Occupation : Army Soldier

4. History of Present Illness
Patient came to the ER with the complain of the
fever he had since 2 days ago. Fever that he had
occurred all day long, even with the anti fever
medication. The complaint also came with the
headache that occurred from behind his eye
balls. He also had muscles and joints pain and
loss of eating appetite. Patient often felt nausea,
but never vomitted. Patient once came to the 24
hours clinic, but didn’t feel better and decided
to go to the ER for a check up.

5. History of Past Illness
- Patient has never been hospitalized before
- Patient has neither hypertention, diabetes,
nor heart disease history.

6. Family Illness
• Diabetes Mellitus (-)
• Hypertension (-)
• Heart disease (-)

7. HABITS AND LIFESTYLE
•Smoking (+)
•Alcohol consumption (-)

8. History of Medication
• Patient is not on any medication at this
moment
• Patient never have a routine drugs to take for
a long time

9. PHYSICAL EXAMINATION
VITAL SIGNS
• General State : Moderate Illness
• Consciousness : Compos Mentis, E4M6V5 GCS 15
• Blood Pressure : 120/80 mmHg
• Heart rate : 90x/minute
• Respiratory Rate : 22x/minute
• Temperature : 38,8 oC
• Body Weight : 75kg
• Body Height : 170 cm
• Habit : athletic

10. PHYSICAL EXAMINATION
General Examination
• Head : Normal
–Eye : anemic conjunctiva (-/-), icteric
sclera (-/-)
–Ears : normal, discharge (-)
–Nose : septum deviation (-), discharge (-)
–Mouth : dry lips (-) ptechie (+)
• Neck : lymph nodes enlargement (-), JVP 5 – 2
cmH2o

11. COR
• Inspection: Ictus cordis (-)
• Palpation: ictus cordis palpable (+), thrill (-)
• Percussion: normal impression
• Auscultation : irregular 1st and 2nd heart
sound, murmur (-), gallop (-)

12. PULMO
Inspection : chest within normal shape, symmetries
on static and dynamic state
Palpation : tactile vocal fremitus in both of lungs
were symmetries.
Percussion : sonor in both of lungs
Auscultation : Vesicular Breath Sound +/+, rhonki -
/-, wheezing -/-

13. Abdomen : convex (+), intestinal motility (n),
tenderness on epigastric regio.
Extremities: no edema , petechiae (+) rumple
leed (+)

14. Laboratory Results
RESULT NORMAL RANGE
Hematologi rutin:
Hb 14 13 - 18 g/dl
Ht 44 40 – 52 %
Erythrocyte 4,7 4.3 - 6.0 mil /ul
Leukocyte 5.620** 4800 - 10800/ul
Thrombocyte 144.000** 150000 - 400000/ul
LABORATORIUM

15. RESUME
Patient came to the ER with the complain of the fever
he had since 2 days ago. Fever that he had occurred all
day long, even with the anti fever medication. The
complaint also came with the headache that occurred
from behind his eye balls. He also had muscles and
joints pain and loss of eating appetite. Patient often felt
nausea, but never vomitted. Patient once came to the
24 hours clinic, but didn’t feel better and decided to go
to the ER for a check up. Blood pressure: 120/80
mmHg, Heart rate:90x/minute, Respiratory rate
:22x/minute, Temperature:38,8 o C, petechiae (+),
leukocyte : 5.620.

16. List of problems
• Dengue hemorrhage fever Grade 2

17. Problem Analysis
• 2 days fever with retroorbital pain, arthralgia,
myalgia, tenderness in epigastric
• Petechiae (+), rumple leede (+)
• Trombocyte: 144.000 /µl
Therapy
1. IVFD 2500 ml/days
2. Paracetamol 3x 500 mg

18. Prognosis
Quo ad Vitam = bonam
Quo ad functionam = bonam
Quo ad sanationam = bonam

19. THANK YOU

20. Vasculopathy in DHF
Viral infection Endotelial cell
CD4/8 ratio
inversion, IL-6
and cytocine
overproductio
n
Trombocyte
dysfunction
and vascular
damage

21. Innate immunity in DHF

22. Innate Imunity in DHF
• Interstitial dendritic cells (DCs) are believed to
constitute the first line of the innate host
defense against invading DV
• Early activation of natural killer (NK) cells and
type-I interferon-dependent immunity may be
also important in limiting viral replication at
the early times of dengue infection

23. Innate imunity in DHF