discussion regarding Dengue Fever Syndrome

1. Admission Conference
University of Perpetual Help
Dr. Jose G. Tamayo Medical University
College of Medicine
Department of Medicine

2. 24-Hour Duty
• Patients seen: 8
• Admissions: 4
• Direct Admission: 1
• ER Admission: 3
• THOC: 0
• DAMA: 0
• Mortality: 1

3. General Data
• This is a case of A.S., a 27-year old
female, married, Filipino, Roman Catholic,
born on March 13, 1988, currently residing
in Barangay Sto. Tomas, Biñan, Laguna,
was admitted for the first time in our
institution on December 1, 2015.

4. Chief Complaint
• Fever x 3 days
• Reliability: 90%
• Informant: Patient

5. History of Present Illness
• 3 days PTC
– (+) fever (Tmax 38.7oc)
– (+) vomiting, (-) ~half cup/bout, blood-streaked,
previously ingested food x 3 bouts
– (+) headache, 8/10, continuous, bilateral, frontoparietal
area, throbbing, non-radiating
– (+) muscle and joint pains
– (+) epgastric pain, 6/10, dull in character, not influenced
by food intake, non-radiating
– (-) colds, (-) cough, (-) dysuria, (-) flank pain,
(-) nose/gum bleed, (-) melena
– Self-medicated with Paracetamol 500mg/tab which
afforded temporary relief from fever

6. History of Present Illness
• 2 days PTC
– Still with above symptoms
– Now (+) vomiting, non-blood tinged, ~half cup/bout,
previously ingested food x 2
– Fever was relieved temporarily by Paracetamol
• Few hours PTC
– Still with above symptoms
– Now (+) vomiting, non-blood tinged, ~half cup/bout,
previously ingested food x 4
– Persistence of fever prompted the patient to seek
consult in our institution, hence admission

7. Past Medical History
• (-) Hypertension
• (-) Diabetes mellitus
• (-) Bronchial asthma
• (-) Pulmonary tuberculosis
• (-) Thyroid disease
• (-) Liver / kidney disease
• (-) Previous hospitalization / surgery
• (-) Allergy to food / drug

8. Family History
• (+) Breast cancer, maternal side
• (+) Colon cancer, maternal side

9. Personal & Social History
• (-) Smoker
• (-) Alcoholic beverage drinker
• (-) Illicit drug use

10. OBGYN History
• OB score: G2P3 (3003)
• Menarche: 11 years old
• Interval: regular (28 to 30 days)
• Duration: 5 – 7 days
• Amount: 5 – 6 moderately soaked ppd
• (-) Dysmenorrhea
• LMP: Nov. 27, 2015 (5th day menses)

11. Review of Systems
• General: (-) weight loss / gain, (-) easy fatigability
• Integumentary: (-) rash, (-) pruritus, (-) skin color changes
• HEENT: (-) eye redness, (-) colds, (-) ear pain, (-) sore throat
• Respiratory: (-) cough, (-) dyspnea, (-) hemoptysis
• Cardiovascular: (-) chest pain, (-) palpitation, (-) orthopnea
• Gastrointestinal: (-) diarrhea, (-) constipation, (-) melena, (-)
hematochezia
• Genitourinary: (-) dysuria, (-) frequency, (-) urgency, (-) hematuria
• Endocrinologic: (-) polyuria, (-) polydipsia, (-) heat / cold intolerance
• Hematologic: (-) easy bruisability, (-) bleeding tendencies
• Neurologic: (-) dizziness, (-) seizures, (-) loss of consciousness

12. Physical Examination
• General Survey: Conscious, coherent,
ambulatory, not in cardiorespiratory distress
• Vital Signs:
– BP: 110/70 mmHg
– HR: 103 bpm
– RR: 19 cpm
– Temp: 36.7oC
– O2 sat: 98%
– Weight: 125 lbs
– Height: 5’2”
– BMI: 22.86 kg/m2 (normal)

13. Physical Examination
• Skin: Warm to touch, good skin turgor
• HEENT: Anicteric sclerae, pink palpebral
conjunctivae, no nasoaural discharge,
no tonsillopharyngeal congestion, no
cervicolymphadenopathy
• Chest & Lungs: Symmetrical chest expansion,
no retraction, clear breath sounds
• Heart: Adynamic precordium, no murmumr,
tachycardic, regular rhythm

14. Physical Examination
• Abdomen: Flabby abdomen, normoactive bowel
sound, soft, (+) direct epigastric tenderness,
(-) kidney punch test
• Extremities: Grossly normal extremities, no
edema, no cyanosis, full and equal pulses

15. Neurologic Examination
• Cerebral: Awake, alert, oriented to time, place,
person
• Cerebellar: Able to perform rapid alternating
movement and finger-to-nose tests with ease
• CN I: Able to smell
• CN II, III: Pupils equally round, reactive to light
and accomodation
• CN III, IV, VI: Intact extraocular muscles
• CN V: Able to clench jaw

16. Neurologic Examination
• CN VII: No facial asymmetry
• CN VIII: Able to hear
• CN IX, X: Uvula at midline, swallows with ease
• CN XI: Good shoulder shrug
• CN XII: Tongue at midline upon protrusion

17. Neurologic Examination
MOTOR SENSORY DEEP TENDON REFLEX
5/5 5/5
5/55/5
100% 100%
100%100%
++
++
++
++

18. Salient Features
HISTORY PHYSICAL EXAMINATION
• 27-year old female
• 3-day history of intermittent fever
• Associated symptoms:
Persistent vomiting
Headache
Muscle and joint pains
Epigastric pain
• Negative symptoms:
No bleeding tendency
No dysuria
No flank pain
No cough and colds
• Afebrile (36.7oC)
• Normotensive (110/70 mmHg)
• Tachycardic (103 bpm)
• Dry lips
• Clear breath sounds
• Direct epigastric tenderness
• Negative kidney punch test
• Full and equal pulses

19. Differential Diagnosis
URINARY TRACT INFECTION
RULE IN RULE OUT
(+) Fever (-) Dysuria
(+) Abdominal pain (-) Kidney punch test
(+) Vomiting
TYPHOID FEVER
(+) Abdominal pain Short duration of fever
(+) Vomiting Intermittent type of fever
(+) Fever
CHIKUNGUNYA
(+) Intermittent fever Join pains not so severe
(+) Joint pains

20. Admitting Impression
T/C Dengue fever syndrome

21. CBC w/ platelet count
Parameter
s
Admission 6:00 AM Parameter
s
Admission 6:00 AM
Hemoglobi
n
117 111 Monocytes 0.09 0.10
Hematocrit 0.38 0.36 Basophils 0.01 0.01
RBC count 4.70 4.39 MCV 81.5 80.9
WBC count 2.97 1.93 MCH 24.9 25.3
Segmenter
s
0.71 0.62 MCHC 306 315
Lymphocyt
e
0.19 0.27 Platelet 224 199

22. Urinalysis
Parameter Values Parameter Values
Color Light yellow Pus cells 1 – 3 / hpf
Transparency Slightly hazy RBC 6 – 8 / hpf
pH 6.5 Epithelial cells Few
Protein Trace Mucus threads Few
Glucose Negative Bacteria Occasional
Specific gravity 1.010

23. Dengue Duo
• Dengue NS1 = Positive
• Dengue IgM = Negative
• Dengue IgG = Negative

24. Blood Chemistry
Parameter Values
Sodium 138.20 mmol/L
Potassium 3.33 mmol/L
SGPT 20.50 U/L

25. Plan
• Diet: DAT, avoid dark colored foods
• IVF: PNSS 1 L @ 170 cc/hr
• Investigations:
• CBC w/ PC
• Dengue NS1 and Duo
• Urinalysis
• Na, K
• SGPT
• Therapeutics:
• Paracetamol 500 mg/tab 1 tablet Q4 PRN T > 37.8oC
• Paracetamol 300 mg/tab IV Q4 PRN T > 38.5oC
• Omeprazole 40 mg/tab 1 tablet ODBB
• Metoclopramide 1 amp IV Q8 PRN for nausea and vomiting

26. Dengue Fever

27. Etiology
• Vectors: Aedes aegypti and Aedes
albopictus
• Family: Flaviviridae
• Genus: Flavivirus
• Serotypes: DEN-1 upto DEN-4

28. Epidemiology
• Dengue is the most rapidly spreading
mosquito-borne viral disease in the world
• Estimated 50 million dengue infections
occur anually
• Dengue has been reported predominantly
among urban and peri-urban populations
where high population density facilitates
transmission

29. Pathophysiology
• Incubation period: 4 – 10 days
• Plasma leakage, hemoconcentration,
homeostasis abnormalities characterize
severe dengue
• Endothelial activation, rather than
destruction, mediate plasma leakage via
activation of infected monocytes, T cells,
complement system and inflammatory
mediators

30. Pathophysiology
• Thrombocytopenia is associated with
alterations in megakaryocytopoiesis by
infection of human hematopoietic cells and
impaired progenitor cell growth
• This results in platelet dysfunction, increased
platelet destruction or consumption
• Hemorrhage is a consequence of
thrombocytopenia, platelet dysfunction, or
disseminated intravascular coagulation

31. Clinical Manifestations
& Dengue Classifications

32. Clinical Manifestations

33. Clinical Manifestations

34. Clinical Manifestations

35. Course of the Disease

37. Febrile Phase
• Acute febrile phase lasts 2 – 7 days
• A positive tourniquet test may increase the
probability of dengue
• Mild hemorrhagic manifestations like
petechiae and mucosal membrane
bleeding may be seen
• The earliest abnormality in the CBC is
progressive decrease in WBC

38. Critical Phase
• Occurs on the 3rd up to the 7th day of illness
• Lasts for 24 – 48 hours
• Increased capillary permeability
• Increasing hematocrit (hemoconcentration)
• Shock occurs when a critical volume of plasma is lost
through leakage (preceded by warning signs)
• Those who improve after defervescence are said to
have non-severe dengue
• Some patients progress to the critical phase of plasma
leakage without defervescence. In such case, changes
in CBC is used to guide the onset of critical phase and
plasma leakage

39. Recovery Phase
• Gradual reabsorption of extravascular
compartment fluid takes place following 48
to 72 hours
• Herman’s rash, generalized pruritus, and
bradycardia are common during this stage
• Fluid overload is to be watched out during
this phase of dengue

41. Treatment
• Fluids is the mainstay of treatment for
patients with dengue with or without
warning signs

42. Treatment
• Dengue with warning signs
• 5 – 7 ml/kg/hr for 1 – 2 hours
• 3 – 5 ml/kg/hr for 2 – 4 hours
• 2 – 3 ml/kg/hr according to clinical response
• Reassess clinical status and repeat Hct
• If Hct is the same or rises minimally, continue the
same rate for 2 – 4 hours
• If VS worsens with rising Hct, increase rate to 5 – 10
ml/kg/hr for 1 – 2 hours.