This document describes the case of a 70-year-old diabetic and hypertensive male who presented with fever, difficulty breathing, and drowsiness. Clinical examination found signs of pneumonia and sepsis. Investigations revealed dengue infection (positive IgM, IgG, NS1), metabolic encephalopathy, and hemorrhagic pleural effusion. The patient was diagnosed with dengue with acute lung injury and pneumonia. He received IV antibiotics, fluids, bronchodilators and supportive care. His condition improved with resolution of pneumonia seen on follow up imaging. The document then discusses dengue infection, its types and manifestations, diagnostic evaluation, and management including fluid resuscitation and symptomatic treatment.

1. Dr. Manikandan R
DNB PG ( INT MED)
Sundaram Arulrhaj Hospitals

2. HISTORY
 A 70 Years old Diabetic and Hypertensive,Old CVA male
came to Emergency department with Complaints of Fever
since 5 days with difficulty in breathing since 1 day,
Drowsiness and Restless+.
Fever was
 Intermittent
 chills & Rigor
 No h/o Vomiting / Loose stools
 No h/o burning Micturition
Past history : Diabetes and Hypertension of over 12 years
duration on OHA.

3. EXAMINATION
 O/E:
Conscious, Febrile- Temp- 100 F, BP-150/80,
HR-88/mt, RR-24/mt, Spo2- 84%,restless,dehydrated
Pale ,Not Icteric, No Lymphadenopathy / Pedal odema
 Systemic Examination:
RS- BAE+,Rt Lower zone Minimal basal crepts
CVS- S1 S2+
P/A- Soft,Non tender,No organomegaly,
CNS- No signs of Meningeal irritation,Drowsy,Mild
Restless

4. CLINICAL DIAGNOSIS
Pneumonitis Rt Lower lobe
Sepsis(?Aspiration)
Metabolic Encephalopathy
Tuberculosis
Malaria
Typhoid
Dengue
T2DM/HTN

5. INVESTIGATION
 HB- 11.6gms
 Total count- 9,600
 ESR – 6/13mm
 Platelets- 2.33 lakhs
 Sugar- 212 mg/dl
 Urea- 32
 Creatinine- 1.0
 Total bilirubin- 1.0
 Direct bilirubin-0.6
 S.Protein- 7.0 Albumin-4.2
 S.ALP- 82
 SGOT/SGPT- 25/94
 Electrolytes- 123/4.1/103/23
 Calcium-8.6
URINE:
Albumin/Sugar - ++/++
Pus cells- 8-10, Epithelial cells-4-
6
BS/BP- Nil
 MP(ICT)- Negative
 Widal- negative
 Dengue(IgM,IgG& NS1)-
Positive
 CK- Negative
 HIV/HbsAg- Negative
Urine C/S- Ecoli growth
Blood C/S- No Growth

6. INVESTIGATION
 ADA-30.2
 Mx-Negative
 Chest X-Ray- Rt Sided
Pneumonitis(ML>LL).
 ECG- T Wave Inversion in
Anterior leads
 ECHO- RA,RV
Dilated,Mild TR,EF-
68,LVDD+,Mod PHT.
 USG Abdomen- Bilateral
Isoechoic kidneys, Rt
Minimal Pleural Effusion.

7. INVESTIGATION
 CT CHEST:
Rt Moderate Pleural
Effusion,Interstitial
septal thickening at
Bilateral Upperlobes.Few
Mediastinal
Lymphnodes.
CT BRAIN:
Bilateral Periventricular
white matter ischaemic
changes,Cerebral
Atrophic changes seen.

8. Course in the Hospital
 On admission to ER ,Patient was given Nasal O2,
 Started on Empirical Antibiotic therapy Meropenem &
Moxifloxacin, Bronchodilators,Caripill(Papaya
Extract),Nilavembu Kashayam and 3%NS.
 Percutaneous USG Guided Pleural Tapping
done,250ml of Hemorrhagic Pleural fluid apirated.
 Strict Diabetic and Hypertension control
 Adequate Hydration
 Fluid C/S Showed No growth,
 Gram stain- No organism

9. FINAL DIAGNOSIS
 DENGUE WITH ACUTE LUNG INJURY
 PNEUMONITIS WITH HEMORRHAGIC PLEURAL EFFUSION(RT)
 METABOLIC ENCEPHALOPATHY
 COMORBID :
> Type II DM/HTN/old CVA.

10. Followup CXR
 Resolving Pnemonitis.

 F/U Electrolytes-146/3.6/107/22 and Ca2+ 8.8
 Platelet-2.3lakhs

11. DISCUSSION
DENGUE
 Dengue fever is a mosquito-borne tropical disease caused
by the dengue virus (Flavi virus – Aedes egyptii Mosquito)
 Incubation period: 1-10 days
 Symptoms typically begin three to fourteen days after
infection.
 This may include a high fever, headache,
vomiting, muscle and joint pains , and a characteristic skin
rash . Recovery generally takes two to seven days.
 In a small proportion of cases, the disease develops into the
life-threatening dengue hemorrhagic fever, resulting
in bleeding, low levels of blood platelets and blood
plasma leakage, or into dengue shock syndrome,
where dangerously low blood pressure occurs.

13. Types Of Dengue Fever:
1.Classical (Simple) Dengue Fever
2.Dengue Hemorrhagic Fever(DHF)
3.Dengue Shock Syndrome(DSS)

14. DENGUE HEMORRHAGIC FEVER
Any Patient with Following 4 criteria
1) Acute Onset of fever for 2-7 days
2)Hemorrhagic Manifestation,atleast one
(-ve tourniquet test,Petechiae,echymosis or
GI Bleed)
3) Thrombocytopenia(<1 lakh)
4) Evidence of plasma leak (Hematocrit>20%,
Pleural effusion, low serum albumin)

15. DENGUE SHOCK SYNDROME(DSS)
All Criteria of DHF + evidence of Circulatory
Failure like
1)Rapid and weak pulse
2)Narrow pulse pressure(20mm hg)
3) Hypotension(<80/60)

16. WHO GRADING OF DHF
Useful in case of Epidemics
Grade 1-No shock only +ve tourniquet
Grade 2-No shock,Spontaneous bleeding
Grade 3-Shock
Grade 4-Profound Shock

17. INVESTIGATIONS
 Physical Examination
 Tourniquet test
 Hb,TC.DC,ESR,Platelet Count,Hematocrit
 Fever Panel(MP,Widal,Ck,Dengue,H1N1)
 Sugar,Urea,Creatinine
 Liver Function test
 Chest X ray
 USG Abdomen
 CT Chest if necessary

18. Treatment
 Oral Rehydration Therapy
 IV Fluid therapy
 NSAIDS for fever
 Bronchodilators
 Papaya Extract
 FFP/Platelet Transfusion, If Hematocrit is decreasing –
Packed cell or Whole blood is recommended.
 Can use Loop diuretic(if fluid overload)
 Symptomatic treatment- pleural or Ascitic tap.

21. Take home message
 Dengue infection is preventable
disease
No direct person to person
transmission
Prevent Man-Mosquito contact to
prevent the disease.
Treatment is Rest, Fluids and
Antipyretics.
Tetravalent vaccine in development.

22. Thank you