This document is a curriculum vitae for Dr. Djatnika Setiabudi that provides biographical information such as date of birth, address, education history, employment history, and areas of specialization. It lists that Dr. Djatnika Setiabudi received a medical doctorate from Universitas Padjadjaran in 1982, became a pediatrician specialist in 1992, obtained a Master's degree in Clinical Tropical Medicine in 2003, and received a doctorate in medicine from Universitas Padjadjaran in 2013. Currently, Dr. Djatnika Setiabudi works as the Head of the Infection and Tropical Disease Division at the Department of Child Health at Hasan Sad

1. Curriculum Vitae
Nama : Dr. dr. Djatnika Setiabudi, Sp.A(K), MCTM (Trop Ped)
Lahir : Bandung, 1 Januari 1958
Alamat : Jl Muliagraha II/14, Ciwastra-Bandung, Telp. 022-751-1137
email: djatnika_setiabudi@yahoo.com; HP 081-123-2417
Pekerjaan : - Kepala Divisi Infeksi dan Penyakit Tropik,
KSM/Departemen Ilmu Kesehatan Anak RSHS - FK Unpad
Pendidikan: - Dokter, Fakultas Kedokteran UNPAD : 1982
- Dokter Spesialis Anak, FK UNPAD : 1992
- Master of Clinical Tropical Medicine (Trop. Ped.);
Faculty of Tropical Medicine, Mahidol University : 2003
- Konsultan Infeksi/Penyakit Tropik, Kolegium IDAI : 2005
- Doktor, bidang Ilmu Kedokteran, Unpad : 2013

2. Pitfalls of Dengue Management
in COVID-19 Pandemic
Djatnika Setiabudi
UKK Infeksi dan Penyakit Tropis
PP IDAI

3. Outline
Pendahuluan
Just remainding: perjalanan penyakit dengue
Pitfall: arti dan akibatnya
Pitfall dalam diagnosis dan indikasi rawat
Pitfall dalam tata laksana
Pitfall dalam pemantauan
Pitfall dalam pelaporan
Take home message

4. Pendahuluan
 Infeksi dengue masih menjadi masalah kesehatan termasuk di Indonesia
 Salah satu faktor yang memperburuk penyakit adalah terdapat beberapa pitfall:
 pitfall dalam diagnosis dan penentuan rawat inap, sehingga datang ke rumah
sakit sudah dalam keadaan berat
 pitfall dalam tata laksana (terapi cairan) sehingga tidak cepat teratasi atau
sebaliknya terjadi overload
 pitfall dalam pemantauan sehingga terlambat deteksi gangguan sirkulasi (syok)
dan perdarahan yang tersembunyi
 Khusus dalam masa pandemi COVID-19, ada sebagian orangtua khawatir membawa
anaknya yang sakit ke fasilitas kesehatan sehingga datang dalam keadaan berat atau
para klinisi tidak memikirkan kemungkinan dengue pada pasien suspek COVID-19
atau co-infeksi COVID-19 terkonfirmasi dengan Dengue

5. The global strategy for dengue prevention and control,
2012–2020

6. Incidence rate (per 100,000 person-years) and case fatality rate (%)
of dengue hemorrhagic fever in Indonesia from 1968 to 2017
Harapan et al. Epidemiology of dengue hemorrhagic fever in Indonesia: analysis of five decades data from
the National Disease Surveillance BMC Res Notes.2019;13:350.https://doi.org/10.1186/s13104-019-4379-9

7. Geographical mapping the provincial incidence rate of
dengue hemorrhagic fever (per 100,000 population)
in Indonesia from 2011 to 2016
Geographical mapping of the provincial case fatality rate
of dengue hemorrhagic fever (%) in Indonesia
from 2011 to 2016
Harapan et al. Epidemiology of dengue hemorrhagic fever in Indonesia: analysis of five decades data from
the National Disease Surveillance BMC Res Notes.2019;13:350.https://doi.org/10.1186/s13104-019-4379-9

8. Lu X, Bambrick H, Pongsumpun P, Dhewantara PW, Toan DTT, Hu W (2021) Dengue outbreaks
in the COVID-19 era: Alarm raised for Asia. PLoS Negl Trop Dis 15(10): e0009778.
Reported monthly case numbers of dengue in Australia, China (Mainland), Indonesia, Thailand, and
Vietnam for 2015–2019 average, and in 2020, shown against monthly cases of COVID-19 in 2020

9. Ending the burden of dengue infection: Indonesia
• On 30 July 2021: launched the 2021-2025 National Strategic Plan for Dengue Control Programme
• National targets: By 2025
≥ 90% districts to achieve an Incidence rate (IR) < 49/100 000 and Case fatality rate (CFR) < 0.5%
• Strategies:
(1) enhancing effective, safe, and continuous vector management;
(2) improving access to and quality of dengue case management;
(3) strengthening comprehensive dengue surveillance and responsive outbreak management;
(4) increasing sustainable community engagement;
(5) strengthening government commitment, policy and programme management, and
partnership;
(6) improving assessment, invention, innovation, and research as the basis of evidence-based
policy and programme management.

10. Apa itu Pitfall…….?
 Arti Pitfall : jebakan, lubang perangkap,batu sandungan, kesulitan tersembunyi
 Kamus bahasa Inggris:
an unsuspected difficulty or danger
Collins English Dictionary. Copyright © HarperCollins Publishers
an unsuspected difficulty, danger, or error that one may fall into
Webster’s New World College Dictionary, 4th Edition. Copyright © 2010 by Houghton Mifflin Harcourt.
a particular activity or situation are the things that may go wrong or may cause
problems.
COBUILD Advanced English Dictionary. Copyright © HarperCollins Publishers
 Dalam kedokteran:
suatu tindakan yang dilakukan (semestinya tidak perlu) atau tidak melakukan
(yang semestinya harus dikerjakan) sehingga berpotensi menimbulkan
kerugian atau bahaya pada pasien

11. Perjalanan penyakit infeksi dengue
Sejak kapan pasien demam?
Penting untuk menghitung hari
ke berapa mulai timbul demam
Perhatikan setiap fase
mempunyai masalah berbeda
Pola kinetik Ht dan trombosit
pada setiap fase berbeda
Uji diagnostik perlu diperhatikan
pada setiap fase
Fase perjalanan penyakit
sangat penting !!!

13. Pitfalls dalam Diagnosis dan Indikasi Rawat
 Tidak mencurigai diagnosis Infeksi
Dengue, apabila:
 ditemukan ruam (morbiliform)
- lebih ke diagnosis demam ruam selain
dengue seperti morbili, rubella dan
chikungunya
- Ruam merupakan salah satu kriteria
probable dengue !!!
 tidak ada perdarahan kulit spontan:
(petekie, purpura, ekimosis)
 lakukan uji tourniquet
Probable Dengue
- Tinggal atau riwayat traveling ke
daerah endemis dengue
- Demam disertai dengan 2 kriteria
sebagai berikut:
1. Nausea/vomitus
2. Ruam (rash)
3. Nyeri kepala/ otot/ sendi
4. Uji Tourniquet positif
5. Leukopenia
6. Ada warning sign apapun
Sumber: Dengue guidelines WHO 2009, WHO-SEARO 2011

14. Pitfalls dalam Diagnosis dan Indikasi Rawat
Kurang atau tidak mencari
adanya warning sign
 Penting untuk indikasi rawat
 sebagai acuan untuk tatalaksana
(khususnya terapi cairan)
 dapat dipakai untuk memantau
atau deteksi dengue berat
Tabel Warning sign (PNPK TATA LAKSANA INFEKSI DENGUE ANAK DAN REMAJA 2021)
Sumber: Morra ME, dkk. Definitions for warning signs and signs of severe dengue according to the
WHO 2009 classification: Systematicreview of literature. Rev Med Virol. 2018 Jul;28(4):e1979.

15. Pitfalls dalam Diagnosis dan Indikasi Rawat
Kurang atau tidak
mencari faktor-faktor risiko
yang dapat memperberat Infeksi
dengue:
 mempermudah terjadi komplikasi
atau kegagalan organ
dapat dijadikan sebagai
indikasi rawat inap
High-risk patients :
 infants
 obesity
 peptic ulcer disease
 women who have menstruation or abnormal
vaginal bleeding
 haemolytic diseases such as glucose-6-
phosphatase dehydrogenase (G-6PD) deficiency,
thalassemia and other haemoglobinopathies
 congenital heart disease
 chronic diseases such as diabetes mellitus,
hypertension, asthma, ischaemic heart disease,
chronic renal failure, liver cirrhosis
 patients on steroid or NSAID treatment
Sumber: Dengue Guidelines, WHHO-SEARO regional, 2011

16. Pitfalls dalam Diagnosis dan Indikasi Rawat
Pemeriksaan laboratorium
diagnostik dilakukan pada waktu
yang tidak tepat
NS1 antigen dengue masih diperiksakan
pada hari sakit lebih dari hari ke-5
 seharusnya pada hari ke 2 - 4
Serologis (IgM dan IgG) diperiksakan
terlalu awal
 seharusnya setelah hari ke-5
!!! Pemeriksaan NS1 antigen positif
saja bukan indikasi rawat inap !!!
Simmons CP et al. N Engl J Med. 2012;366:1423-1432

17. Pitfalls dalam Tata Laksana
.
Tindakan Potensi Komplikasi
Terlalu dini/agresif memberi IVFD
Overload dengan komplikasi:
memperberat efusi pleura,
edem paru, distress napas
Terlambat menghentikan/
memperlambat tetesan IVFD
Terlalu cepat menurunkan cairan
pada pasien DSS
syok berulang, sehingga tata
laksananya lebih sulit
Terlambat memberikan cairan
koloid pada kebocoran plasma
yang hebat (syok tidak teratasi
dengan cairan kristaloid)
Prolonged shock, komplikasi:
Perdarahan hebat sampai DIC,
hipoksia organ vital
(multiple organ dysfunction
sampai multiple organ failure)
Prinsip 4 J pada pemberian cairan:
1. Jalan atau Jalur pemberian
- apakah masih dapat per oral atau harus
diberikan melalui i.v.
2. Jenis cairan yang diberikan
- per oral : oralit/cairan elektrolit, jus buah
- IVFD: rumatan vs rehidrasi vs resusitasi
kristaloid vs koloid
3. Jumlah yang dibutuhkan:
- rumatan, rehidrasi (DMC), resusitasi
- umumnya berdasarkan berat (Kg)
(obesitas: berat ideal, maks. 40 kg)
4. Jadwal pemberian:
- bagi rata untuk kebutuhan 24 jam
- diberikan dalam waktu tertentu,
disesuaikan dengan klinis dan hasil lab (Ht)
- bolus 1 – 2 jam atau 15 – 30 menit
!!! Untuk pasien dengue berikan cairan sesuai kebutuhan !!!

18. Pitfalls dalam Tata Laksana
.
Tindakan Akibat atau kerugian
Terlambat memberi transfusi darah pada perdarahan
masif tersembunyi
Prolonged shock, komplikasi:
Perdarahan hebat sampai DIC, hipoksia organ vital
(multiple organ dysfunction sampai multiple organ
failure)
Terlalu agresif memberi suspensi trombosit
(Transfusi tidak berdasar indikasi yaitu trombositopenia
disertai perdarahan nyata hebat atau bila tidak ada
perdarahan nyata jumlah trombosit < 10.000/mm3)
• Tidak dapat mencegah perdarahan hebat
• Meningkatkan efek simpang (adverse effects)
- Hemolytic Transfusion Reactions
- Febrile Non-Hemolytic Reactions
- Allergic Reactions ranging from urticaria to anaphylaxis
- Septic Reactions
- Transfusion Related Acute Lung Injury (TRALI)
- Circulatory Overload
- Transfusion Associated Graft Versus Host Disease
• Meningkatkan lama hari rawat
• Meningkatkan biaya perawatan
Terlambat/lupa memberi Oksigen pada DSS hipoksia organ vital (multiple organ dysfunction sampai
multiple organ failure)

19. Improved *REASSESS
Obtain reference HCT before starting IVF therapy
Start with isotonic
crystalloids
5–7 ml/kg/hr for 1–2
hours
* Reassess haemodynamic state
1. Vital signs
2. “5-in-1 magic touch”: CCTV-R
Colour
Capillary refill time
Temperature
Volume of pulse
Rate
3. Urine volume
IV isotonic crystalloids^
3–5 ml/kg/hr for 2–4 hours
IV isotonic crystalloids^
2–3 mL/kg/hr for 2–4 hours
Clinical improvement or
improved oral intake,
reduce IVF accordingly
Stop IVF therapy within
24–48 hours
If improvement in oral intake,
HCT remains same or minimal high:
1. Step-wise reduction in IVF
2. Consider glucose-electrolyte for
children
Continue to monitor patient until out
of critical period
Stop IVF within 24–48 hours
Group B: Dengue with warning signs (not in shock)
– Inpatient fluid management
3
Start IV isotonic crystalloids
5–7 ml/kg/hr for 1–2 hours
Increase IV
crystalloids
5–10 ml/kg/hr for 1–2
hours
Bleeding?
Consider "Severe
Dengue"
algorithm
Obtain reference HCT before starting IVF
* Reassess the patient’s clinical condition (vital signs, 5-in-1 magic touch – CCTV-R and urine output) and
decide on the situation.
*REASSESS Not improved
Improved
IV crystalloids
3–5 mL/kg/hr for 2–4 hours
IV crystalloids
2–3 mL/kg/hr for 2–4 hours
Clinical improvement or
improved oral intake,
reduce IVF accordingly
Stop IV fluids at 48 hours
Check haematocrit
Increasing
Or high HCT
Decreasing
HCT
Group B: Dengue with warning signs (not in shock)
– No improvement after first bolus (cont.)
5
Sumber : WHO-TDR guidelines. 2009

20. Sumber : WHO-TDR guidelines. 2009

21. Thrombocytopenia and Platelet Transfusions in Dengue
Haemorrhagic Fever and Dengue Shock Syndrome
• In conclusion:
a large number of patients with DHF/DSS in Bandung hospitals receive p
latelet transfusions, even if thrombocyte counts are above 25,000/μl.
This study suggests that in most DHF/DSS cases, platelet transfusions do
not influence the incidence of severe bleeding.
Treatment costs for DHF/DSS cases could be reduced if these unnecessa
ry platelet transfusions are avoided
Chairulfatah A, Setiabudi D, Agoes R, Colebunders R. Dengue Bulletin.2003;27:138-43

22. Role of platelet transfusion in children with bleeding in
dengue fever
• Interpretation & conclusion:
Platelet transfusion was required in children with severe dengue infection in
the form of significant spontaneous bleed, shock and severe
thrombocytopenia
Bleeding should not be considered only indicator to transfuse platelets as it
occurred in children even with normal platelet counts.
The community and treating physicians should be educated regarding the
judicious transfusion of platelets.
Unnecessary and empirical use of platelets should be completely avoided
especially during an epidemic when there is scarcity in its availability.
Pothapregada S, Kamalakannan B, Mahalakshmy M. J Vector Borne Dis.2015;52:304–8.

23. Prophylactic and therapeutic interventions for bleeding in dengue:
a systematic review
• Conclusions
1) Prophylactic platelet transfusion should not be routinely prescribed in patients with
dengue with no bleeding based on low platelet count.
2) Therapeutic platelet transfusion should not be routinely prescribed in patients with
dengue with thrombocytopenia and mild bleeding.
3) There is inadequate evidence to support or refute the use of platelet transfusion in
patients with severe bleeding in dengue.
4) There is a need for further, well-designed RCTs to evaluate the role of platelets and
plasma transfusion in patients in both the prevention of bleeding and in the setting
of clinically significant bleeding in dengue infection.
5) There is currently insufficient evidence regarding the role of rFVIIa, anti-D globulin,
Ig or tranexamic acid in the prevention or treatment of bleeding in dengue infection
and there is a place for further research on these therapeutic agents.
• Currently there is no evidence that any of the above interventions would have a
beneficial effect in preventing or treating clinically significant bleeding in dengue.
Rajapakse S, de Silva NL, Weeratunga P, Rodrigo C, Fernando SD.
Trans R Soc Trop Med Hyg. 2017; 111: 433–9

24. Safety and costs of blood transfusion practices
in dengue cases in Brazil
• Conclusion
Transfusion without following WHO recommendations increased the
time and cost of hospitalisation.
Receiving a transfusion increased the hospitalization time by 1.29
days (p = 0.0007; IRR = 1.29), and the costs were 5.1 times higher
than those without receiving blood components (IRR = 5.1; p< 0.001;
median US$ 504.4 vs US$170.7).
In contrast, patients who were transfused according to WHO criteria
had a reduction in costs of approximately 96% (IRR = 0.044; p<0.001;
β = -3.12) compared to that for those who were not transfused
according to WHO criteria.
Machado AAV, Negrão FJ, Croda J, deMedeiros ES, Pires MAdS. PLoS ONE 2019 14(7):
e0219287. https://doi.org/10.1371/journal.pone.0219287

25. Pitfalls dalam Pemantauan
 Deteksi gangguan sirkulasi (syok) jangan terfokus pada pemeriksaan tekanan darah
saja (CCTVR)
 Deteksi tanda-tanda perdarahan (saluran cerna) jangan menungu sampai timbul
hematemesis-melena
 Pemantauan harus berdasarkan asesmen klinis dan pemeriksaan laboratorium (serial)
 Pemeriksaan serial Hematokrit dan trombosit jangan dianggap pemeriksaan rutin,
tapi harus dianggap pemeriksaan cito yang hasilnya ingin segera diketahui
Jangan lupa memantau balans cairan dan diuresis

26. Pitfalls dalam Pemantauan
Hari sakit
emp
Klinis memburuk, lemah,
tidak ada nafsu makan
gelisah, tangan kaki dingin,
nafas cepat, diuresis berkurang,
Time of fever defervescence
Kurang memahami
makna dari penurunan
suhu tubuh (defervescence)
• Penurunan suhu tubuh dapat
berarti dua keadaan yang sangat
berbeda:
1. Pasien menuju ke arah perbaikan
(penyembuhan) bila disertai
perbaikan keadaan klinis
2. Sebailknya bila keadaan klinis
memburuk, berarti masuk ke
dalam fase kritis (syok)

27. Pitfalls dalam Pemantauan
• Kurang memahami makna dari penurunan hematokrit pada saat pemantauan
• Penurunan nilai hematokrit dapat berarti dua keadaan yang sangat berbeda:
1. Pasien menuju ke arah perbaikan bila penurunan hematokrit disertai perbaikan
keadaan klinis
2. Sebailknya bila keadaan klinis pasien kurang baik atau memburuk, nyeri perut
bertambah hebat, nadi cepat dan syok ( atau bila sebelumnya sudah syok , tidak
membaik dengan pemberian cairan yang cukup), maka harus dicurigai terjadi
perdarahan saluran cerna yang tersembunyi.
 lihat tatalaksana syok

28. Pearls dalam pemeriksaan klinis pasien dengue
Pegang tangan pasien untuk mengevaluasi perfusi perifer
Selamatkan jiwa dalam 30 detik dengan mengenali shock

29. Pemantauan Selama Fase Kritis
• Keadaan umum, nafsu makan, muntah, perdarahan serta tanda dan
gejala lainnya
Monitoring
• Sesering mungkin sesuai indikasi
Perfusi
perifer
• Tiap 2-4 jam pada pasien yang tidak shock
• Tiap 1-2 jam pada pasien shock
Tanda vital
• Tiap 4-6 jam pada kasus stabil (ideal), atau sesuaikan dengan fase
penyakit
• Lebih sering pada pasien tak stabil atau curiga perdarahan
Hematokrit
serial
• Tiap 8-12 jam pada kasus tanpa komplikasi
• Tiap jam pada profound/prolonged shock atau kelebihan cairan
Diuresis

30. Pitfalls dalam Pelaporan
• Seberapa sering kita melakukan pelaporan kasus dengue..?
• Kapan kita harus membuat laporan..?
• Apa saja yang harus dilaporkan..?
• Kemana saja laporan harus disampaikan..?
Hospital-based Surveillance: Accuracy, Adequacy, and
Timeliness of Dengue Case Report in Bandung, West Java,
Indonesia of 2015
Data from Bandung Municipality Health Authority revealed
that only 1553 (45.7%) of 3397 hospitalized cases with
suspected DF,DHF,and DSS were reported.
The timeliness of report was varied, ranging from days to
month.
Adrizain R, Setiabudi D, Chairulfatah A. J Global Infect Dis. 2018;10:201-5.
Hospital based clinical surveillance for dengue
haemorrhagic fever in Bandung, Indonesia 1994–1995
Only 199 (31%) of the 650 hospitalised cases with
suspected DHF/DSS were reported to the Bandung
Municipality Health Office. The percentage of fatal cases
was significantly lower among all hospitalised cases
11/650 (1.7%) than among reported cases 5/199 (2.5%).
Chairulfatah A, Setiabudi D, Agoes R, van Sprundel M, Colebunders R.
Acta Tropica. 2001;80(2):111-5

31. Approach to diagnosis of suspected co-infection
(Dengue and COVID-19)
• A high index of suspicion must be maintained for epidemic prone diseases
prevalent in a particular geographic region
• a high index of suspicion of dengue must be there when a fever case is
diagnosed as COVID-19, particularly during the rainy and post rainy season
in areas endemic for these diseases.
• Dengue can coexist with other infections
 confirmation of dengue infection does not rule out the possibility of the
patient not suffering from COVID-19.

32. The Differences Criteria of Dengue and COVID-19
Probable Dengue criteria (WHO 2009) Suspected COVID-19 Criteria (WHO)
Patient lives in or traveled to dengue-endemic area and
fever AND two or more of the following clinical features:
Acute onset of fever AND cough; OR
Acute onset of ANY THREE OR MORE of the following signs or
symptoms:
Nausea, vomiting
Rash
Aches and pains (formerly, headache, eye pain, myalgia,
and arthralgia)
Tourniquet test positive
Leukopenia
Any Warning Signs*
Abdominal pain or tenderness
Persistent vomiting
Clinical fluid accumulation
Mucosal bleed
Lethargy or restlessness
Liver enlargement > 2 cm
Laboratory finding of increasing HCT concurrent with rapid
decrease in platelet count
fever,
cough,
general weakness/fatigue,
headache, myalgia,
sore throat, coryza (rhinorrhea), dyspnea,
anorexia/nausea/ vomiting,
diarrhea,
altered mental status.
*Some COVID-19 cases with cutaneous manifestation:
- Morbilliform rash, varicellaform rash, urticarial rash

33. Clinical features of Dengue vs COVID-19
Dengue Infection COVID-19
Onset Incubation period 3 – 14 days
(onset of symptom average 4 – 7 days)
Acute onset of high-grade continuous fever
Incubation period 2 – 14 days
(onset of symptom average 5 – 7 days)
Acute onset of low to moderate continuous fever
Symptoms fever, headache, retro-orbital pain, myalgia, arthralgia
nausea/ vomiting,
Rash, bleeding
cough, sore throat, rhinorrhea, dyspnea
Fever, myalgia, headache
diarrhea, vomiting, abdominal pain
Signs Bleeding manifestations or Positive Tourniquet test
Signs of hypotension and shock
Tachypnea, decreased oxygen saturation
Multi organ failure
Warning signs Abdominal pain or tenderness
Persistent vomiting
Clinical fluid accumulation
Mucosal bleed
Lethargy or restlessness
Liver enlargement > 2 cm
Laboratory finding of increasing HCT concurrent with
rapid decrease in platelet count
Respiratory distress SpO2 < 94%
MIS-C
Complication Hypovolemic shock, severe bleeding,
Severe organ involvement, metabolic derangement
ARDS, pulmonary embolism, respiratory failure
Arrythmia, acute cardiac injury, acute stroke

34. Characteristics of SARS-CoV-2 and dengue virus co-infection
Tsheten, et al. Clinical features and outcomes of COVID-19 and dengue co-infection: a systematic review.
BMC Infect Dis. 2021; 21:729 https://doi.org/10.1186/s12879-021-06409-9

35. Comparison of Dengue and MIS-C in Hospitalized Children
Dengue (n = 44) MIS-C (n = 40) p value Odds ratio (CI, 95%)
Age (months) 91.6 (35) 83.5 (39) 0.316 -
Sex (boys) 27 (61.4%) 26 (65%)
Fever 43 (97.7%) 39 (97.5%) 0.946 -
Vomiting 32 (72.7%) 20 (50%) 0.044 2.53 (1.02 – 6.31)
Abdominal pain 30 (68.2%) 23 (57.5%) 0.311 -
Myalgia 17 (38.6%) 4 (10%) 0.002 1.89 (1.33 – 2.69)
Edema 14 (31.8%) 7 (17,5%) 0.130 -
Petechiae 13 (29.5%) 3 (7.5%) 0.010 1.78 (1.25 – 2.53)
Headache 10 (22.7%) 1 (2.5%) 0.006 1.95 (1.43 – 2.66)
Rash 10 (22.7%) 29 (72,5%) < 0.0001 2.61 (1.58 – 4.32)
Diarrhea 5 (11.4%) 12 (30.0%) 0.029 1.72 (1.13 – 2.63)
Conjunctival injection 1 (2.3%) 24 (60.0%) < 0.0001 3.54 (2.31 – 5.42)
Oral mucosal changes 0 11 (27.5%) < 0.0001 2.52 (1.90 – 3.34)
Randhawa MS, et al. Comparison of Multisystem Inflammatory Syndrome (MIS-C) and Dengue
in Hospitalized Children. Indian J Pediatr.2022.https://doi.org/10.1007/s12098-022-04184-2

36. Comparison of Dengue and MIS-C in Hospitalized Children
Dengue (n = 44) MIS-C (n = 40) p value Odds ratio (CI, 95%)
Hepatomegaly 30 (68.2%) 11 (27.5%) < 0.0001 5.46 (2.13 – 14.00)
Liver dysfunction 25 (56.8%) 9 (22.5%) 0.001 1.94 (1.29 – 2.91)
Shock at admission 20 (45.5%) 17 (42.5%) 0.785 -
Acute kidney injury 11 (25.0%) 18 (45.0%) 0.120 -
Lymphadenopathy 2 (4.5%) 2 (5%) 0.902 -
Splenomegaly 1 (2.3%) 1 (2.5%) 0.931 -
Gallop rhythm 0 6 (15.0%) 0.008 2.29 (1.78 – 2.95)
Fluid bolus at admission 19 (43.2%) 14 (35.0%) 0.345 -
PICU admission 19 (43.2%) 34 (85.0%) 0.007 1.98 (1.15 – 3.40)
Vasoactive/inotrope 17 (38.6%) 24 (60.0%) 0.051 1.57 (0.99 – 2.51)
Invasive ventilation 10 (22.7%) 9 (22.5%) 0.970 -
Renal replacement th/ 4 (9.0%) 0 0.050 2.00 (1.61 – 2.49)
Randhawa MS, et al. Comparison of Multisystem Inflammatory Syndrome (MIS-C) and Dengue
in Hospitalized Children. Indian J Pediatr.2022.https://doi.org/10.1007/s12098-022-04184-2

37. Medicolegal Pitfalls
 Failure to admit patients with signs and symptoms of intravascular
volume loss for intravenous hydration
 Failure to administer appropriate fluids to patients with dengue
hemorrhagic fever or dengue shock syndrome
 Failure to notify public health authorities about suspected cases of
dengue infection
Medscape Pediatrics

38. • EMPAT LANGKAH TATA LAKSANA DENGUE:
1. Diagnosis dini dan indikasi rawat inap yang tepat
(termasuk pemeriksaan laboratorium diagnostik pada waktu yang tepat)
2. Terapi cairan cepat dan adekuat (tidak kekurangan maupun kelebihan)
3. Pemantauan ketat dan asesmen (penilaian) cermat
(Deteksi dini tanda-tanda gangguan sirkulasi dan perdarahan, secara klinis
dan pemeriksaan laboratorium)
4. Pencatatan dan pelaporan tepat (laporan KDRS): WAKTU - I S I - SASARAN
• Pada pasien COVID-19, baik terkonfirmasi (apalagi masih suspek), kemungkinan co-
infeksi dengan Dengue harus dipikirkan, terutama pada saat peningkatan kasus dengue
Take Home Message

39. 39
Terima kasih