Dengue Hemorrhagic Fever

Astrie Hananda Febriancy

Duas Jourgie S. 090100274

By:
090100299

Supervisor:
dr. Hj. Sri Sofyani, Sp.A(K)
FACULTY OF MEDICINE UNIVERSITY OF SUMATERA UTARA
HAJI ADAM MALIK GENERAL HOSPITAL
MEDAN
2013

Introduction
According to WHO 2008, about 50 million dengue
infections and 25,000 deaths occur worldwide
annually
There are several factor that increased insidence of
Dengue Infection which are :
uncontrolled urbanization and population growth
inappropriate sanitation
lack of preventive programs for
epidemic transmission

Literature Review
Defenition
is an acute disease caused by dengue virus
which includes an arbovirs of the flavivirus
family that has four different serotypes ( DEN1, -2, -3, and -4)
Transmission
Human, virus and vector

Pathogenesis

Clinical presentation

Diagnosis

Differential
diagnose

Influenza
Malaria
Thypoid Fever
Chikungunya
Rubella
Leptospirosis
Meningococcemia
Fever

Liver
dysfunction

Acute
Renal
Failure

Encephalitis

Complication

Pancreatitis

Cardiomyopathy

Bed rest
Antipiretic drugs
Electrolytes and oral fluid
Monitoring temperature

Replacement of plasma fluid

Metabolic and electrolyte correction
Oxygen treatment
Blood transfusion
Monitoring

DHF
DF
Treatment

Case Report
Name
: EM
Age
: 17 Years
Sex
: Male
Date of Admission: September, 20th
2013

Main complaint : Vomiting blood

History :
He has been vomitting blood since 2 days ago.
Vomit is not always started with eat. History of
vomitting blood (-). At emergency instalation of
General Hospital Haji Adam Malik, he has puke
twice. Malaise (+) since 3 days ago. Patient has
lost of consciousness when he arrived. Fever (+)
since 5 days ago. The fever responded to
antipiretic drug. Joint pain (-), shortness of breath
(-). History of drugs (-). History of bloody stool (+)
since 5 days ago. Epistaxis (+). The patient has
been treated at other general hospital and
diagnosed with DHF grade II.

 Presens status
Sensorium : Apatis, Body temperature: 37,8 oC, Pulse rate :
100 bpm,Respiratory Rate : 32 bpm
Localized status
Head : Light reflex (+/+), isochoric pupil, Icteric sclera
(-/-), Paleness of inferior palpebral conjunctiva (-/-), Ear,
nose, mouth: normal.
Neck : Lymph node enlargement (-).
Thorax : Symmetrical fusiformis. Epigastrial retraction (-).
HR: 100 bpm, regular, murmur (-)
RR: 32 bpm, regular, rhonchi (-/-)
Abdomen : Soepel. Peristaltic (+) normal. Liver palpable 2
cm below arcuscosta. Lien: could not palpable
Extremities : Pulse 100 bpm, regular, adequate pressure
and volume, warm acral, CRT < 3

Laboratory Result

 Differential Diagnosis
Dengue Hemorrhagic Fever
Dengue Fever
Malaria
Working Diagnosis
Dengue Hemorrhagic Fever
Management
NGT
02 1-2 L/i
Adrenaline tamponade
IVFD Ringer lactate 5 cc/weight(kg) 1st line 46 gtt/i macro
2st line 46 gtt/i macro
Inj. Ranitidin 50 mg/ 12h
Inj. Ceftriaxon 1 gr/12h
Spooling NGT/8 h
Paracetamol 3x500 mg
Antacid syr 3xC1
Advice
Thrombocyte transfusion
FFP transfusion
Full blood count/ 6h
IgG, IgM anti dengue test

Follow Up

September 20th 21th 2013

S :Vomiting blood (+) , Fever (+)
O : Sensorium: Compos Mentis, T: 37,9C, BW: 55 kg
Head : Light reflex (+/+), isochoric pupil, Icteric sclera
(-/-), Paleness of inferior Palpebral conjunctiva (-/-),
Ear : normal, nose : NGT (+) filled with blood, mouth:
normal.
Neck : Lymph node enlargement (-).
Thorax : Symmetrical fusiformis. Epigastrial
retraction (-). HR: 109 bpm, reguler, murmur (-). RR:
24 rpm, regular, rhonchi (-/-)
Abdomen: Soepel. Peristaltic (+) normal. Liver
palpable 2 cm below arcuscosta. Lien: not palpable
Extremities: Pulse 109 bpm, regular, adequate pressure
and volume, warm acral, CRT < 3

A :

- Dengue Fever
- DHF grade II

P :
- IVFD Ringer lactate 5 cc/weight(kg)
1st line 46 gtt/i macro
2st line 46 gtt/i macro
- Inj. Ceftriaxone 1 g/12 hour/IV
- Inj. Ranitidin 50 mg/12 h / IV
- Spooling NGT / 8 h
- Paracetamol 3x500 mg (if NGT is clear)
- Antacid syr 3x Cth II
- Fasting until NGT is clear

Infection and Tropical Diseases Consult (September, 21th

2013):
Conclusion : DHF grade II
Advice therapy :
D 5% Nacl 0,9 % 5cc/kgBW/h
Evaluate fluid therapy/ 6 h
Check Hb, Ht and thrombocyte count / 6h
Monitoring vital sign, urine output also hemorrhage
16.45 pm ( 20/9/13)
FFP transfusion 2 unit
18.30 pm (20/9/13)
Thrombocyte transfusion 250 cc (5 bag)

September 22th 2013

S :Vomiting blood (+) , Fever (+)
O : Sensorium: Compos Mentis, T: 37,8C, BW: 55 kg
Head : Light reflex (+/+), isochoric pupil, Icteric sclera
(-/-), Paleness of inferior Palpebral conjunctiva (-/-),
Ear : normal, nose : NGT (+) filled with blood, mouth:
normal.
Neck : Lymph node enlargement (-).
Thorax : Symmetrical fusiformis. Epigastrial retraction
(-). HR: 90 bpm, reguler, murmur (-). RR: 24 rpm,
regular, rhonchi (-/-)
Abdomen: Soepel. Peristaltic (+) normal. Liver
palpable 2 cm below arcuscosta. Lien: not palpable
Extremities: Pulse 109 bpm, regular, adequate pressure
and volume, warm acral, CRT < 3

A:
P :

- DHF grade II
- IVFD D5% Nacl 0,9% 55 gtt/i
- Inj. Ceftriaxone 1 g/12 hour/IV
- Inj. Ranitidin 50 mg/12 h / IV
- Spooling NGT / 8 h
- Paracetamol 3x500 mg (if NGT is clear)
- Antacid syr 3x Cth II
- Fasting until NGT is clear

September 23th 2013

S : Fever (-)
O : Sensorium: Compos Mentis, T: 36,8C, BW: 55 kg
Head : Light reflex (+/+), isochoric pupil, Icteric sclera
(-/-), Paleness of inferior Palpebral conjunctiva (-/-),
Ear : normal, nose : NGT (+) clear mouth: normal.
Neck : Lymph node enlargement (-).
Thorax : Symmetrical fusiformis. Epigastrial
retraction (-). HR: 72 bpm, reguler, murmur (-). RR: 24
rpm, regular, rhonchi (-/-)
Abdomen: Soepel. Peristaltic (+) normal. Liver not
palpable. Lien: not palpable
Extremities: Pulse 109 bpm, regular, adequate pressure
and volume, warm acral, CRT < 3

A:
P :

- DHF grade II
- IVFD D5% Nacl 0,9% 28 gtt/i macro
- Inj. Ceftriaxone 1 g/12 hour/IV
- Inj. Ranitidin 50 mg/12 h / IV
- Inj. Transamin 500 mg/8h/IV
- Paracetamol 3x500 mg (if NGT is clear)
- Antacid syr 3x Cth II
- Cold milk diet

September 24 26th 2013

S : Fever (-)
O : Sensorium: Compos Mentis, T: 36,9C, BW: 55 kg
Head : Light reflex (+/+), isochoric pupil, Icteric
sclera (-/-), Paleness of inferior Palpebral conjunctiva
(-/-), Ear : normal, nose : normal mouth: normal.
Neck : Lymph node enlargement (-).
Thorax : Symmetrical fusiformis. Epigastrial
retraction (-). HR: 70 bpm, reguler, murmur (-). RR:
24 rpm, regular, rhonchi (-/-)
Abdomen: Soepel. Peristaltic (+) normal. Liver not
palpable. Lien: not palpable
Extremities: Pulse 70 bpm, regular, adequate pressure
and volume, warm acral, CRT < 3

A :
P :

- DHF grade II
- IVFD D5% Nacl 0,9% 28 gtt/i macro
- Inj. Ceftriaxone 1 g/12 hour/IV
- Inj. Ranitidin 50 mg/12 h / IV
- Inj. Transamin 500 mg/8h/IV
- Paracetamol 3x500 mg (if NGT is clear)
- Antacid syr 3x Cth II
- Diet M II 2000 kkal

Discussion
E, 17 years old boy, was admitted to the Pediatric
Department of General Hospital Haji Adam Malik on
September 20th 2013 with vomitting blood as the main
complaint. He has been vomitting blood since 2 days ago.
Vomit is not always started with eat. History of vomitting
blood (-). At emergency instalation of General Hospital
Haji Adam Malik, he has puke twice. Malaise (+) since 3
days ago. Patient has lost of consciousness when he
arrived. Fever (+) since 5 days ago. The fever responded
to antipiretic drug. Joint pain (-), shortness of breath (-).
History of drugs (-). History of bloody stool (+) since 5
days ago. Epistaxis (+). The patient has been treated at
other general hospital and diagnosed with DHF grade II.
Patient later was on diagnosed with Dengue Hemorrhagic
Fever grade II.

DHF is a potentially fatal illness marked by high

fever, hemorrhagic manifestations, and evidence of
plasma leakage. In this patient, high fever and
hemorrhagic manifestations was found, but the
evidence of plasma leakage such as hematocrit is
not increased up to 20%. Thrombocytopenia was
found in this patient In the third day of
hospitalization, IgG and IgM anti dengue test was
done and the result shows IgM positive and IgG
negative which interpretated with primary dengue.
About treatment this patient is treated base on
literature, adequate fluid therapy, with first
management of shock by IVFD Ringer Lactate 20
cc/kgBW bolus. And continued by D5% NaCl 0,9%
5cc/kgBW/hour when patient is already stable.

Thank You