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Dengue Hemorrhagic Fever grade I

with
Right Pleural Effusion and Ascites
Supervised by: dr. Ulinar Marpaung, Sp.A

Created by: Amiradyta Mahartiza (07120100076)

Departemen of Pediatrics
Clerkship of Clinical Pediatrics Hospital Bhayangkara Tk. I Raden Said
Sukanto
Faculty of Medicine University of Pelita Harapan

IDENTITY OF THE PATIENT


Name

MRA

Age

4 years 5 months

Gender

Male

Address

Jl. Alsafiah Gg. H. Muktar RT


08/03 No. 1, Cilangkap

Nationalit
y

Indonesian

Religion

Moslem

Education

IDENTITY OF THE PATIENTS


PARENTS
Father

Mother

Mr. B

Mrs. E

42 years old

36 years old

Jl. Alsafiah Gg. H.


Muktar RT 08/03 No. 1,
Cilangkap

Jl. Alsafiah Gg. H.


Muktar RT 08/03 No. 1,
Cilangkap

Indonesian

Indonesian

Moslem

Moslem

Education

Senior High School

Junior High School

Occupati
on

Private Employee

Housewife

Name
Age
Address

Nationalit
y
Religion

HISTORY TAKING
Anamnesis was done with alloanamnesis
method with the patients mother on the
date of admission, June 25th 2014.
Chief complaint: Fever since 4 days before
admission to the hospital
Additional complaint: body feels sore, pain in
the stomach

HISTORY OF PRESENT ILLNESS


The patient had fever since 4 days before admission.
The fever was sudden and instantly went to the high
temperature, but it was never measured. The fever was
continuous throughout the day. The patient was also
often shivering. History of seizure was denied.
Since the onset of illness, the patient also complained
about sore all over his body, and also he felt pain in the
upper-middle area of the abdomen. The pain was sharp,
continuous, and not migrating to the other part of the
body. He felt nausea but there isnt any vomiting. The
patients appetite had decreased since the onset of
illness

The patient had no complain about urination. The


patient hadnt defecated since the onset of the illness.
History of nosebleeds, gum bleeding, red spots on the
skins was denied.
3 days before admission the patient went to the
physician in the clinic. The patient had been given
paracetamol and some antibiotics, but there was no
significant improvement regard the patients symptoms.
The fever only relieved for several hours when the
patient took paracetamol, and the body temperature
would rise again.

2 days before admission the mother gave ibuprofen to


the patient and the body temperature was declined. The
patient had gained his appetite, and the patient was
able to do his activities again. At night the fever
returned suddenly and the patient took some ibuprofen.
Several hours before admission the body temperature
was declined in the morning and the patient went to the
nearest Puskesmas to get his blood tested.

HISTORY OF PAST ILNESSES


Pharingitis/ Tonsilitis

Enteritis

Bronchiolitis

Bacilarry Dysentery

Pneumonia

Dysentery Amoeba

Morbili/Measles

Typhoid

Pertusis

Worm

Varicella

Surgery

Diphtheria

Brain Concussion

Malaria

Fracture

Polio

Drug Reaction

Dengue Fever/Dengue
Hemorrhagic Fever

Hospitalized

MOTHERS PREGNANCY HISTORY


Antenatal Care: Mother checkups her pregnancy
to the health center (midwife/obstetrician) every
month. No problem during pregnancy and the
fetus in the womb was healthy.
Disease during pregnancy: no history of problems
and diseases during pregnancy.
Drugs taken: Mothers get vitamins every
antenatal care.

BIRTH HISTORY

Labor : Pasar Rebo Hospital


Birth attendants : Obstetrician
Mode of delivery : Caesarean delivery
Gestation : 37 weeks
Fetal membrane: Clear
Infant state : Healthy
Birth weight : 4 kg
Body length : 48 cm
According to the mother, the baby started to cry and
the baby's skin is red. No congenital defects.

POST NATAL HISTORY


The baby and the mother was examined
by the midwife
The health state of the infant: Healthy

HISTORY OF DEVELOPMENT
First dentition: 7 months
Psychomotor development
Smile : 2 months
Slant: 4 months
Prone : 4 months
Sitting : 7 months
Crawling : 8 months
Standing : 9 months
Walking : 10 months
Conclusion: good motor developmental status

HISTORY OF EATING
Breast milk: from birth until 2 years old.
Formula milk: from 2 years old until now,
but rarely; only 1 glass each time, 2-3
times a week.
Fruits and vegetables: apple, banana,
spinach
Solid food: rice, chicken, fish, meat, and
some other vegetables

IMMUNIZATION HISTORY
Immunization
BCG
Hepatitis B
DPT
Polio
MMR

Frequency
1 times
3 times
4 times
4 times
1 times

Time
1 month
0, 1, 6 month
2, 4, 6, 18 month
2, 4, 6, 18 month
15 months

FAMILY HISTORY
Family data
Information

Father

Mother

Number of marriage

Age at marriage

33 years old

27 years old

State of health

Healthy

Healthy

Mode of reproduction
The patient is the second child of two
siblings
Number of children Age
Gender
1

8 years old

Female

4 years 5 months

Male

Father: The patients father is 42 years old. The patients


father is healthy and has no history of the disease. No
history of drug or food allergies.
Mother: The patients mother is 36 years old. The
patients mother is healthy and has no history of the
disease. No history of drug or food allergies.

HISTORY OF DISEASE IN OTHER FAMILY


MEMBERS/AROUND THE HOUSE
Family members: The patients older sibling has
just recovered from fever illness 1 week before
the patient admitted to the hospital.
Around the house: for the past 1 month there
were 2 children whose admitted to the hospital
because of dengue hemorrhagic fever.

PHYSICAL EXAMINATION
Generalized status
General appearance
: moderately
ill
Awareness
: compos mentis
Vital signs
GCS
:E4/M6/V5
Heart rate : 111x/min
Respiratory rate
:
37x/min
Blood pressure : 100/70
mmHg
Temperature
: 38,2 0C
(axilla)
Anthropometric
Data
Weight : 14 kg
Height : 100 cm

(June 25th, 2014)

Nutritional
Status

Nutritional Status based


NCHS (National Center for
Health Statistics) year 2000:
Interpretation based on
Lokarya Antropometri
Depkes 1974 dan Puslitbang
Gizi 1978
WFA (Weight for Age): 14/17
x 100% = 82,3%
HFA (Height for Age):
100/105 x 100% = 95,23%
WFH (Weight for Height):
14/16 x 100% = 87,5%
Conclusion: nutrition
status of the patient is
good.

SYSTEMIC PHYSICAL
EXAMINATION Ears :
Skin :
Color: Tones, not pale, no
cyanosis, no petechiae
Turgor: normal

Head :
Shape and size: Normocephali,
no deformity
Large fontanel: Closed
Hair: black, not easy to repeal,
equitable distribution
Eyes :
Pupil
: Isokor
Pupil reflex : +/+
Eyes movement
: no
deformity
Conjungtiva
: Anemis -/Sklera
: Icterus -/Sunken eyelids : -/-

Cerumen : Tympanic membrane :


Intact +/+
Nose :
Shape : Normal
Septum : Deviation (-)
Secrete
: No secrete
Mucosa : Hyperemia -/Mouth and throat
Lips: pale (-), cyanosis (-),
dry (-)
Teeth : caries (-)
Tongue : clear, tremor (-)
Pharynx
: hyperemia (-)
Tonsils : T2/T2

Neck
Tyroid
(-)
Trachea

: enlargement
: In the middle

Lymph nodes :
Neck lymph nodes : no
enlargement
Axilla lymph nodes: no
enlargement

Thorax
Lungs :
Inspection
: Symmetric in a static state and dynamic,
suprasternal
retractions (-), intercostal retractions (-), ictus cordis is not
visible
Palpation
: ictus cordis palpable in the fourth intercostals
space of the
left linea midclavicularis, tactile fremitus are symmetrical
Percusion
: sonor in both lung fields
Top border of heart
: ICS II linea left parasternalis
Left border of heart
: ICS IV linea left midclavicula
Right border of heart : ICS IV linea right parasternalis
Auscultation :
Breath sound:Vesicular breath sounds, no rhonki, no wheezing
Heart sound : First and second heart sounds regular, murmur (-),
gallop(-)

Abdomen
Inspection : Convex, epigastric retraction (-), there is no a
widening of the veins, no spider nevi.
Palpation
: Supple, tenderness in right upper
quadrant and
epigastrium, liver is palpable +- 2cm below
costal margin,
abdominal mass (-), kidney ballotenment (-)
Percussion : The entire field of tympanic abdomen, shifting
dullness (-)
Auscultation
: Bowel sound (+) 5 times / minutes

Vertebrae : Theres no scoliosis, kyphosis, and lordosis, do


not
look any mass along the line of the vertebral
Genitalia
: Covering the labia majora labia minora
Anus
: Hole intact, does not seem that out of the
mass of
the anus
Extremities : Warm, capillary refill time <2 seconds,
infusion sets
mounted on the left hand

NEUROLOGICAL
EXAMINATION
Meningeal signs:
Neck stiffness : (-)
Brudzinski I maneuver : (-)
Brudzinski II maneuver: (-)
Kernig maneuver : (-)
Physiological Reflex
Biceps Reflex : normoreflex/normoreflex
Triceps Reflex : normoreflex/normoreflex
Patellar Reflex : normoreflex/normoreflex
Achilles Reflex : normoreflex/normoreflex
Pathological Reflec
Hoffmann-TrommerReflex : -/ Babinski Reflex: -/ Oppenheim Reflex : -/ Schaefer Reflex : -/ Chaddock Reflex : -/ Gordon Reflex : -/-

INVESTIGATION

(June 25th, 2014)

From Puskesmas Ciracas


Hematology
Results
(morning)

Normal Value

Hemoglobin

15,9 g/dL

13-16 g/dL

Hematocrit

47%

40-48%

Leukocytes

7.700/uL

5-10.000/uL

Thrombocytes

95.000/uL

150.000-40.000/uL

Erythrocytes

5,8 millions/uL

4,5-5,5 millions/uL

From Puskesmas Ciracas


Widal Serology

Salmonella Typhi O

Salmonella Paratyphi AO

Salmonella Paratyphi BO

Salmonella Paratyphi CO

Salmonella Typhi H

Salmonella Paratyphi AH

Salmonella Paratyphi BH

Salmonella Paratyphi CH

Results

From Polri Hospital


Hematology

Results

Normal Value

Hemoglobin

15,2 g/dL

13-16 g/dL

Hematocrit

44%

40-48%

Leukocytes

9.600/uL

5-10.000/uL

Thrombocytes

27.000/uL

150.000-40.000/uL

Erythrocytes

5,86 millions/uL

4,5-5,5 millions/uL

INVESTIGATIONS

(June 26th, 2014)

Urinalysis

Results

Normal Value

Colour

Yellow

Clearness

Clear

Reaction / pH

5 8.5

Specific gravity

1,025

1000 1,030

Protein

Negative

Bilirubin

Negative

Glucose

Negative

Ketones

Negative

Blood / Hb

Negative

Nitrite

Negative

Urobilinogen

0.1

0.1 1,0 IU

Leukocytes

Negative

Sediment
Leukocytes

0-1 / field of view

Erythrocytes

0-1 / field of view

Epithelial cells

+ / field of view

Cylinder

Crystal

etc.

FECES
Macroscopic
o

Color

Yellow

Consistency

Soft

Mucus

Blood

Microscopic
o

Leukocytes

1-3/field of view

Eritrocytes

0-2/field of view

Worm egg
o

Ascaris Sp

Anchilostoma Sp

Trichiuris Sp

Oxyuris Sp

WORKING DIAGNOSIS
Dengue Hemorrhagic Fever grade
I

MANAGEMENT
Parenteral infusion Ringer Lactate
Maintenance (Holiday-Segaar):
1200 ml
+10% because of DHF: 120 ml
Total parenteral fluid/24 hours:
1320 ml 18 dpm
Injection of Vitamin K 3x1 ampul
Paracetamol 3x500mg (if fever
presents)
Isprinol 3x5ml

PROGNOSIS
Quo ad vitam
: dubia ad
bonam
Quo ad functionam : bonam
Quo ad sanationam : bonam

Follow Up

The first day of hospitalization, 5 th


day of sickness June 25th 2014
S

Fever, Body feels sore, Nausea, but no vomit, Pain above the umbilical

General condition: moderately ill


Awareness: Compos mentis
Vital Signs
Blood pressure: 100/70 mmHg
Heart rate: 111 times/minute, strong, full, regular
Respiratory Rate: 37 times/minute
Temperature: 38,2 C
Abdominal Examination

Inspection : Flat, epigastric retraction (-)

Palpation : Supple, tenderness (+) in right upper quadran and epigastrium, liver is
palpable 2 cm below costal margin, abdominal mass (-)
Percusion : Tympanic, shifting dullness (-)

Auscultation : Bowel sounds 8 times / minutes

Investigation
From Puskesmas Ciracas (morning)
Hematology

Results

Normal Value

Hemoglobin

15,9 g/dL

13-16 g/dL

Hematocrit

47%

40-48%

Leukocytes

7.700/uL

5-10.000/uL

Thrombocytes

95.000/uL

150.000-40.000/uL

Erythrocytes

5,8 millions/uL

4,5-5,5 millions/uL

Widal Serology

Results

Salmonella Typhi O

Salmonella Paratyphi AO

Salmonella Paratyphi BO

Salmonella Paratyphi CO

Salmonella Typhi H

Salmonella Paratyphi AH

Salmonella Paratyphi BH

Salmonella Paratyphi CH

From Polri Hospital:


Hematology

Results

Normal Value

Hemoglobin

14,5 g/dL

13-16 g/dL

Hematocrit

42%

40-48%

Leukocytes

5.300/uL

5-10.000/uL

Thrombocytes

44.000/uL

150.000-40.000/uL

Erythrocytes

5,65 millions/uL

4,5-5,5 millions/uL

Dengue Hemorrhagic Fever grade I

Parenteral infusion Ringer Lactate 18 dpm


Paracetamol 3x500mg (if fever presents)
Isprinol 3x5ml

The 2nd day of hospitalization, 6th day of sickness,


June 26th 2014
S

Body feels sore, Pain above the umbilical

General condition: moderately ill


Awareness: Compos mentis
Vital Signs
Blood pressure: 100/70 mmHg
Heart rate: 107 times/minute, strong, full, regular
Respiratory Rate: 36 times/minute
Temperature: 37,5 C
Abdominal Examination

Inspection : Flat, epigastric retraction (-)

Palpation : Supple, tenderness (+) in right upper quadran and epigastrium, liver is
palpable 2 cm below costal margin, abdominal mass (-)
Percusion : Tympanic, shifting dullness (-)

Auscultation : Bowel sounds 12 times / minutes

06.42
Hematology

Results

Normal Value

Hemoglobin

15,2 g/dL

13-16 g/dL

Hematocrit

44%

40-48%

Leukocytes

9.600/uL

5-10.000/uL

Thrombocytes

27.000/uL

150.000-40.000/uL

Erythrocytes

5,86 millions/uL

4,5-5,5 millions/uL

Hematology

Results

Normal Value

Hemoglobin

13,3 g/dL

13-16 g/dL

Hematocrit

38%

40-48%

Leukocytes

10.800/uL

5-10.000/uL

Thrombocytes

32.000/uL

150.000-40.000/uL

Erythrocytes

4,93 millions/uL

4,5-5,5 millions/uL

18.20

Urinalysis

Results

Normal Value

Colour

Yellow

Clearness

Clear

Reaction / pH

5 8.5

Specifc gravity

1,025

1000 1,030

Protein

Negative

Bilirubin

Negative

Glucose

Negative

Ketones

Negative

Blood / Hb

Negative

Nitrite

Negative

Urobilinogen

0.1

0.1 1,0 IU

Leukocytes

Negative

Leukocytes

0-1 / field of view

Erythrocytes

0-1 / field of view

Epithelial cells

+ / field of view

Cylinder

Crystal

etc.

Sediment

STOOL
Macroscopic
o

Color

Yellow

Consistency

Soft

Mucus

Blood

Microscopic
o

Leukocytes

1-3/field of view

Eritrocytes

0-2/field of view

Worm egg
o

Ascaris Sp

Anchilostoma Sp

Trichiuris Sp

Oxyuris Sp

Dengue Hemorrhagic Fever grade I

Parenteral infusion Ringer Lactate 18 dpm


Paracetamol 3x500mg (if fever presents)
Isprinol 3x5ml

The 3rd day of hospitalization, 7th


day of illness, June 27th 2014
S

Pain above the umbilical, Body feels sore

General condition: moderately ill


Awareness: Compos mentis
Vital Signs
Blood pressure: 100/70 mmHg
Heart rate: 118 times/minute, strong, full, regular
Respiratory Rate: 27 times/minute
Temperature: 36,5 C
Thorax Examination
Inspection :Symmetric in a static state and dynamic, suprasternal retractions (-), intercostal

retractions (-), ictus cordis is not visible.


Palpation : ictus cordis palpable in the fourth intercostal space of the left linea

midklavikularis

Percusion : Sonor on both lung fields

Auscultaion : Decrease vesicular breath sound on lower right lung felds, no


wheezing, no rhonchi, first and second heart sounds regular, murmur (-), gallop (-)

Abdominal Examination
Inspection : looks distended, epigastric retraction
Palpation : Supple, tenderness (+) in right upper quadran and epigastrium,
liver is palpable 2 cm below costal margin, abdominal mass (-)
Percusion : Tympanic, shifting dullness (+)
Auscultation : Bowel sounds 10 times / minutes

Skin: mild rash in the trunk


Investigation:
Morning
Hematology

Results

Normal Value

Hemoglobin

13,2 g/dL

13-16 g/dL

Hematocrit

38%

40-48%

Leukocytes

12.800/uL

5-10.000/uL

Thrombocytes

34.000/uL

150.000-40.000/uL

Erythrocytes

4,90 millions/uL

4,5-5,5 millions/uL

Afternoon
Hematology

Results

Normal Value

Hemoglobin

12,7 g/dL

13-16 g/dL

Hematocrit

37%

40-48%

Leukocytes

11.400/uL

5-10.000/uL

Thrombocytes

34.000/uL

150.000-40.000/uL

Erythrocytes

4,68 millions/uL

4,5-5,5 millions/uL

3,1 g/dL

3,5-5,2 g/dL

Clinical chemistry
Albumin

Viral Immunoserology
Anti Dengue IgG /

Results

Normal Value

Anti DengueIgM

Negative

Negative

Anti DengueIgG

Positive

Negative

IgM

Thorax X-ray RLD:


Interpretation:
Sinus/diaphragm is normal
Mediastinum isnt widened
Heart is hard to assessed
Pulmonary: right pleura is widened,
no active lesion is seen
No abnormalities in the bone

Conclusion: right pleural effusion


A

Dengue Hemorrhagic Fever grade I with right pleural effusion and ascites

Parenteral infusion Ringer Lactate 6 dpm


Injection of Vitamin K 3x1ampul
Paracetamol 3x500mg (if fever presents)
Isprinol 3x5ml

The 4th day of hospitalization, 8th


day of illness, June 28th 2014
S

Pain in the upper abdomen

General condition: moderately ill


Awareness: Compos mentis
Vital Signs
Blood pressure: 100/70 mmHg
Heart rate: 100 times/minute, strong, full, regular
Respiratory Rate: 24 times/minute
Temperature: 36 C
Thorax Examination
Inspection :Symmetric in a static state and dynamic, suprasternal retractions (-), intercostal

retractions (-), ictus cordis is not visible.

Palpation : ictus cordis palpable in the fourth intercostal space of the left linea midklavikularis

Percusion : Sonor on both lung fields

Auscultaion : Decrease vesicular breath sound on lower right lung fields, no wheezing, no
rhonchi, first and second heart sounds regular, murmur (-), gallop (-)

Abdominal Examination
Inspection : epigastric retraction (-) , looks distended
Palpation : Supple, tenderness (+) in right upper quadrant and epigastrium,
liver is palpable 2 cm below costal margin, abdominal mass (-)
Percusion : Tympanic, shifting dullness (+)
Auscultation : Bowel sounds 8 times / minutes
Investigation
Morning
Hematology

Results

Normal Value

Hemoglobin

12,5 g/dL

13-16 g/dL

Hematocrit

36%

40-48%

Leukocytes

11.900/uL

5-10.000/uL

Thrombocytes

56.000/uL

150.000-40.000/uL

Erythrocytes

4,64 millions/uL

4,5-5,5 millions/uL

Afternoon
Hematology

Results

Normal Value

Hemoglobin

12,4 g/dL

13-16 g/dL

Hematocrit

35%

40-48%

Leukocytes

15.500/uL

5-10.000/uL

Thrombocytes

66.000/uL

150.000-40.000/uL

Widal Serology

Results

Salmonella Typhi O

Salmonella Paratyphi AO

Salmonella Paratyphi BO

Salmonella Paratyphi CO

Salmonella Typhi H

Salmonella Paratyphi AH

Salmonella Paratyphi BH

Salmonella Paratyphi CH

+1/80

Dengue Hemorrhagic Fever grade I with right pleural effusion and ascites

Parenteral infusion Ringer Lactate 6 dpm


Injection of Vitamin K 3x1ampul
Isprinol 3x5ml

The 5th day of hospitalization, 9th


day of illnes, June 29th 2014
S

General condition: mildly ill


Awareness: Compos mentis
Vital Signs
Blood pressure: 110/70 mmHg
Heart rate: 90 times/minute, strong, full, regular
Respiratory Rate: 20 times/minute
Temperature: 36,5 C
Thorax Examination
Inspection :Symmetric in a static state and dynamic, suprasternal retractions (-), intercostal

retractions (-), ictus cordis is not visible.


Palpation : ictus cordis palpable in the fourth intercostal space of the left linea

midklavikularis

Percusion : Sonor on both lung fields

Auscultaion : Vesicular breath sounds in both lung fields, no wheezing, no rhonchi, first and
second heart sounds regular, murmur (-), gallop (-)

Abdominal Examination
Inspection : epigastric retraction (-) , looks flat
Palpation : Supple, tenderness (-), , liver is palpable 2 cm
below costal margin, abdominal mass (-)
Percusion : Tympanic, shifting dullness (-)
Auscultation : Bowel sounds 9 times / minutes
Investigation
Hematology

Results

Normal Value

Hemoglobin

12,9 g/dL

13-16 g/dL

Hematocrit

36%

40-48%

Leukocytes

13.400/uL

5-10.000/uL

Thrombocytes

110.000/uL

150.000-40.000/uL

Erythrocytes

4,62 millions/uL

4,5-5,5 millions/uL

Dengue Hemorrhagic Fever grade I with right pleural effusion and ascites refinement

Parenteral infusion Ringer Lactate 6 dpm


Injection of Vitamin K 3x1ampul
Isprinol 3x5ml

The 6th day of hospitalization, 10th


day of illness, June 30th 2014
S

General condition: well


Awareness: Compos mentis
Vital Signs
Blood pressure: 100/70 mmHg
Heart rate: 106 times/minute, strong, full, regular
Respiratory Rate: 26 times/minute
Temperature: 37,3 C
Investigation
Hematology
Hemoglobin

Results

Normal Value

11,9 g/dL

13-16 g/dL

Hematocrit

35%

40-48%

Leukocytes

9.800/uL

5-10.000/uL

Thrombocytes

211.000/uL

150.000-40.000/uL

Erythrocytes

4,39 millions/uL

4,5-5,5 millions/uL

Dengue Hemorrhagic Fever grade I with right pleural effusion and ascites

Observation

Hematology

J une25th

J une25th

J une26th

J une26th

J une27th

(morning)

(afternoon)

(morning)

(afternoon)

(morning)

Hemoglobin

15,9

14,5

15,2

13,3

13,2

Hematocrit

47

42

44

38

38

Leukocytes

7.700

5.300

9.600

10.800

12.800

Thrombocytes

95.000

44.000

27.000

32.000

34.000

Erythrocytes

5,8

5,65

5,86

4,93

4,90

Hematology

J une27th

J une28th

J une28th

J une

J une

(afternoon)

(morning)

Hemoglobin

12,7

Hematocrit

Normal Value

(afternoon)

29th

30th

12,5

12,4

12,9

11,9

13-16 g/dL

37

36

35

36

35

40-48%

Leukocytes

11.400

11.900

15.500

13.400

9.800

5-10.000/uL

Thrombocytes

34.000

56.000

66.000

110.000

211.000

150.00040.000/uL

Erythrocytes

4,68

4,64

4,64

4,62

4,39

4,5-5,5
millions/uL

SPECIAL CONTROL LIST


Date

June 26th,
2014

June 27th,
2014

June 28th,
2014

Input

Output

IVFD (ml)

Eat, Drink
(ml)

Urine
Output
(ml)

8pm (June
25th)-6am

540

350

400

6am-10am

216

100

325

10am-4pm

324

200

675

4pm-11pm

378

400

950

11pm-6am

378

500

600

6am-10am

216

800

600

Time

10am-4pm

324

550

800

4pm-8pm

216

400

300

8pm-7am

594

1000

1000

7am-11am

216

500

750

11am-6pm

270

300

420

6pm-11pm

90

Balance
(ml)

Diuresis

311

2508
2350 =
+158

6,2/kg/hour

311

2664
2300 =
+364

5,98/kg/ho
ur

311

2970
2170 =
+800

5,74/kg/ho
ur

IWL (ml)

Input
Date

June 29th,
2014

Output

IVFD (ml)

Eat, Drink
(ml)

Urine
Output
(ml)

11pm-6am

126

200

500

6am-12pm

108

12pm-6pm

108

250

200

Time

Balance
(ml)

Diuresis

311

792 - 700
= +92

0,63/kg/ho
ur

311

1570
1200 =
+370

5,7
ml/kg/hour

IWL (ml)

June 30th,
2014

6pm-9am

270

1300

1200

Literature Review
Dengue Hemorrhagic Fever

DEFINITION
Dengue fever is a benign syndrome caused by several
arthropod-borne viruses and characterized by biphasic
fever, myalgia or arthralgia, rash, leukopenia and
lymphadenopathy.
Dengue hemorrhagic
fever (DHF) is a severe, often fatal,
febrile disease caused by dengue viruses characterized
by abnormalities of hemostasis and capillary permeability
that leads, in severe cases, to a protein-losing shock
syndrome (dengue shock syndrome, DSS).
Dengue and dengue hemorrhagic fever (DHF) are caused
by one of four closely related, but antigenically distinct,
virus serotypes (DEN-1, DEN-2, DEN- 3, and DEN-4), of the
genus Flavivirus.

EPIDEMIOLOGY
Estimation: 50 million infections per year
in 100 countries
First time appeared in Asia: Thailand, 1950
and first time appeared in Indonesia:
1969.
In 2007the number of dengue incidence
in ESA was increased about 18% and the
morbidity was 15% higher than in 2007.

ETIOLOGY
Dengue and DHF are caused by one of four virus serotypes
dengue virus (DEN).
In Indonesiaall serotypes are found and DEN 3 is the most
common one
Flavivirus has spherical shape with a lipid envelope; the particles are

approximately 50 nm in diameter. The dengue virus genome is


11,644 nucleotides in length.
The flavivirus structural protein genes encoding the nucleocaprid or
core protein (C), a membrane-associated protein (M), an envelope
protein (E), and seven non-structural protein (NS) genes. Among
non-structural proteins, envelope glycoprotein, NS1, is of diagnostic
and pathological importance.

Infection with one dengue serotype provides lifelong


immunity to that virus, but there is no cross-protective
immunity to the other serotypes. Thus, persons living in
an area of endemic dengue can be infected with three,
and probably four, dengue serotypes during their lifetime.
Aedes aegypti and Aedes albopictus are the two most
important vectors of dengue. A. aegypti, the principal
vector, is a small, black-and-white, highly domesticated
tropical mosquito that prefers to lay its eggs in artificial
containers commonly found in and around homes, for
example, flower vases, old automobile tires, buckets that
collect rainwater, and trash in general.
Aedes aegypti originates from Africa, but now is spreading worldwide
and become the most common dengue virus transmitter in the world.
Aedes albopictus originates from South East Asia, Western Pacific,
and Indian Ocean.

PATHOPHYSIOLOGY
Several theories; the most common one:
Secondary-infection or immune
enhancement hypothesis.

patients experiencing a second infection


with a heterologous dengue virus serotype
have a significantly higher risk for
developing DHF and DSS.

Preexisting
heterologous dengue
antibody recognizes
the infecting virus and
forms an antigenantibody complex

increased
vascular
permeability

Hypovolemia
and shock

AAC bound to and


internalized by
immunoglobulin Fc
receptors on the cell
membrane of
leukocytes,
especially
macrophages

produce and secrete


vasoactive
mediators
(cytokines,
complements) in
response to dengue
infection

the virus is not


neutralized and
is free to
replicate once
inside the
macrophage

Prior infection
(Antibodydependent
enhancement
(ADE)) enhances
the infection and
replication of
dengue virus in
cells of the
mononuclear cell
lineage

Endothelial cells dysfunction disruption in the function of endothelial


glycocalyx.

Glycocalyx functions as a molecular sieve

Proteinuria and
hypoalbuminemi
a
Glycocalyx has
heparan sulfate

Selectively restricting molecules


within plasma according to their
size, charge, and shape

Albumin and protein loss

Dengue virus and


NS1 bind to
heparan sulfate

Glycocalyx loss its


function

Increase heparan sulfate in urine has been


detected in severe dengue cases

Thrombocytopen
ia

Early bone marrow suppression

Increased peripheral destruction of


platelets during the febrile and early
convalescent phase
1. Dengue produces transient suppression of hematopoiesis via direct
infection or macrophage inflammatory protein 1-alpha
2. Dengue virus binds to platelets in the presence of virus-specific antibody

Mechanism of coagulopathy unknown

Mechanisms of liver injury in dengue may be due to:


direct effects of the virus or host immune
response on liver cells
circulatory compromise
metabolic acidosis and/or hypoxia caused by
hypotension
localized vascular leakage inside the liver.
The predominant findings in these studies were
microvesicular steatosis and small foci of
hepatocellular necrosis in addition to the presence
of councilman bodies, Kupffer cell hyperplasia and
mononuclear cell infiltrates at the portal tract.

CLINICAL MANIFESTATION
Undifferentiated fever
The people who got infected by dengue virus may develop a simple fever
that cant be distinguished from other viral infections (atypical symptoms).
Maculopapular rashes may accompany the fever or may appear during
defervescence. Upper respiratory and gastrointestinal symptoms are
common.
Dengue Fever
Dengue fever (DF) is most common in older children, adolescents and adults.
It is generally an acute febrile illness, and sometimes biphasic fever with
severe headache, myalgias, arthralgias, rashes, leucopenia and
thrombocytopenia may also be observed. Severe headache, muscle and joint
and bone pains (break-bone fever), particularly in adults. Occasionally
unusual haemorrhage such as gastrointestinal bleeding, hypermenorrhea and
massive epistaxis occur.

Dengue Hemorrhagic Fever

DHF is characterized by the acute onset of high fever. There are


common haemorrhagic diatheses such as positive tourniquet test
(TT), petechiae, easy bruising and/or GI haemorrhage in severe
cases. By the end of the febrile phase, there is a tendency to develop
hypovolemic shock (dengue shock syndrome) due to plasma leakage.
The presence of preceding warning signs such as persistent
vomiting, abdominal pain, lethargy or restlessness, or
irritability and oliguria are important for intervention to prevent
shock. Abnormal haemostasis and plasma leakage are the main
pathophysiological hallmarks of DHF. Thrombocytopenia and
rising haematocrit/haemoconcentration are constant findings
before the subsidence of fever/ onset of shock.

Febrile Phase
High temperature (38.5C) accompanied by
headache, vomiting, myalgia, and joint pain,
sometimes with a transient macular rash.
Anorexia, nausea and vomiting
Petechiae, mucosal membrane bleeding and bruising,
palpable liver are commonly noted
Laboratory findings mild-to-moderate
thrombocytopenia and leukopenia
Lasts 3-7 days

Critical Phase
Defervescence (day 3-7 illness)
Increase in capillary permeability
hemoconcentration, hypoproteinemia, pleural
effusions, and ascites
Clinically significant plasma leakage 24-48
hours
Hemorrhagic manifestation in children isnt
clinically significant, associates with profound
and prolonged shock
Moderate-to-severe thrombocytopenia
Looking for warning signs

Recovery/Convalescent Phase
Vascular permeability is back to normal
after 48-72 hours after critical phase
Rapid improvement of patients
symptoms; stabilization of vital signs
Second rash may appear, might be
generalized pruritus
Caution of administration of intravenous
fluids

Investigations
The following laboratory tests are available to diagnose
dengue fever and DHF:
Virus isolation: serotypic/genotypic characterization
Viral nucleic acid detection: RT-PCR
Viral antigen detection: NS1
Immunological response based tests: IgM and IgG
antibody assays; MAC-ELISA, IgG/IgM ratio, MAC ELISA,
haemaglutination inhibition test, complement fixation
test, neutralization test
Analysis for hematological parameters

Primary antibody response individual


who are not immune to dengue
Secondary immune response
previous dengue infection
Primary infection: slow and low-titre
antibody response
Immunoglobulin (Ig)M antibodies are the
first isotype to appear, by day 35 of
illness in 50% of hospitalized patients
and by day 610 of illness in 9399% of
cases. The IgM levels peak ~2 weeks
after the onset of fever and then
generally decline to undetectable levels
over the next 23 months
Dengue-specific IgG is detectable at low
titre at the end of the first week of illness
and slowly increases

Secondary infection:
high levels of IgG
antibodies that are
detectable even in the
acute phase and rise
dramatically over the
following 2 weeks.
as IgM levels are
significantly lower in
secondary dengue
infections, falsenegative test results for
dengue-specific IgM
have been reported
during secondary
infections.
Following a dengue
infection, IgG can be
lifelong, which
complicates the

MANAGEMENT AND TREATMENT


No specific therapy is available at the
present time for symptomatic dengue
infections. Effective treatment relies on
good supportive care, with particular
emphasis on fluid therapy and
management of bleeding complications

Indications for IV fluid in critical period of DHF:


inadequate oral fluid intake or vomiting in patient
hematocrit continues to rise 10%-20% despite oral
rehydration
impending shock/warning signs.
The following parameters should be monitored:
General condition, appetite, vomiting, bleeding and
other signs and symptoms.
Peripheral perfusion
Vital signs must be checked every 24 hours in nonshock patients and 12 hours in shock patients.
Serial haematocrit must be checked every four to six
hours in stable cases.
Urine output (amount of urine) should be recorded. During
this period the amount of urine output should be about 0.5
ml/kg/h (this should be based on the ideal body weight).

General principles of fluid therapy in DHF:


Isotonic crystalloid solutions should be used throughout
the critical period
Hyper-oncotic colloid solutions (osmolarity of >300
mOsm/l) such as dextran 40 or starch solutions may be used in
patients with massive plasma leakage, and those not responding
to the minimum volume of crystalloid.
A volume of about maintenance +5% dehydration should
be given to maintain a intravascular volume and circulation.
The duration of IV fluid therapy not exceed 24-48 hours for
shock patients
the duration of intravenous fluid therapy not more than 60 to
72 hours for nonshock
In obese patients, the ideal body weight should be used as a
guide to calculate the fluid volume

Managing DHF Grade I and II


without Shock
the fluid allowance (oral + IV) is about
maintenance (for one day) + 5% deficit
(oral and IV fluid together), to be
administered over 48 hours.
The rate of IV replacement should be
adjusted according to the rate of plasma
loss, guided by the clinical condition, vital
signs, urine output and haematocrit levels.
Antipyretic such as paracetamol can be
given

Managing DHF Grade III


Most cases of DSS will respond to 10 ml/kg in
children over one hour or by bolus, if
necessary.
before reducing the rate of IV replacement:
the clinical condition, vital signs, urine output
and haematocrit levels should be checked to
ensure clinical improvement. It must be
continued for a minimum duration of 24 hours
and discontinued by 36 to 48 hours

Managing DHF Grade IV


10 ml/kg of bolus fluid be given as soon as possible, within 10-15
minutes
Not reversible
restored
Continuing IV fluid
as in Grade 3

Repeat 10 ml/kg bolus and obtain lab


results to be corrected
Urgent blood transfusion should be
considered as the next step (after
reviewing the pre- resuscitation HCT)
and followed up by closer monitoring,
e.g. continuous bladder
catheterization, central venous
catheterization or arterial lines.

Management of Convalescence
Convalescence can be recognized by the improvement in
clinical parameters, appetite and general well-being.
Haemodynamic state such as good peripheral perfusion and
stable vital signs should be observed.
Decrease of HCT to baseline or below and dieresis are usually
observed.
Intravenous fluid should be discontinued.
In those patients with massive effusion and ascites,
hypervolemia may occur and diuretic therapy may be
necessary to prevent pulmonary oedema.
Bradycardia is commonly found and requires intense
monitoring for possible rare complications such as heart block
or ventricular premature contraction (VPC).
Convalescence rash is found in 20%30% of patients.

Signs of Recovery
Stable pulse, blood pressure and breathing
rate.
Normal temperature.
No evidence of external or internal bleeding.
Return of appetite.
No vomiting, no abdominal pain.
Good urinary output.
Stable haematocrit at baseline level.
Convalescent confluent petechiae rash or
itching, especially on the extremities.

Criteria for Discharging Patients


Absence of fever for at least 24 hours without the use of
anti-fever therapy.
Return of appetite.
Visible clinical improvement.
Satisfactory urine output.
A minimum of 23 days have elapsed after recovery from
shock.
No respiratory distress from pleural effusion and no ascites.
Platelet count of more than 50 000/mm3. If not, patients
can be recommended to avoid traumatic activities for at
least 12 weeks for platelet count to become normal. In
most uncomplicated cases, platelet rises to normal within 3
5 days.

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Smith DR, Khakpoor A. Involvement of the liver in dengue infections. Molecular Pathology Laboratory, Institute of
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