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Case Presentation:

By Michael B. Valderrama

To present a case of Dengue Fever with

warning signs
To be able to discuss the differentials,
pathophysiology, clinical manifestations and
prognosis of a patient with dengue with
warning signs
To be able to discuss the appropriate
management of a patient with dengue fever
with warning signs

General Data
JXDN, 12yo, M
Roman Catholic
Montalban, Rizal
Admitted on: June 8 2015
Accompanied by the Father, Reliability 80%

Chief Complaint
Fever and Vomiting

History of the Present

Five days prior to admission,
Intermittent, undocumented fever
relieved by paracetamol (250 mg)
No vomiting, no cough and colds, and no loose


History of the Present

Two days prior to admission,
Still with no cough and colds, no vomiting and no

loose stools
Fever persisted
Now with accompanying abdominal pain in the
epigastric area with no radiation to surrounding areas.
Consult sought at Ynares Hospital
CBC(Hgb: 112, Hct: 0.27, WBC: 3.7, Platelets: 125).
Initial Diagnosis: Urinary tract infection
prescribed Cefalexin (unrecalled dose) and
paracetamol 250 mg before discharge.

History of the Present

One day prior to admission,
Fever and epigastric pain still persisted
Now with accompanying vomiting of three



Still with no coughs and colds, no loose stools

History of the Present

On the day of admission,
Fever, epigastric pain and vomiting were

persistent which prompted consult.

Still with no coughs and colds, and loose stools.
CBC was ordered at the PCMC (Hgb: 146, Hct:
43, WBC: 5.2, Platelets: 97).
Advised admission

Temporal Profile

Review of Medications and Labs

No medications, vitamins and herbal

CBC from Ynares Hospital: (Hgb: 112, Hct:
0.27, WBC: 3.7, Platelets: 125).
CBC from PCMC: (Hgb: 146, Hct: 43, WBC: 5.2,
Platelets: 97).
Rising Hct, decreasing platelet count.

Review of Systems

Past Medical History

No history of Asthma, allergies, and primary

Previous Hospitalizations
2005 for Acute gastroenteritis

Previous Surgeries
2004 for incision and drainage of a Neck
There are no known allergies to food and

Family History
There is no History of Malignancies, DM, HTN,

Atopy/Allergies, Bronchial Asthma, TB in the

Paternal side of the family.
The patients mother is hypertensive and
the maternal grandmother was an Ovarian
Cancer survivor.
There are no other known heredo-familial

Family Genogram

Nutritional History
Breastfeeding: Birth until 1.5 years
Formula (Nestogen, Bona) until 6 years.
Complementary feeding at 5 months.
24 hour diet recall:
Rice and adobo for breakfast
Rice and pork sinigang for lunch
fried fish and mongo for dinner.
Morning snack was bread and milk.
Preference for chicken, pork, beef and squash and

regularly consumes softdrinks and junk food for


Birth and Maternal

Preterm (unrecalled AOG) to a 25 year old

G3P2 (0212)
Non-smoker, non-drinker, regular prenatal
check-ups starting 1 month
Caesarean Section by an OB-GYN in a
Birth weight and height was unrecalled
APGAR: good cry after delivery.

Birth and Maternal

Mother took unrecalled Multivitamins
Maternal complications: pre-ecplamptic during

Vitamin K and eye care
Newborn screening done
Baby noted to jaundiced
resolved after one week.

Immunization History
BCG (1), DPT (3), OPV (3), HiB (3), HepB (4),

MMR (2), measles (1)

Rotavirus (0), Pneumococcal (0), Influenza (0)
Varicella (0), Hep A (0) and Typhoid (0).
He has not yet had boosters for Hep B, DTaP,
and MMR

Developmental History
Gross motor: Can stand on his own at 10

months, walk up stairs alone at 2yrs

Fine Adaptive: Makes circular strokes at 2
Language: Knows name and sex, most of
speech intelligible to strangers at 3yrs.
Social: Parallel play and helps in dressing at
3 yrs

Developmental History
at par with age, with no noted delay in gross

motor, fine adaptive, social and language

developmental milestones.

Personal, Social and Environmental

Dwelling: one storey, two-bedroom, concrete

house with adequate ventilation

Six-member household
Access to electricity
Potable water from a refilling station
No exposure to environmental toxins,
biohazards and tobacco.
Garbage collection: three times a week,
No history of recent travel.

Home life is happy
Parents provide for the needs of the family
Patient expressed love and respect for the

parents and his sibling.

Occasional disciplinary spanking
Rules are fairly strict especially in academics
Parents can be relied upon when having a
No recent major changes in the family

Education: The child is in grade 6

elementary, a consistent honor student and is

currently top 1 of his class. He was not bullied
by classmates or other children in the

Grade 6 elementary
Consistent honor student
Currently top 1 of his class.
Favorite subject: Science
Gets along well with teachers and classmates
He is not bullied by classmates or other children

in the community.
No goals/plans yet for future career

Eating Behavior
Preference for chicken, pork, beef and squash
and regularly consumes softdrinks and junk
food for snacks
Especially likes fried chicken and
No diets
Sees self as thin

Likes to play basketball and tumbang preso
with friends and classmates
Spends about 2 hours browsing social media
during holidays and weekends. None during
school days
TV: 1 hour everyday
Has a male bestfriend in his class.

Has no friends who smoke, drink or tried drugs
Has not tried drugs himself: fears parents

Interested in opposite sex, but has no crushes
or girlfriends
No forced or uncomfortable sexual experiences.

Suicide and Depression
Has no suicidal ideations
Does not hurt himself
Financial situation of family makes him sad
Sleeps well
Vents anger or sadness through crying

Not a member of a gang or fraternity
Accompanied by the mother or father going to
and from school

Roman Catholic
Believes in God
Prays at night but does not go to church

Stakeholders Analysis

Physical Examination
General Appearance
Awake, alert, and not in cardiorespiratory
distress. Weak-looking.

Physical Examination
Weight: 34kg
Height: 140cm
BMI 17.3
HFA: between -1 and -2 (Normal)
BMIFA: between 0 and -1 (Normal)

Physical Examination
Vitals Signs: BP: 90/60 HR: 69 bpm RR: 12

bpm T: 36.5 C
Head and Neck: Normocephalic, flushed
face, No CLADS, No neck vein engorgement.
No lesions in scalp
Eyes: Anicteric sclerae, Pink palpebral
conjunctivae, No eye discharge, No periorbital
edema, No matting of eyelashes, Eyes are
briskly reactive to light, (+) Red orange reflex.

Physical Examination
Ears: Ears are symmetric. Ear canal is non-

hyperemic and tympanic membrane is not

bulging. No tragal tenderness. Visible cone of
light bilaterally, with brownish retained
cerumen partially occluding the ear canals
Nose: Nasal Bridge is flat, no alar flaring,
nasal septum is midline, and turbinates are
pink with no watery nasal discharge.

Physical Examination
Oral Cavity: Dry lips, moist oral mucosa,

hyperemic buccal mucosa and pharyngeal

walls. No tonsilar enlargement. Dental carries
present. No gingival and mucosal lesions.
Cardiovascular: Adynamic precordium, No
heaves no thrills, Regular cardiac rate and
rhythm, Distinct heart sounds s1>s2 at the
base, Apex beat at the 4th ICS MCL, No
murmurs appreciated.

Physical Examination
Chest and Lungs: Symmetric chest

expansion, No retractions, No lesions or

masses. Clear breath sounds
Back and Spine: No lesions and obvious
spinal deformities.
Abdomen: Flat abdomen, no distention, no
scars, no masses, normoactive bowel sounds
and tympanitic on all quadrants, with
epigastric tenderness (pain scale= 5/10) but
no organomegaly on palpation.

Physical Examination
Pelvis and GU tract: N/A
Rectal: N/A
Upper and Lower Extremities: Negative

tourniquet test, no obvious deformities, no lesions,

no clubbing, and no cyanosis. Full range motion of
upper and lower extremities on active and passive
Skin and Nails: No rashes, no lesions, no
jaundice no cyanosis, good skin turgor. CRT<2secs
Neurologic: Glasgow Coma Scale: 15, Cranial
Nerves testing not done.

Salient Features

Physical Examination

Physical Examination

Primary Working Impression

Dengue Fever with Warning signs
(vomiting and abdominal pain).
Symptom presentation
Absence of hemorrhagic symptoms
Initial and follow up CBC
(rising haematocrit 5-10%, leukopenia
<5000cells/mm and mild thrombocytopenia
Presence of warning signs vomiting and abdominal
pain further classifies it as dengue fever with
warning signs.

Pathophysiology of Dengue
Mosquito-borne viral disease
Transmission: female mosquitoesAedes

aegyptiand, to a lesser extent,A. albopictus.

Widespread throughout the tropics, with local
variations in risk influenced by rainfall,
temperature and unplanned rapid
(DEN-1, DEN-2, DEN-3 and DEN-4).

Pathophysiology of
Recovery from infection by one provides

lifelong immunity against that particular

Cross-immunity to the other serotypes after
recovery is only partial and temporary.
Subsequent infections by other serotypes
increase the risk of developing severe dengue.

Pathophysiology of
The immune system is implicated early in the

acute stage of secondary dengue infections

Rapid activation of the complement system
Increase in the levels of tumor necrosis factor

receptor, interferon-, and interleukin-2 and the

virus itself, or viral non-structural protein 1 (NS1)

may interact with endothelial cells, blood clotting

factors, and platelets to produce increased vascular
permeability leading to the plasma leakage and
the accompanying symptoms of dengue fever.

Pathophysiology of
Warning signs occur 37 days after the first

symptoms in conjunction with a decrease in

temperature (below 38C/100F) and include:
Severe abdominal pain
Persistent vomiting
Rapid breathing
Bleeding gums
Blood in vomit.

Course of Illness

Virus isolation serotypic/genotypic

-Only useful in the first 6 days and if
processed without delay
Viral nucleic acid detection
-Dengue genome detection using RT-PCR
Viral antigen detection (NS1)
-Declines to undetectable levels at day 5-6.

Immunological response based tests IgM and IgG antibody

simple and rapid test based on detecting the dengue-specific

IgM antibodies in the test serum using anti-human IgM

Analysis for haematological parameters

Thrombocytopenia, a drop in platelet count below 100 000
per l, is usually found between the third and eighth day of
illness often before or simultaneously with changes in
Haemoconcentration with an increase in the haematocrit of
20% or more is considered to be a definitive evidence of
increased vascular permeability and plasma leakage.


Treatment of uncomplicated dengue fever is

Antipyretics should be used to keep body
temperature <40C (104F).
Aspirin is contraindicated

Fluid and Electrolyte Replacement

required for deficits caused by sweating,
fasting, thirsting, vomiting, and diarrhea.

Monitoring of dengue/DHF patients during the critical

General condition, appetite, vomiting, bleeding and

other signs and symptoms

Peripheral perfusion and vital signs monitoring
should be performed frequently
Thrombocytopenia around 100 000 cells/mm3
Rising haematocrit of 10% above baseline

early objective indicator of plasma leakage. Serial haematocrit

should be performed at least every four to six hours

Urine output every 8 to 12 hours in uncomplicated


Should be about 0.5 ml/kg/h based on the ideal body weight.

Good but care should be taken to avoid use of

drugs that suppress platelet activity.

In dengue hemorrhagic fever, Death has
occurred in 40-50% of patients with shock, but
with adequate intensive care, deaths should
occur in <1% of cases.

Preventive Measures and Public

Health Issues
Avoidance of daytime household-based

mosquito bites.
Insecticides, repellents, body covering with

clothing, screening of houses, and destruction of A.

aegypti breeding sites.

Water should not be stored for long periods of

time to prevent it from becoming mosquito

breeding sites.
Larvaecides can be used in stored drinking water.
Vaccines are not yet available but are currently
under development.

Progress Notes

Progress Notes

Kliegman et. al. (2011) Nelsons Textbook of
Pediatrics, 19th edition
World Health Organization. 2011.
Comprehensive guidelines for prevention and
control of dengue and dengue haemorrhagic
fever. Revised and expanded edition. WHO:
Regional Office for South-East Asia.

Thank you!