Case

Discussion
Tanaphon Kusonthomarat, 600710062
6th year medical student, CMU
 TABLE OF
CONTENTS

01
Case Presentation
04
Basic knowledge

02
Discussion
05
Evaluation and
Management

03
Diagnosis and Management
plan
2
 Case
Presentation

Case
Presentation

3
Identification
Data

A Thai male patient, 38 years old.

Chief complaint : Having a erythematous rash at his back 3 day prior to met a doctor

4
Present Illness

Chief complaint : 3 day PTA, he reported that there was a rash at his back
area

Present Illness : 3 day prior to met a doctor, he found that there was a
erythematous rash at his back area. The rash was not itching and non
blanchable. There was a fever observed by the patient. He was noted that
there were headache and myalgia when the fever persisted. However, there
was no other symptoms such as URI symptoms, joint pain, ocular pain, and
abnormal bleeding. There were no dizziness,

5
Past history

Underlying disease : Gout (F/U at Lamphun Hospital)

Known allergic reaction to Aspirin
No known allergic reaction to specific foods
No history of alcohol usage and smoking
No family history of bleeding tendency and bleeding disorder in his family
No history of malignancy in his family

6
 Physical
examination

General appearance : A middle aged thai man, look well, normal conscious, good
comprehension, orientate to time, place, and person
Vital signs : BP, HR, RR, BT, O2sat
HEENT : no pale conjunctiva, no icteric sclera, no lymph node enlargement
Heart : regular rate and rhythm, normal s1 and s2, no murmur
Lung : normal chest wall expansion, clear and equal breath sound both lungs, no
adventitious breath sound
Abdomen : fatty abdominal contour, no distention,normal active bowel sound, no
tenderness, no guarding, liver and spleen cannot be palpated
Extremities : normal movement all extremities, no pitting edema
Neurological : E4V5M6, EOM full, Motor grade V all, sensation intact

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Discussion and
Differential
diagnosis

8
ifferential diagnosis
 Laboratory
Investigation

CBC
BUN, Cr
Elyte
CXR
Tourniquet test
NS1 Antigen
CB
C

1
1
CBC

1
2
CBC

1
3
BUN, Cr, Elyte

1
4
BUN, Cr, Elyte

1
5
Urine analysis

1
6
Urine analysis

1
7
efinite Diagnosis

Definite diagnosis : Dengue Hemorrhagic Fever

Management plan
Dengue Viral
Infection

2
0
Epidemiology

2
1 687-702.
Sudipta Kumar Roy and Soumen Bhattacharjee. Dengue virus: epidemiology, biology, and disease aetiology. Canadian Journal of Microbiology. 67(10):
https://doi.org/10.1139/cjm-2020-0572
Epidemiology

2
2
Epidemiology

2
3
Epidemiology

2
4
Pathogen

Dengue virus (DENV)

- ssRNA
- 4 serotypes : DENV-1,2,3,4

Lifelong immunity

Transient cross protection

Secondary infection : Dengue hemorrhagic fever (DHF), Dengue shock

syndrome (DSS), Antibody dependent enhancement

2
5
 Antibody
dependent
enhancement

- Antibody from primary infection

cannot neutralize virus

- increase overall replication of the

virus

2
Ulrich, H., Pillat, M.M. and Tárnok, A. (2020), Dengue Fever, COVID-19 (SARS-CoV-2), and Antibody-Dependent Enhancement (ADE): A Perspective.6Cytometry,
97: 662-667. https://doi.org/10.1002/cyto.a.24047
Vectors

Mosquito-borne disease
Vectors
- Aedes agypti - urban region
- Aedes albopictus - rural region

27
Course of disease

- Incubation period : 7-10 days

- Febrile phase : fever, N/V, myalgia

- Critical phase ; increase capillary

permeability, plasma leakage, shock

- Recovery phase : increase appetite,

bradycardia, convalescent rash, diuresis
2
8
Assir, Muhammad Zaman Khan. (2011). GUIDELINES FOR CLINICAL CASE MANAGEMENT OF DENGUE FEVER/ DENGUE HEMORRHAGIC FEVER/ DENGUE SHOCK SYNDROME 2011
 Clinical
characteristics

2
9
Comprehensive Guidelines for Prevention and Control of Dengue and Dengue Haemorrhagic Fever : WHO
Dengue Fever

- Benign course

- characteristics

fever phase
no critical phase : no plasma leakage
recovery phase : convalescent rash

30
Dengue fever

31
Tourniquet test

- Blow bp cuff at half of SBP and DBP

- maintain pressure for 5 minutes

- more than 10 points of bleeding spots in

1x1 square inches -> positive

32
Dengue fever

33
 Dengue
Hemorrhagic fever

- secondary infection

- clinical characteristics
- fever phase
- critical phase : plasma leakage, shock (grade 3,4)
- recovery phase

3
4
 Dengue
Hemorrhagic fever

35
Koul, Parvaiz & Bali, Nargis. (2015). Viral hemorrhagic fevers in India.
 Dengue
hemorrhagic fever

36
Koul, Parvaiz & Bali, Nargis. (2015). Viral hemorrhagic fevers in India.
Warning signs

37
Zi, Chong & Fijen, Lucas & Dijk, Marit & Libin, Michelle & Asheila, Nur & Abdul Taib, Nur Asheila & Simon, Shanna. (2019). DengAway: A self-screening application for
prevention and early detection of Dengue .
 Laboratory
investigations
- Virus detection and component
viral culture
nucleic acid detection : RT-PCR
Viral antigen detection : NS-1 test

- antibody assays
Hemagglutination inhibition test
ELISA
Immunochromatography

- Supportive laboratory tests

CBC : hemoconcentration, leukopenia
Plt count : thrombocytopenia
LFT : transaminitis
CXR : Rt. pleural effusion 3
8
 Laboratory
investigations

3
Queensland Dengue Management Plan 2015>2020. Queensland Health, Communicable Diseases Branch. 9 2015:
https://www.health.qld.gov.au/__data/assets/pdf_file/0022/444433/dengue-mgt-plan.pdf
Management of
Dengue

Febrile phase
- adequate rest
- antipyretics : Acetaminophen (<15mg/kg, not exceed 75mg/kg in 24 hr)
- soft diet
- fluid replacement : oral fluid, IV (when meet indication)

Indications for IV fluid replacement

- severe vomiting
- moderate to severe dehydration
- suspected plasma leakage (plt < 100,000 cells/cu.mm. / increase Hct > 10%) 4
0
Management of
Dengue

IV fluid replacement
- Isotonic crystalloid : 5% DNSS, 0.9% NSS
- balanced crystalloid : Acetate Ringer’s, Lactate Ringer’s

4
1
Management of
Dengue

Critical phase
- rapid diagnosis of plasma leakage & shock
- avoid invasive procedure
- for DSS
- record V/S, I/O, CRT q 5-15 min
- Hct q 1-2 hr
- monitor O2 saturation keep >= 95%
- IV fluid (as indication) not exceed more than 24-36 hours
(in shock) and not more than 48-60 hours (not shock) after plasma leakage
4
2
Management of
Dengue

Recovery phase (recover in 24-48 hr after shock)

- increase appetite -> stop IV fluid supplement
- bradycardia, decreased Hct, convalescent rash

Criteria for discharge

- look clinically good & stable
- no fever more than 24 hours
- urine output >= 1 ml/kg/hr
- normal Hct
- Plt > 50,000 cells/cu.mm. 4
3
4
4
4
5
Causes of death

- Fluid overload
- Prolong shock : plasma leakage, internal bleeding
- Massive bleeding : delay diagnosis
- Unusual manifestation : liver failure, renal failure

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