HEMA CASE 2

D.F., 34/F, from Tabaco City

Chief Complaint: Fever
History of Present Illness:
4 days, D.F. experienced body malaise associated with fever and joint pains. She
took Alaxan and Bioflu which afforded temporary relief. Persistence of symptoms
prompted to seek consult and was subsequently admitted.

(+) headache
(+) sore throat
(+) myalgia
Identify the pertinent data in the case.
• 34/F
• Tabaco City
• Fever
• malaise
• joint pains
• Temporarily relieved by Alaxan and Bioflu
• Persitence of symptoms for 4 days
What other important aspects or relevant
information should be asked?
• Identifying Data- occupation, source of history or referral, religion, and reliability.
• HPI- Activities prior to onset of symptom, To what extent did the symptom
affected her daily activities? How high is the fever?, how painful are the joint
pains?, What joints are affected? To what extent the home remedies relieved the
symptoms?, compared to the previous days, did the symptoms get worse,
maintained, or reduced? Aggravating and palliative factors? Are there any other
associated symptoms that are present? Had the patient traveled to areas with
endemic diseases?
What disease entities can be considered based on the limited
data?
The main complaint is fever, so the patient could be:
• Make also sure that the patient isn’t making it up
• Since we are in a tropical country, we need to consider fever associated with
travel
 There are a lot of diseases related to fever, but do
remember that the patient also have body malaise and
joint pain
• Influeza
• Dengue fever
• Malaria
• Acute bacterial arthritis
• Travel associated infections
• Immunosuppressive diseases
• PAST MEDICAL HISTORY
• (-) HPN
• (-) Asthma
• FAMILY HISTORY
• (+) HPN – Father
• PERSONAL/SOCIAL HISTORY
• - Works as a fruit vendor
• - Non-smoker
• PHYSICAL EXAMINATION:
• BP 110/80 HR 98 RR 20 Temp 38.8C
• General Survey: weak-looking, conscious, coherent, not in cardiorespiratory distress
• HEENT: pink palpebral conjunctive, no neck vein engorgement
• Lungs: symmetrical chest expansion, clear breath sounds
• Heart: Adynamic precordium, normal rate, regular rhythm, parasternal border, no
murmurs
• Abdomen: flat, normoactive bowel sounds, soft, no tenderness
• Extremities: no edema, full and equal pulses
For patients with fever, what should you
look for?
. What are your differential diagnosis
based on PE?
• Influeza
• Dengue fever
• Malaria
2. What laboratory tests or procedures will
you request to confirm your diagnosis?
• CBC
• Creatinine
• nucleic acid amplification test (NAAT) for Dengue (RT-PCR or NS1)
• Serologic test (IgM and IgG antibody tests)
• Liver function tests
• Creatinine level
• Blood smear with giemsa stain
• LABS
• CBC
• Hgb 112g/L
• Hct 0.34 L/L
• WBC 3.1
• Platelets 88 x 10u/L
• CREA 110
• SGPT 45
• CXR-PA view: Negative chest
Interpret the laboratory results.
Test Value Reference Interpretation
Hgb 112g/L 13-17 g/dL (men), 12-15 Low
g/dL (women)
Hct 0.34 L/L 40%-52% (men), 36%- Low
47%
WBC 3.1 4-10 x 10^9/L Low
Platelets 88 x 10u/L 150-400 x 10^9/L Low
CREA 110 74.3 to 107 Slightly elevated/ upper
range in some
references
SGPT 45 7 to 55 units per liter WNL
CXR-PA view: Negative chest No abnormalities?
Malaria
Anemia
Thrombocytopenia
Luekopenia
What other diagnostic tests will you request
to aid in your prognosis and diagnosis?
• nucleic acid amplification test (NAAT) for Dengue
• Serologic test (IgM and IgG antibody tests)
• Tourniquet test
• Blood smear with giemsa stain
20 petechiae in 1in x 1in
area indicates positive
result
What is your working diagnosis?
• Dengue Fever; To rule out Malaria.
What is your
therapeutic plan?
• Management:
• Venoclysis with PNSS 1L at 30gtts/min
• Paracetamol 500mg/tab 1 tab Q4 RTC

Definition of Term
venoclysis (vi-nok-li-sis) n. the continuous infusion into a vein of saline or other
solution.
Review the
pathophysiology of fever.
What is wrong with Dengue?
The primary pathophysiological abnormality seen in dengue infection is
an acute increase in vascular permeability that leads to leakage of plasma
into the extravascular compartment, resulting in haemoconcentration
and hypovolaemia or shock.

• Hypovolaemia leads to reflex tachycardia and generalised vasoconstriction

due to increased sympathetic output
What is wrong with Dengue?
• Inadequate perfusion  increased anaerobic glycolysis and lactic acidosis.
progression leads to refractory shock state  lactic acidosis further depresses the
myocardium and worsens the hypotension.
• In refractory shock state, the tissue perfusion would not respond to vasopressor
drugs, even if the blood pressure and intravascular volume were to be restored
and cardiac output would remain depressed.
Discuss the clinical course of Denger Fever Syndrome.

• After the incubation period, the illness begins abruptly and will be followed by
three phases: febrile, critical and recovery phase
Febrile phase
• develop high grade fever (2-7 days)
• facial flushing,
• rash,
• generalised body ache,
• vomiting
• Headache
• May also experience facial flushing, rash, generalised body ache, vomiting and
headache
Febrile phase
• Mild haemorrhagic manifestations may be seen (petechiae and mucosal
membrane bleeding)
• vaginal bleeding may occur but rarely massive
• Gastrointestinal bleeding is not uncommon
• Tender Liver! (Warning sign)
• CBC results- progressive decrease in total white cell count followed by platelet
reduction
Critical Phase
• often occurs after third day of fever (may occur earlier) or around defervescence
indicated by a rapid drop in temperature.
• Increased capillary permeability

In other viral infections, the patient’s condition improves as the

temperature subsides, but the contrary happens in severe
dengue infection wherein the patient may deteriorate and
manifest third space plasma leakage or organ dysfunction
Critical Phase
• lasts about 24-48 hours
• Varying circulatory
disturbances can develop
(Refer to table)
• Disturbance can be
minimal and transient
(Less severe) and recover
spontaneously or after a
short period of fluid or
electrolyte therapy
Critical Phase
• In more severe forms of plasma leakage, the patients may develop
compensated or decompensated shock
• Clinical Warning Signs
• Abdominal pain,
• persistent vomiting and/or diarrhoea,
• restlessness,
• altered conscious level,
• clinical fluid accumulation,
• mucosal bleed or
• Tender Liver
Critical Phase
• Lab works
• thrombocytopaenia and haemoconcentration are usually detectable in
this phase
• haematocrit (HCT) level correlates well with plasma volume loss and
disease severity
• Leucopaenia with relative lymphocytosis, clotting abnormalities,
elevation of transaminases (AST>ALT)
• hypoproteinaemia and hypoalbuminaemia
Recovery/Reabsorption Phase
• After 24-48 hours of critical phase, usually plasma leakage stops followed by
reabsorption of extravascular fluid.
• Patient’s general well being improves, appetite returns, gastrointestinal symptoms
improve, haemodynamic status stabilises and diuresis ensues.
• Some may have classical rash of “isles of white in the sea of red” with generalised
pruritus
• organ dysfunctions may worsen (hepatitis, encephalitis and intracranial bleed) as the
patient enters reabsorption phase
• Lab works
• HCT level stabilises and drops further due to haemodilution following reabsorption of
extravascular fluid
• The recovery of platelet count is typically preceded by recovery of white cell count
. What are the laboratory findings?
• Decline in Hemoglobin
The greater the deviation, the
• Increased Hematocrit higher the risk for mortality
• Thrombocytopenia:
• Increased Creatinine Levels:
• Increased AST
• Acidosis
• Prolonged Partial Thromboplastin Time
• Prolonged Prothrombin Time (PT)
• Low Albumin Levels:
What are the indications for transfusion of blood products?
What are the possible complications of Dengue Fever?

• Complications and sequelae of dengue virus infections are rare but may include the
following:
• Cardiomyopathy.
• Seizures, encephalopathy, and viral encephalitis.
• Hepatic injury.
• Depression.
• Pneumonia.
• Iritis.
• Orchitis.
• Oophoritis.
• common late complications of prolonged shock are massive bleeding, disseminated
intravascular coagulopathy (DIC) and multi-organ failure which are often fatal
Clinical signs and symptoms warrant admission?
Among patients with dengue, which risk factors are
associated with mortality?