REFERAT Dengue Hemoragic Fever

ACKNOWLEDGMENTS

We are greatly indebt to the Almighty One for giving us blessing to finish this case report, “Dengue Hemoragic Fevers”. This case report is requirement to complete the clinical assistance program in Department of Child Health in Haji Adam Malik General Hospital, Medical Faculty of North Sumatera University.

We are also indebt to our supervisor and adviser, dr. Rizky Ardiansyah, M. Ked (Ped), Sp. A (K) for much spent time to give us guidance, comments, and suggestions. We are grateful because without Him, this case report wouldn’t have taken its present shape.

This case report has gone through series of developments and corrections. There were critical but constructive and relevants suggestions from the reviewers. Hopefully the content will be useful for everyone the future.

Writers

CONTENTS

ACKNOWLEDGMENTS.................................................................................................... i

CONTENTS.......................................................................................................................... ii

CHAPTER 1 INTRODUCTION.......................................................................................... 1

CHAPTER 2 LITERATURE REVIEW............................................................................... 3

CHAPTER 3 CASE REPORT.............................................................................................. 15

CHAPTER 4 DISCUSSION................................................................................................ 25

CHAPTER 5 SUMMARY.................................................................................................... 27

REFERENCES .................................................................................................................... 30

CHAPTER 1

INTRODUCTION

1.1 Background

Dengue is the most rapidly spreading mosquito-borne viral disease of man kind, with a 30- fold increase in global incidence over the last five decades. It is a major public health concern throughout the tropical and subtropical regions of the world. Almost half the world's population lives in countries where dengue is endemic. According to World Health Organization (WHO), about 50–100 million new dengue infections are estimated to occur annually in more than 100 endemic countries, with a steady increase in the number of countries reporting the disease.⁽¹⁾ An estimated 500 000 people with DHF require hospitalization each year. A very large proportion (approximately 90%) of them are children aged less than five years, and about 2.5% of those affected die. Epidemics of dengue are increasing in frequency. During epidemics, infection rates among those who have not been previously exposed to the virus are often 40% to 50% but can also reach 80% to 90%.⁽³⁾

Approximately 1.8 billion (more than 70%) of the population at risk for dengue worldwide live in Member States of the WHO South-East Asia Region (SEAR) and Western Pacific Region, which bear nearly 75% of the current global disease burden due to dengue. Of the 11 countries of SEAR, 10 countries including Indonesia are endemic for dengue. The only exception is the Democratic People's Republic of Korea. In 2012, SEAR countries reported approximately 0.29 million cases, of which Thailand contributed almost 30%, Indonesia 29% and India 20%. ⁽²⁾

Since 2000, epidemic dengue has spread to new areas and has increased in the already affected areas of the region. In 2003, eight countries -- Bangladesh, India, Indonesia, Maldives, Myanmar, Sri Lanka, Thailand and Timor - Leste reported dengue cases. Epidemic dengue is a major public health problem in Indonesia, Myanmar, Sri Lanka, Thailand and Timor-Leste which are in the tropical monsoon and equatorial zone where Aedes aegypti is widespread in both urban and rural areas, where multiple virus serotypes are circulating, and where dengue is aleading cause of hospitalization and death in children.⁽¹⁾

The number of dengue cases has increased over the last three to five years, with recurring epidemics. Moreover, there has been an increase in the proportion of dengue cases with their severity, particularly in Thailand, Indonesia and Myanmar. Reported case fatality rates for the region are approximately 1%, but in India, Indonesia and Myanmar, focal outbreaks away from the urban areas have reported case-fatality rates of 3--5%.⁽³⁾

In Indonesia, where more than 35% of the country’s population lives in urban areas, 150 000 cases were reported in 2007 (the highest on record) with over 25 000 cases reported from both Jakarta and West Java. The case-fatality rate was approximately 1%.⁽¹⁾

CHAPTER 2

LITERATURE REVIEW

2.1 Epidemiology

Dengue is one of the most important emerging viral disease of humans in the world afflicting humanity in terms of morbidity and mortality. Currently the disease is endemic in all continents except Europe. The Epidemiology of dengue is a complex phenomenon that mainly depends upon an intricate relationship between the 3 epidemiological factors: the host (man and mosquito), the agent (virus) and the environment. The complexity of relationship among these factors eventually determines the level of endemicity in an area.⁽⁴⁾

2.1.1. Dengue Virus

The agent of dengue, i.e. dengue viruses, are categorized under the genus Flavivirus. These viruses contain single stranded RNA and are small in size (50 nm). There are four dengue virus serotypes which are designated as DENV-1, DENV-2, DENV-3 and DENV- 4. These serotypes may be in circulation either singly, or more than one can be in circulation in any area at the same time. Although all four serotypes are antigenically similar, they are different enough to elicit crossprotection only for a few months after infection by any one of them. Infection with any one serotype confers lifelong immunity to the virus serotype. ⁽¹⁾

The genome is cleaved by host and viral proteases in three structural proteins (capsid, C, prM, the precursor of membrane, M, protein and envelope, E) and seven nonstructural proteins (NS).⁽²⁾

2.1.2 Vector

Dengue viruses are transmitted by the bite of female Aedes (Ae) mosquitoes. Ae.aegypti is the most potential vector but other species such as Ae albopictus, Ae. polynesiensis and Ae. niveus have also been incriminated as secondary vectors. Dengue is transmitted by the bite of female Aedes mosquito. Female Aedes mosquito deposits eggs singly on damp surfaces just above the water line. Under optimal conditions the life cycle of aquatic stage of Ae. aegypti can be as short as seven days. It is a day time feeder and can fly up to a limited distance of 400 meters. To get one full blood mea the mosquito has to feed on several persons, infecting all of them.⁽⁴⁾

2.1.3. Host

Dengue viruses, having evolved from mosquitoes, adapted to non-human primates and later to humans in an evolutionary process. The viraemia among humans builds up high titres two days before the onset of the fever (non-febrile) and lasts 5–7 days after the onset of the fever (febrile). It is only during these two periods that the vector species gets infected. Thereafter, the humans become dead-ends for transmission. The spread of infection occurs through the movement of the host (man) as the vectors’ movements are very restricted. The susceptibility of the human depends upon the immune status and genetic predisposition. ⁽³⁾

2.1.4. Environmental Factors

The population of Ae. aegypti fluctuates with rainfall and water storage. Its life span is influenced by temperature and humidity, survives best between 16º-30º C and a relative humidity of 60-80%. Ae. aegypti breeds in the containers, in and around the houses. Altitude is an important factor in limiting the distribution of Ae. aegypti, it is distributed between sea level and 1000 ft above sea level. Ae. aegypti is highly anthropophilic and rests in cool shady places. The rural spread of Ae. aegypti is a relatively recent occurrence associated with the development of rural water supply schemes, improved transport systems, scarcity of water and like style changes. Ae. aegypti breeds almost entirely in domestic man-made water receptacles found in and around households, construction sites and factories; natural larval habitats are tree holes, leaf axils and coconut shells. In hot and dry regions, overhead tanks and ground water storage tanks become primary habitats. Unused tyres, flower pots and desert coolers are among the most common domestic breeding sites of Ae. Aegypti. ⁽⁴⁾

2.1.5. Transmission cycle

            The female usually becomes infected with the dengue virus when it takes a blood meal from a person during the acute febrile (viremia) phase of dengue illness. After an extrinsic incubation period of 8 to 10 days, the mosquito becomes infected. The virus is transmitted when the infected female mosquito bites and injects its saliva into the wound of the person bitten. The cycle of dengue continues by this process. Dengue begins abruptly after an intrinsic incubation period of 4 to 7 days (range 3–14 days). There is also evidence of vertical transmission of dengue virus from infected female mosquitoes to the next generation. Though transmission primarily occurs through the bite of a vector, there are reports of dengue transmission through blood transfusion and organ transplantation. There are also reports of congenital dengue infections occurring in neonates born to mothers infected very late in pregnancy.⁽¹⁾

2.2 Pathogenesis

            Primary or first infection in non immune persons usually causes Dengue fever. Subsequent dengue infection by different serotype causes more severe illness like DHF/DSS. The key manifestations of the DHF/DSS are sudden onset of shock, capillary leakage, haemorrhagic diathesis/ thrombocytopenia occurring at the time of defervescence of fever. Pathogenesis is not well defined but it is suggested that it ismediated through soluble mediators, compliment activation and cytokines that are responsible for various manifestations. ⁽⁴⁾

2.3. Clinical Manifestation

Dengue virus infection may be asymptomatic or may cause undifferentiated febrile illness (viral syndrome), dengue fever (DF), or dengue haemorrhagic fever (DHF) including dengue shock syndrome (DSS). Infection with one dengue serotype gives lifelong immunity to that particular serotype, but there is only short-term cross-protection for the other serotypes. The clinical manifestation depends on the virus strain and host factors such as age, immune status, etc. ⁽³⁾

Differentiation between dengue fever and dengue hemorrhagic fever is difficult early in the course of illness. A relatively mild 1st phase with abrupt onset of fever, malaise, vomiting, headache, anorexia, and cough may be followed after 2-5 days by rapid clinical deterioration and collapse. In this 2nd phase, the patient usually has cold, clammy extremities, a warm trunk, flushed face, diaphoresis, restlessness, irritability, mid epigastric pain, and decreased urinary output. Frequently, there are scattered petechiae on the forehead and extremities; spontaneous ecchymoses may appear, and easy bruising and bleeding at sites of venipuncture are common. A macular or maculopapular rash may appear, and there may be circumoral and peripheral cyanosis. Respirations are rapid and often labored. The pulse is weak, rapid, and thready, and the heart sounds are faint. The liver may enlarge to 4-6 cm below the costal margin and is usually firm and somewhat tender. Approximately 20-30% of cases of dengue hemorrhagic fever are complicated by shock (dengue shock syndrome). Dengue shock can be subtle, arising in patients who are fully alert, and is accompanied by increased peripheral vascular resistance and raised diastolic blood pressure. Shock is not from congestive heart failure but from venous pooling. With increasing cardiovascular compromise, diastolic pressure rises toward the systolic level and the pulse pressure narrows. Fewer than 10% of patients have gross ecchymosis or gastrointestinal bleeding, usually after a period of uncorrected shock. After a 24-36 hr period of crisis, convalescence is fairly rapid in the children who recover. The temperature may return to normal before or during the stage of shock. Bradycardia and ventricular extrasystoles are common during convalescence.⁽⁵⁾

2.4 Laboratory Diagnosis

Unequivocal diagnosis of dengue infection requires laboratory confirmation, either by isolating the virus or detecting dengue-specific antibodies. For virus isolation or detection of DENV RNA in serum specimens by serotype-specific, real-time reverse transcriptase polymerase chain reaction (RT-PCR), an acute-phase serum specimen should be collected within 5 days of symptom onset. If the virus cannot be isolated or detected from this sample, a convalescent-phase serum specimen is needed at least 6 days after the onset of symptoms to make a serologic diagnosis by testing for IgM antibodies to dengue with an IgM antibody-capture enzyme-linked immunosorbent assay (MAC-ELISA).⁽⁵⁾

Acute-phase and convalescent-phase serum samples should be sent to the state health department or tothe Centers for Disease Control and Prevention (CDC) for testing. Acute-phase samples for virus diagnosis may be stored on dry ice (-70°C) or, if delivery can be made within 1 week, stored unfrozen in a refrigerator (4°C). Convalescent-phase samples should be sent in a rigid container without ice, if next-day delivery is assured. Otherwise, they should be shipped on ice in aninsulated container to avoid heat exposure during transit.

Most tests for anti-dengue antibodies yield nonspecificresults for flaviviruses, including West Nile and St. Louis encephalitis viruses. Because commercial kits may vary in sensitivity and specificity, test results may need to be confirmed by a reference laboratory.⁽⁶⁾

2.5 Criteria for clinical diagnosis of DHF/DSS

Clinical manifestations

• Fever: acute onset, high and continuous, lasting two to seven days in most cases.

• Any of the following haemorrhagic manifestations including a positive tourniquet test (the most common), petechiae, purpura (at venepuncture sites), ecchymosis, epistaxis, gum bleeding, and haematemesis and/or melena.

• Enlargement of the liver (hepatomegaly) is observed at some stage of the illness in 90%–98% of children. The frequency varies with time and/or the observer.

• Shock, manifested by tachycardia, poor tissue perfusion with weak pulse and narrowed pulse pressure (20 mmHg or less) or hypotension with the presence of cold, clammy skin and/or restlessness.

Laboratory findings

• Thrombocytopenia (100 000 cells per mm3 or less).

• Haemoconcentration; haematocrit increase of ≥20%i from the baseline of patient or population of the same age.

The first two clinical criteria, plus thrombocytopenia and haemoconcentration or a rising haematocrit, are sufficient to establish a clinical diagnosis of DHF. The presence of liver enlargement in addition to the first two clinical criteria is suggestive of DHF before the onset of plasma leakage.

The presence of pleural effusion (chest X-ray or ultrasound) is the most objective evidence of plasma leakage while hypoalbuminaemia provides supporting evidence. This is particularly useful for diagnosis of DHF in the following patients:

• anaemia.

• severe haemorrhage.

• where there is no baseline haematocrit.

• rise in haematocrit to <20% because of early intravenous therapy.

In cases with shock, a high haematocrit and marked thrombocytopenia support the diagnosis of DSS. A low ESR (<10 mm/first hour) during shock differentiates DSS from septic shock.⁽³⁾

2.6. Management

Approach to clinical management of dengue Fever may vary depending on severity of illness. The patients who have simple fever without any danger signs or complications may be managed with symptomatic approach. Those who have warning signs and symptoms should be closely monitored for progression of disease. The patients of DHF without shock, significant bleeding or involvement of various organs require aggressive management to reduce morbidity and mortality. Patient may develop complications during later stage of fever (defervescence) or a febrile phase, where clinician should be careful to look for danger signs and signs of fluid overload.

2.6.1. Management of dengue fever

Management of dengue fever is symptomatic and supportive

i. Bed rest is advisable during the acute phase.

ii. Use cold/tepid sponging to keep temperature below 38.5 C.

iii. Antipyretics may be used to lower the body temperature. Aspirin/NSAIDS like Ibuprofen, etc should be avoided since it may cause gastritis, vomiting, acidosis, platelet dysfunction and severe bleeding. Paracetamol is preferable in the doses given below:

• 1-2 years: 60 -120 mg/dose

• 3-6 years: 120 mg/dose

• 7-12 years: 240 mg/dose

• Adult : 500 mg/dose

Note: In children the dose of paracetamol is calculated as per 10 mg/Kg body weight per dose. Paracetamol dose can be repeated at the intervals of 6 hrs depending upon fever and body ache.

iv. Oral fluid and electrolyte therapy is recommended for patients with excessive sweating or vomiting.

v. Patients should be monitored for 24 to 48 hours after they become afebrile for development of complications.

Management during febrile phase

Paracetamol is recommended to keep the temperature below 39 C. Adequate fluid should be advised orally to the extent the patient tolerates. Oral rehydration solution (ORS), such as those used for the treatment of diarrhoeal diseases and / or fruit juices are preferable to plain water. Intravenous fluid should be administered if the patient is vomiting persistently or refusing to feed.

Patients should be closely monitored for the initial signs of shock. The critical period is during the transition from the febrile to the afebrile stage and usually occurs after the third day of illness. Sometimes serial haematocrit determinations are essential to guide treatment plan, since they reflect the degree of plasma leakage and need for intravenous administration of fluids. Haematocrit should be determined daily specially from the third day until the temperature remains normal for one or two days.

2.6.2 Management of DHF without Shock                                                                                                                                                                                                                                                                                                                                            

Any person who has dengue fever with thrombocytopenia, high haemoconcentration and presents with abdominal pain, black tarry stools, epistaxis, bleeding from the gums etc. needs to be hospitalized. All these patients should be observed for signs of shock. The critical period for development of shock is during transition from febrile to abferile phase of illness, which usually occurs after third day of illness. Rise of haemoconcentration indicates plasma leakage and loss of volume for which proper fluid management plays an important role.

Despite the treatment, if the patient develops fall in BP, decrease in urine output or other features of shock, the management for Grade III/IV DHF/DSS should be instituted. Oral rehydration should be given along with antipyretics like Paracetamol.

Notes:

*Improvement: Hct falls, pulse rate and blood pressure stable, urine output rises

**No Improvement: Hct or pulse rate rises, pulse pressure falls below 20 mmHg, urine output falls

2.6.3 Management of Shock

Immediately after hospitalization, the haematocrit, platelet count and vital signs should be examined to assess the patient's condition and intravenous fluid therapy should be started. The patient requires regular and continuous monitoring. If the patient has already received about 1000 ml of intravenous fluid, it should be changed to colloidal solution preferably Dextran 40 or if haematocrit further decreases fresh whole blood transfusion 10-

20ml/kg/dose should be given.

However, in case of persistent shock even after initial fluid replacement and resuscitation with plasma or plasma expanders, the haematocrit continues to decline, internal bleeding should be suspected. It may be difficult to recognize and estimate the degree of internal blood loss in the presence of haemoconcentration. It is thus recommended to give whole blood in small volumes of 10ml/kg/hour for all patients in shock as a routine precaution. Oxygen should be given to all patients in shock. Treatment algorithm for patients with DHF with shock:

Crystalloid: Normal Saline, ringer lactate

Colloid: Dextran 40/degraded gelatine polymer (polygeline)

#ABCS= Acidosis, Bleeding, Calcium (Na++ &K+), Sugar

Notes:

*Improvement: Hct falls, pulse rate and blood pressure stable, urine output rises

**No improvement: Hct or pulse rate rises, pulse pressure falls below 20 mmHg, urine

output falls

Unstable vital signs: urine output falls, signs of shock

-Crystalloid: Normal Saline, ringer lactate

-Colloid: Dextran 40/degraded gelatine polymer (polygeline)

- ABCS= Acidosis, Bleeding, Calcium (Na++ &K+), Sugar

Notes:

*Improvement: Hct falls, pulse rate and blood pressure stable, urine output rises

**No Improvement: Hct or pulse rate rises, pulse pressure falls below 20 mmHg, urine output falls

·         Unstable vital signs: Urine output falls, signs of shock

·         In cases of acidosis, hyperosmolar or Ringer's lactate solution should not be used

·         Serial platelet and Hct determinations: drop in platelets and rise in Hct are essential for early diagnosis of DHF

·         Cases of DHF should be observed every hour for vital signs and urine output

2.6.4. Management of severe bleeding

In case of severe bleeding, patient should be admitted in the hospital and investigated to look for the cause and site of bleeding and immediately attempt should be made to stop the bleeding. Internal bleeding like GI bleeding may be sometime severe and difficult to locate. Patients may also have severe epistaxis and haemoptysis and may present with profound shock. Urgent blood transfusion is life saving in this condition. However, if blood is not available shock may be managed with proper IV fluid or plasma expander.. If the patient has thrombocytopenia with active bleeding, it should be treated with blood transfusion and then if required platelet transfusion. In case of massive haemorrhage blood should be tested to rule out coagulopathy by testing for prothrombin time (PT) and aPTT. Patients of severe bleeding may have liver dysfunction and in such case, liver function test should also be performed. In rare circumstances, intracranial bleed may also occur in some patients who have severe thrombocytopenia and abnormality in coagulation profile.

2.7. Criteria for admission of a patient

If a DF patient presents with significant bleeding from any site, signs of hypotension,

persistent high grade fever, rapid fall of platelet count, sudden drop in temperature should

be admitted in hospital. However, those patients who have evidence of organ involvement

should also be admitted for proper monitoring and management. Dengue patients with warning signs and symptoms should be admitted and closely monitored.

2.8. Criteria for discharge of patients

The admitted patients who have recovered from acute dengue infection having no fever for atleast 24 hours, normal blood pressure, adequate urine output, no respiratory distress, persistent platelet count >50,000/cu.mm should be discharged from hospital.

2.9. Indication of Platelet transfusion

1. Platelet count less than 10000/cu.mm in absence of bleeding manifestations (Prophylactic platelet transfusion).

2. Haemorrhage with or without thrombocytopenia.

Packed cell transfusion/FFP along with platelets may be required in cases of severe bleeding with coagulopathy. Whole fresh blood transfusion doesn't have any role in managing thrombocytopenia.

Platelets can be classified as random donor platelets (prepared by buffy coat removal method or by platelet rich plasma method), BCPP (buffy coat pooled platelet) and single donor platelets (SDP) or aphaeretic platelets (AP).

2.10. Vaccine for dengue infection

Till now there is no licensed vaccine available against dengue viral infection. Several  rials are ongoing in the world for the development of tetravalent dengue vaccine. So far phase III trials of a recombinant, live attenuated tetravalent dengue vaccine (CYD-TDV) has completed in Five Asian countries in children which may be promising in preventing dengue infection in near future.

CHAPTER 3

CASE REPORT

3.1.      Case

KA, a five years 7 months old boy with 15 kg of body weight nd 109 cm of body height came to Unit Gawat Darurat RS Haji Adam Malik on 6th mei 2016 at 20.10 p.m. His  chief complaint  was a fever since 3 days ago.

3.2.      History Of Disease

            KA, a five year 7 months years   old boy with 15 kg of body weight and 109 cm of body height. KA is the eldest child in the family (from2 siblings) came to Unit Gawat Darurat RS with a fever as a main complaint , and the fever is  reduce with antipyretic drugs. The highest temperature measure was 39. It was taken by his mother. No history of shivering.

            Diarhhea was experienced within these 6 days before being admitted to the hospital. The frequency of diarrhea experienced  more than 3 times a day. The consistensy of stool  was  more liquid than a waste. The patient also felt nauseated since 6 days before came to the hospital. Patient vomited once before coming to the hospital. The vomit contents is the food and the drinks he consumed.

            Patient also experienced headache and joint pain since 3 days ago. Abdominal pain  also found during history taking. There is no history of epixtasis, hematemesis and melena. There was no problem found with his urinary system. Defecation frequency is more then 3 times a day. His mother also complaint there was a reddish skin (rash) at the upper and lower extrimities. There was no history of seizure.

3.3. History of Medication

            Patient previously treated by a general practitioner prior to referral to RS Haji Adam Malik, Medan.he was givem Chloramphenicol, Parasetamol, pseudoefedrin HCL, metoclopramide and diazepam.

3.4. History of Family’s Disease

 Patient’s family does not have the same history of disease as patient but the symptoms showed by patient’s friend is the same with patient.

Mother		Father
Name	: Vivin Sofyana	Name	: Ilhamsyah
Age	: 29 tahun	Age	: 36 tahun
Religion	: Islam	Religion	: Islam
Race	: Jawa	Race	: Jawa
Occupation	: Ibu Rumah Tangga	Occupation	: Staf pengajar / Dosen
Education	: SMA	Education	: S2
Revenue	: -	Revenue	: Rp. 3 juta/ bulan
First son	: Khairul Azman	Second daughter	: Khanza Alia Fitri
Age	: 5 years 7 months	Usia	: 1 years 9 monts
Gender	: Boy	Gender	: Girl
Occupation	: siswa TK	Occupation	: -

3.5.      Family Medical History

            No history of disease in patient’s family

3.6.      History of Birth

            The patient was born spontaneously pervaginam, assisted by a midwife. Gestation weeks were approximately 36 months. Body weight at birth was 2800 gram. Cyanosis and Jaudice were not found at bitrh. Patient’s mother was 22 years old when she gave birth and there was no history of disease.  Medication consumed during pregnancy (-) Herbal medication (+)

3.7.      History of feeding

            0 - 3 month  : Breast feeding

3 – 6 month : Breast feeding and Formula feeding

> 6 month    : Formula feeding and porridge

3.8.      History of Immunization

            Patient had a complete immunization.

Hepatitis B                              : 3x

BCG                                        : 1x at 2 month

Polio                                        : 4x at 0,2,4,6 months

DTP                                         : 3x at 2,4,6 months

Measles                                   : 1x at 9 month

3.9.      History of Growth and Development

            According to patient’s mother growth and development went normal. Patient lifted up his head at 3 month, patient could stand up and walk at 1 year 2 months.

3.10.    Physical Examination :

Present Status:

Sensorium : Compos mentis, GCS : 15

Temperatur : 36,4  

Body Weight: 15 kg                           Body Height: 109 cm.

dyspnea (-), cyanosis (-), edema (-)

Localized Status :

      Head

·        Face : edema (-)

·         Eye : light reflex (+/+), isochoric pupil, pale inferior palpebral     conjunctiva(-/-)

·         Ears : both ear lobe in normal morphologic

·         Hidung  : septum deviation (-), nasal flares (-), normal morphologic

·         Mouth  : Normal morphologic

Neck

·       Lymph node enlargement (-)

Thorax

·       Simetris fusiformis, retraction (-/-),  RR: 25 bpm, regular, ronchi (-/-) Respiratory sound : vesiculer, additional sound (-), HR: 90 bpm, regular, murmur (-).

·       Abdomen: Soepel, peristaltik sound (+) normal, epigastric pain (+). Hepar and Lien: unpalpable.

·       Extremity:

TD : 90/70 mmHg, HR: 90 kali/min, regular, warm exterimity, CRT < 3”,  pretibial oedem (-), ptechie (+) at upper and lower extrimity.

Laboratory Finding: 07 May 2016 07:02:46

Complete Blood Analysis:

Test	Result	Unit	References
Hemoglobin	13.2	g%	10.8 – 15.6
Erythrocyte	4.97	106/mm3	4.50 – 6.50
Leucocyte	3.03	103/mm3	4.5 - 13.5
Thrombocyte	84	103/mm3	150-450
Hematocrite	39	%	33 – 45
Eosinophil	0	%	1-5
Basophil	0.3	%	0-1
Neutrophil	56.50	%	25 – 60
Lymphocyte	35.30	%	25 – 50
Monocyte	7.90	%	1 – 6
Neutrophil Absolute	1.71	103/µL	2.4-7.3
Lymphocyte Absolute	1.07	103/µL	1.7-5.1
Monocyte  absolute	0.24	103/µL	0.2-0.6
Basophil absolute	0.01	103/µL	0-0.1
Eusinophil absolute	0	103/µL	0.1 – 0.3
MCV	79	fL	69 – 93
MCH	26.6	Pg	22 – 34
MCHC	33.5	g%	32 – 36
RDW	12.4	%	11 – 15
PCT	0.110	%	0.1 – 0.5
ELECTROLYTE
Calsium	7.9	Mg/dl	8.4 – 10.2
Sodium	131	Mg/dl	135 – 155
Pottasium	3.6	Mg/dl	3.6 – 5.5
Chloride	96	Mg/dl	96 – 106

Laboratorium findings: 07 may 2016 21:17:18

Complete Blood Analysis:

Test	Result	Unit	References
Hemoglobin	14.2	g%	10.8 – 15.6
Erithrocyte	5.28	106/mm3	4.50 – 6.50
Leukocyte	2.94	103/mm3	4.5 - 13.5
Trombocyte	32	103/mm3	150-450
Hematocrite	42	%	33 – 45
Eosinophil	0	%	1-5
Basophil	1	%	0-1
Neutrophill	38.8	%	25 – 60
Lymphocyte	53.70	%	25 – 50
Monocyte	6.50	%	1 – 6
Neutrophil Absolute	1.14	103/µL	2.4-7.3
Lymphocyte Absolute	1.58	103/µL	1.7-5.1
Monocyte absolute	0.19	103/µL	0.2-0.6
Basophil absolute	0.03	103/µL	0-0.1
Eusinophil absolute	0	103/µL	0.1 – 0.3
MCV	80	fL	69 – 93
MCH	26.9	Pg	22 – 34
MCHC	33.5	g%	32 – 36
PCT	0.04	Mg/dl	0.1 – 0.5

Laboratorium Findings: 08 may 2016 09:41:42

Complete Blood Analysis:

Tes	Hasil	Unit	Rujukan
Hemoglobin	14.3	g%	10.8 – 15.6
Eritrocyte	5.37	106/mm3	4.50 – 6.50
Leukocyte	4.1	103/mm3	4.5 - 13.5
Trombocyte	18	103/mm3	150-450
Hematocrite	43	%	33 – 45
Eosinophil	0.2	%	1-5
Basophil	1	%	0-1
Neutrophil	29	%	25 – 60
Lymphocyte	59.8	%	25 – 50
Monocyte	10	%	1 – 6
Neutrophil Absolute	1.19	103/µL	2.4-7.3
Lymphocyte Absolute	2.45	103/µL	1.7-5.1
Monocyte absolute	0.41	103/µL	0.2-0.6
Basophil absolute	0.03	103/µL	0-0.1
Eosinophil  absolute	0.01	103/µL	0.1 – 0.3
MCV	79	fL	69 – 93
MCH	26.6	Pg	22 – 34
MCHC	33.6	g%	32 – 36
PCT	0.02	%	0.1 – 0.5
RDW	12.3	%	11- 15

               

Laboratorium Findings: 08 may 2016 21:45:43

Complete Blood Analysis:

Tes	Hasil	Unit	Rujukan
Hemoglobin	12.8	g%	10.8 – 15.6
Eritrocyte	4.77	106/mm3	4.50 – 6.50
Leukocyte	4.9	103/mm3	4.5 - 13.5
Trombocyte	26	103/mm3	150-450
Hematocrite	38	%	33 – 45
Eosinophil	0.4	%	1-5
Basophil	0.4	%	0-1
Neutrophil	29	%	25 – 60
Lymphocyte	62.7	%	25 – 50
Monocyte	7.5	%	1 – 6
Neutrophil Absolute	1.44	103/µL	2.4-7.3
Lymphocyte Absolute	3.11	103/µL	1.7-5.1
Monocyte absolute	0.37	103/µL	0.2-0.6
Basophil absolute	0.02	103/µL	0-0.1
Eosinophil  absolute	0.02	103/µL	0.1 – 0.3
MCV	79	fL	69 – 93
MCH	26.8	Pg	22 – 34
MCHC	34	g%	32 – 36
PCT	0.03	%	0.1 – 0.5
RDW	12.3	%	11- 15

Laboratory findings: 09 may 2016 01:40:30

Complete Blood Analysis:

Test	Result	Unit	References
Hemoglobin	12.7	g%	10.8 – 15.6
Eritrhocyte	4.78	106/mm3	4.50 – 6.50
Leucoyte	6.34	103/mm3	4.5 - 13.5
Trombocyte	36	103/mm3	150-450
Hematocrite	38	%	33 – 45
Eosinophill	0.3	%	1-5
Basophil	0.5	%	0-1
Neutrophil	36.9	%	25 – 60
Limphocyte	56.6	%	25 – 50
Monocyte	5.7	%	1 – 6
Neutrophil Absolute	2.34	103/µL	2.4-7.3
Lymphocyte Absolute	3.59	103/µL	1.7-5.1
Monocyte absolute	0.36	103/µL	0.2-0.6
Basophil absolute	0.03	103/µL	0-0.1
Eosinophil absolute	0.02	103/µL	0.1 – 0.3
MCV	79	fL	69 – 93
MCH	26.6	Pg	22 – 34
MCHC	33.8	g%	32 – 36
PCT	0.04	%	0.1 – 0.5
RDW	12.2	%	11- 15

3.11.  Differential diagnose

            1. Dengue hemorrhagic fever without shock

            2. Typhoid fever

            3. Leptospirosis

3.12.    Confirm Diagnosis

Dengue Hemorrhagic fever without shock

3.13.    Therapy

-           IVFD RL 3cc / KgBB , 45 cc/ hour

-          Zinc 1x 20 mg

-          Paracetamol 3 x 150 mg

3.14.    Planning

-          Complete blood analysis / 6 jam, IgG dan IgM  anti dengue, Foto Thorax

3.15.    Prognosis

            Dubia ad Bonam

FOLLOW UP

Date  : 7 may 2016                                                    

S	Fever (+), Spontaneous bleeding (-), diarrhea (+)
O	Sens: CM   T: 37,9 oC   BW: 15 kg    BH: 109 cm Head : Eye : LR (+/+),isochoric pupil , pale inferior palpebral conjunctiva (-/-), E/N/M: normal morphologic Thorax: Simetris fusiformis, retraction, HR: 100 x/min, regular, murmur (-) RR: 22 x/min, regular, ronchi (-/-) Abdomen: soepel, peristaltik (+) N, H/L : unpalpable Upper extrimity: HR 94 x/min, regular, P/V adequate, warm extrimity, CRT <3”, BP: 110/70 mmHg, ptechie (+) Lower extrimity : pretibial oedem (-)
A	1. DHF without shock
P	IVFD RL 3 cc / kgBB / jam Zinc 1x20 mg Paracetamol 150 mg / day Planning :complete blood analysis, IgG dan IgM anti dengue, chest radiography

Date : 8 may 2016

S	Fever (+), Spontaneous bleeding (-), mencret (+)
O	Sensorium: CM   T: 38,1 oC   BW: 15 kg    BH: 109 cm Head: Mata RC (+/+), Isochoric pupil,pale  konj. palpebral inferior (-/-), E/N/M: normal morphologic Thorax: Simetris fusiformis, retraction (-). HR: 100 x/min, regular, murmur (-) RR: 20 x/min, regular, ronchi (-/-) Abdomen: soepel, peristaltik (+) N, H/L : unpalpable, shifting dullness (+) Upper extrimity: HR 95 x/min, regular, P/V adequate, warm extrimity, CRT <3”, BP: 100/70 mmHg,  ptechie (+) at upper and lower extrimity
A	1. DHF without shock
P	IVFD RL 3 cc / kgBB / jam Zinc 1x20 mg Paracetamol 150 mg /  day Planning : complete blood analysis every 6 hour

  

Date : 9 may 2016

S	Fever (+), Spontaneous bleeding  (-),
O	Sens: CM   T: 37,9 oC   BW: 15 kg    BH: 109 cm Head : Eye LR(+/+),Isochor pupil, pale inferior palpebra conjunctiva (-/-), E/N/M: normal morphologic Thorax: Simetris fusiformis, Retraction (-), HR: 104 x/min, regular, murmur (-) RR: 22 x/min, regular, Respiratory sound : weaker at right lungs, ronchi (-/-) Abdomen: soepel, peristaltik (+) N,shifting dullness (+) H/L : unpalpable Upper extrimity: HR 94 x/min, regular, P/V cukup, warm extrimity, CRT <3”, BP: 110/70 mmHg, ptekie (+) pada ekstrimitas atas dan bawah
A	1. DHF without shock
P	IVFD RL 3 cc / kgBB Zinc 1x20 mg Paracetamol  150 mg / day Planning : Complete blood analysis , IgG dan IgM anti dengue,

Date : 10 may 2016

S	Fever (-), Spontaneous bleeding  (-),
O	Sens: CM   T: 36,9 oC   BW: 15 kg    BH: 109 cm Head : Eye LR(+/+),Isochor pupil, pale inferior palpebra conjunctiva (-/-), E/N/M: normal morphologic Thorax: Simetris fusiformis, Retraction (-), HR: 120 x/min, regular, murmur (-) RR: 18 x/min, regular, Respiratory sound : weaker at right lungs, ronchi (-/-) Abdomen : soepel, peristaltik (+) N,shifting dullness (-) H/L : unpalpable Upper extrimity: HR 94 x/min, regular, P/V cukup, warm extrimity, CRT <3”, BP: 100/70 mmHg
A	1. DHF without shock
P	IVFD RL 3 cc / kgBB Zinc 1x20 mg Planning : Complete blood analysis , IgG dan IgM anti dengue,

Date : 11 may 2016

S	Fever (-), Spontaneous bleeding  (-),
O	Sens: CM   T: 36,9 oC   BW: 15 kg    BH: 109 cm Head : Eye LR(+/+),Isochor pupil, pale inferior palpebra conjunctiva (-/-), E/N/M: normal morphologic Thorax: Simetris fusiformis, Retraction (-), HR: 120 x/min, regular, murmur (-) RR: 18 x/min, regular, Respiratory sound : weaker at right lungs, ronchi (-/-) Abdomen: soepel, peristaltik (+) N,shifting dullness (-) H/L : unpalpable Upper extrimity: HR 94 x/min, regular, P/V cukup, warm extrimity, CRT <3”, BP: 100/70 mmHg
A	1. DHF without shock
P	Patient discharge after fever was diminished but the respiratory sound still weaker at right lungs with improvement. Patient’s education: Patient needs a rest Drink enough water Parasetamol is given if fever is found

CHAPTER 4

DISCUSSION

Dengue viral infected person may be asymptomatic or symptomatic and clinical manifestations vary from undifferentiated fever to florid haemorrhage and shock. Clinical Features of DF: An acute febrile illness of 2-7 days duration with two or more of the following manifestations: Headache, retro-orbital pain, myalgia, arthralgia, rash, haemorrhagic manifestations. In this case was found fever as a main complaint. The fever was reduce with antipyretic drugs. The highest temperature measure was 39. It was taken by his mother. No history of shivering. Patient experienced headache and joint pain since 3 days ago. His mother also complaint there was a reddish skin (rash) at the upper and lower extrimities. The patient also felt nauseated since 6 days before came to the hospital. Patient vomited once before coming to the hospital. The vomit contents is the food and the drinks he consumed.

Diagnosis of Dengue Hemoragic Fever is a case of clinical criteria of dengue Fever, plus Haemorrhagic tendencies evidenced by one or more of the following: Positive tourniquet test, petechiae, ecchymoses or purpura, bleeding from mucosa, gastrointestinal tract, injection sites or other sites, plus thrombocytopenia (<100 000 cells per cumm), plus evidence of plasma leakage due to increased vascular permeability, manifested by one or more of the following: Arise in average haematocrit for age and sex > 20%, a more than 20% drop in haematocrit following volume replacement treatment compared to baseline, and Signs of plasma leakage (pleural effusion, ascites, hypoproteinemia). In this case there was petechiae, Abdominal pain  also found during history taking. Based on the laboratorium result show that there was thrombocytopenia (84.000/mm³). There was shifting dullness and when auskultasi in the respiratory sound found weaker at right lungs. This auskultation was supported by chest radiography that found pleural effusion in the right lung. In this case there was no rapid and weak pulse and narrow pulse pressure ( mmHg) or hypotension for age, cold and clammy skin and restlessness.

Any person who has dengue fever with thrombocytopenia, high haemoconcentration and presents with abdominal pain, black tarry stools, epistaxis, bleeding from the gums etc. needs to be hospitalized. All these patients should be observed for signs of shock. The critical period for development of shock is during transition from febrile to abferile phase of illness, which usually occurs after third day of illness. Rise of haemoconcentration indicates plasma leakage and loss of volume for which proper fluid management plays an important role. Despite the treatment, if the patient develops fall in BP, decrease in urine output or other features of shock, the management for DHF without shock should be instituted. Oral rehydration should be given along with antipyretics like Paracetamol, sponging, etc. So, for this patient was given IVFD RL 3 cc / kgBB

for rehydration, Zinc 1x20 mg, and Paracetamol 3x 150 mg if the patient got fever.

Criteria for discharge of patients, the admitted patients who have recovered from acute dengue infection having no fever for atleast 24 hours, normal blood pressure, adequate urine output, no respiratory distress, persistent platelet count >50,000/cu.mm should be discharged from hospital. ⁽³⁾

Vaccine for dengue infection till now there is no licensed vaccine available against dengue viral infection. Several trials are ongoing in the world for the development of tetravalent dengue vaccine. So far phase III trials of a recombinant, live attenuated tetravalent dengue vaccine (CYD-TDV) has completed in Five Asian countries in children which may be promising in preventing dengue infection in near future.⁽³⁾

CHAPTER 5

SUMMARY

            KA, a boy, a five years 7 months old boy with 15 kg of body weight nd 109 cm of body height came to Unit Gawat Darurat RS Haji Adam Malik on 6th mei 2016 at 20.10 PM with fever asa a chief complaint. Diarrhea, joint pain, headache, stomach pain were found during history taking. Ptekie was also found during physical examination. Patient diagnosed with Dengue Hemorrhagic Fever and treated with supportive and symptomatic therapy. Patient treated with Fluid therapy, Zinc and Paracetamol for the symptomatic complaint. Therapy were given onward for 4 days with an improvement in clinical manifestation on day 4. On 11th may 2016, patient returned home after clinical improvement found during examination.

REFERENCE

1.      World Health Organization. National Guidelines for Clinical Management of Dengeu Fever; 2015.

2.      World Health Organization and Tropical Diseases Research. Handbook for clinical management of dengue. Geneva: World Health Organization; 2012.

3.      World Health Organization Guidelines for Clinical Management of Dengue Fever, Dengue Hemorragic Fever, and Dengue Shock Sindrome;CDC.

4.      World Health Organization Dengue Guidelines for Diagnosis, Treatment, Prevention, and Controls; 2009.

5.      World Health Organization. Comprehensive guidelines for prevention and control of dengue and dengue hemorrhagic fever. New Delhi:WHO,SEARO; Revised and expanded edition.2008.

6.      Elsevier. Nelson Textbook of Pediatrics. 2015

7.      World Health Organization. Dengue and Dengue Hemoragic Fever; 2008