Case Write Up 1: Dengue Haemorrhagic Fever Saarah Huurieyah bt Wan Rosli 1050024 Year 4 Internal Medicine
IDENTIFICATION DATA Name
: Najwa bt Ahmad Nazri
Age
: 19 years old
Sex
: Female
Race
: Malay
Religion
: Islam
Registration No.
: AM00072269
Address
: Pandan Indah
Occupation
: Clerk in a clinic
Marital Status
: Not married
Date of admission
: 26/08/2008
Date of discharge
: 31/08/2008
Date of clerking
: 27/08/2008
Source of clerking
: Patient
CHIEF COMPLAINT Fever for the last 9 days before admission, associated with vomiting and muscle weakness
HISTORY OF PRESENTING ILLNESS Her fever started since 9 days ago and it was constant. It is aggravated at night with shivering. The fever is associated with headache, myalgia and muscle weakness, arthralgia, back pain, loss of appetite, loss of weight, rigor and chills, retro-orbital pain, restlessness at night, vomiting, diarrhea, per-vaginal bleeding, syncopal attack, light sensitivity, sore throat, cough and dyspnoea, generalized abdominal pain especially at the epigastric region and pain in the suprapubic and loin regions. The vomiting also started on the same day as the fever. It was also constant for 9 days. It varies with time and came quite frequently. The content of the vomitus is whitish mucous and some food and the amount also varies. The vomiting is associated with shortness of breath and epigastric pain. However, the vomitus has no blood stain. The episodes of diarrhea started on the 4th day of fever. The frequency is twice a day. It is watery dark brown ant the amount also varies. It is not associated with any blood stain or any pain.
Meanwhile, the per-vaginal bleeding is characterized as intermenstrual period. This is because it stated on the 4th day of the fever. It is to be an abnormal period because she already had her period for this particular month in 8th of August 2008. She never had any history of similar episodes and it is said that her menstrual cycle is regular every month. Besides, her regular menstrual cycle usually lasted only for 3 days, but this time it was still bleeding even though it was already on the 5th day. During this particular episode, 3 pads were fully soaked compared to her regular menstrual cycle where on only 2 and half pads soaked. Her fever is not associated with any history of travelling,rashes, epistaxis, gum bleeding, pleuritic pain, haemoptysis, purulent sputum, haematuria, dysuria, urgency, strangury and neck stiffness. Due to the fever, she went to General Practitioner 3 times. On first day of fever, she was given antibiotics and pain killer. As the fever doesn’t subside, she went again to the General Practitioner on the 3rd day of fever, and was given another type of antibiotic yet the fever did not subside. So, she went again to the General Practitioner on the 8th day of fever where she did a blood test. Without knowing the blood test result, she was referred to Hospital Ampang due to suspected dengue fever.
SYSTEMIC REVIEW Cardiovascular system She had dypsnoea. However, there were no chest pain, palpitation, orthopnea and paroxysmal nocturnal dypsnoea. Respiratory system She had sore throat and non- productive cough. She also had shortness of breath everytime after vomiting. No heamoptysis. Gastrointestinal system She had vomiting frequently and diarrhea twice a day. She also had generalized abdominal pain especially at the epigastric region. No hematemesis. Genitourinary system She had suprapubic pain and per-vaginal bleeding (intermenstrual bleeding). But, there were no dysuria, polyuria, polydypsia, hematuria, urgency, swollen ankle or urinary incontinence. Musculoskeletal System She complained of myalgia, muscle weakness, arthralgia, backpain and rigor and chills. However, there were no muscle stiffness and abnormal gait. Central Nervous System She had headache, light sensitivity, restlessness at night and syncopal attack. But, there were no tremor, loss of sensory, diplopia, fit, paralysis, speech defect or body incoordinations.
PAST MEDICAL HISTORY The patient had history of bronchitis in the end of June 2008. It was treated with nebulizer. She also had gastritis which was diagnosed in 2007 by a General Practitioner. She is compliance to her medication but no endoscopy was done. She had no other medical illness such as Diabetes Mellitus, Hypertension, Ischemic Heart Disease and asthma. She had been admitted twice in Hospital Klang in 2001 due to high fever and the other was in 2005 due to an accident.
PAST SURGICAL HISTORY She had no past surgical history.
DRUG HISTORY She had Paracetamol and some antibiotics for her fever before she came to Hospital Ampang. She is currently on a long term medication for her gastritis but she only takes it whenever necessary. The medication were Tagamet (Cimetidine), Mexalone and Buscopan. She also had no known drug allergies or other known allergies.
FAMILY HISTORY Both her parents are still alive. Her father is 47 years old and is having brain tumor. Meanwhile her mother is 56 years old and is having asthma and a uterus problem which she could not name it. She has no siblings.
SOCIAL HISTORY She is currently living with friends in Pandan Indah, which is known to be an area of fogging. They live in a shop house at level 3 which has no elevator and she had no problem in climbing
up the stairs. She is not married. She is a non smoker and drinker. She also had no sexual promiscuity OBSTETRICS AND GYNAECOLOGICAL HISTORY Her menarche is at the age of 12 years old. Her menstrual cycle is regular which usually lasts for 3 days.
PHYSICAL EXAMINATION General examination On inspection, patient was lying flat, looked comfortably and well. She was well orientated to time place and person. There was a cannula on the dorsum of the right hand which was connected to a normal saline. Her vital signs were Blood pressure : 112/70 mmHg Pulse rate
: 72 beats per minute, regular and normal volume
Respiratory rate : 20 breaths per minute Temperature
: 380C
O2 saturation
: 96% on air
There were no facies abnormalities, muscle wasting, scars or any other abnormalities. There were also no signs of jaundice, pallor or cyanosis. Patient was fairly hydrated. Hand Warm, no excessive sweating, capillary filling time was less than 2 seconds, no finger clubbing, no nicotine stain, no rashes or petechiae. Hess test was not done. Eye No signs of pallor on the conjunctiva and no jaundice. Mouth No central cyanosis, no gum bleeding and hydration was fair. Neck No lymphadenopathy, no neck stiffness and jugular venous pressure was not raised. Lower limb No rashes or petechiae, no ankle edema.
Specific physical examination Abdomen Inspection: Abdomen is flattened, not distended and umbilicus was centrally located and inverted. It moves with respiration. There were no scratch marks, obvious mass, dilated veins or any obvious peristaltic activities. Inguinal orifices were intact. Palpation: On superficial palpation, the abdomen was soft and quite tender on all 9 regions especially at the epigastric region. No rebound tenderness, guarding, rigidity and mass were found. On deep palpation, no organomegaly detected. Percussion: Abdominal resonance was presence with no ascites. Auscultation: Bowel sound was hyperactive and no renal bruit was heard. Respiratory system Inspection: Chest moved bilaterally symmetrical with respiration. Chest was normal in shape; no kyphosis, no scoliosis and no lordosis. No dilated veins and no surgical scars. Palpation: Chest expansion was equal in both sides. Vocal fremitus were reduced at the lower zones on both sides. Percussion: Lung percussion was dull on the lower zones of both sides. Other parts were resonance. Auscultation: Breath sound was normal which was vesicular breath sound, air entry was equal bilaterally, no wheezing, no crepitation, no pleural rub and other added sounds. Vocal resonance was reduced at the lower zones on both sides.
Systemic examination Cardiovascular system Inspection: Apex beat could not be seen. There was also no scars, precordial bulge and extra pulsation observed. Palpation: The apex beat was present at the 5th intercostal space at the mid clavicular line with normal character. Palpable murmur (thrills) and heaving were absent. No other pulsation found. Auscultation: The first and second heart sounds were present and normal. There was no murmur and added heart sound heard. Musculoskeletal system On inspection, no skull, long bones and spine deformities observed. There was also no bone deformities, tenderness, muscle wasting and swelling present at the joints. In addition, there were also no abnormal movements detected. Central Nervous system Patient was conscious, alert and well oriented with time, place and person. The speech, cranial nerves, sensation, motor function and reflexes, cerebellar function and gait were normal. CASE SUMMARY A 19 year-old Malay lady, came in with history of constant fever for 9 days associated headache, myalgia, backpain, retro-orbital pain, weakness, restlessness, loss of appetite, chills and rigor, She also had vomiting, diarrhea, pervaginal bleeding, syncopal attack, light sensitivity, sore throat, cough, dyspnoea, generalized abdominal pain especially at the epigastric region, suprapubic region pain and loin pain. Physical examination shows that there was slight tenderness on all 9 regions of the abdomen especially at the epigastric area. Lung percussion was dull at the lower zone on both sides. The vocal fremitus, air entry and vocal resonance were reduced at the lower zone on both sides.
PROVISIONAL DIAGNOSIS Dengue haemorrhagic fever with gastritis. Reasons for dengue haemorrhagic fever: -Constant fever for 9 days - Presence of the associated symptoms of a viral fever - vomiting - diarrhea - menorrhagia - syncopal attack - light sensitivity - sore throat, cough and dyspnoea - generalized abdominal pain esp. at epigastric region - suprapubic region pain - loin pain
-Living in endemic area -Fever with menorrhagia -Signs of pleural effusion (signify plasma leakage) Reasons for gastritis: -Abdominal pain especially at epigastric region -Vomiting -Diarrhea
DIFFERENTIAL DIAGNOSIS 1) Typhoid fever Reasons for: -patient ate outside food -intermittent fever, headache and abdominal pain -abdominal tenderness Reasons against: -no hepatosplenomagaly, no lymphadenopathy and no scanty maculopapular rashes -absence of bradycardia at the peak of fever 2) Malaria Reasons for: -fever, headache, vomiting and diarrhea -rigors Reasons against: -temperature did not reach up to 410C -absence of classical tertian or quartan fever -no hepatosplenomegaly 3) Chikugunya Reasons for: -arthralgia, fever and myalgia Reasons against: -rare in Malaysia but common in Indian Ocean islands 4) Leptospirosis Reasons for: -fever, headache, myalgia, Reasons against: - no exposure to water contaminated with animal urine
-absence of hepatosplenomegaly and lymphadenopathy INVESTIGATION The investigation planned on her as below: FBC- Hb, Haematocrit, WBC, Platelet ABO Group Activated Partial Thromboplastin Time Dengue IgM PT INR Liver Function Test (LFT) Renal Pofile Widal Test Chest X-Ray
TEST RESULTS 1i) FBC- Hb, Haematocrit, WBC, Platelet and others (done on 26/08/2008) Objective: To look specifically for the white blood cells count, platelet and haematocrit level for dengue infection. white blood cells
:
3.7 K/uL
platelet
:
10 K/uL
mean platelet volume
:
16.7 fL
red blood cells
:
4.69
haemoglobin
:
15.1 g/dL
haematocrit
:
45.4 %
mean cell volume
:
96.9 fL
mean cell haemoglobin
:
32.2 pg
mean cell haemoglobin concentration:
33.2g/dL
Impression: The white blood cells and the platelet count are decreased, but haematocrit level is still in normal range. Mean platelet volume, mean cell volume and mean cell haemoglobin are raised too. Other readings are normal.
1ii) FBC- WBC, Platelet and haematocrit (done on 27/08/2008, 28/08/2008 and 29/08/2008) Objective: To look specifically for the pattern of white blood cells count, platelet and haematocrit level for dengue infection. 27/08/08
28/08/08
29/08/08
06:29
13:12
06:00
09:55
17:53
00:43
05:49
14:51
6.6
8.4
6.9
6.9
6.1
5.3
5.1
4.7
Platelet (K/uL)
16
20
27
12
12
27
17
23
Haematocrit(%)
46.0
41.6
37.7
38.3
37.7
35.2
35.2
35.8
White blood cells (K/uL)
Impression: The white blood cells count was in normal range throughout the 3 days. The platelet level was still low while the haematocrit level which was normal at the beginning started to decrease on the 29th of August 2008. The results of Full blood count on 30th August 2008 and 31st August 2008 could not be obtained.
2) ABO Group (done on 27/08/2008) Objective: to detect patient’s blood group in case for any blood transfusion. Blood group
:
O
Rh Group
:
D positive
Impression: The patient has an O and Rh positive blood group
3) Activated Partial Thromboplastin Time (APTT) (done on 27/08/2008) Objective: To see coagulation time. APTT
:
52.7 sec
Impression: The APTT is raised
4) Dengue IgM (done on 27/08/2008) Objective: To look for any recent Dengue infection
Dengue IgM
:
detected
Impression: Suggestive of a recent dengue infection 5) PT INR (done on 27/08/2008) Objective: To see coagulation profile Prothrombin ratio
:
12.0 sec
International Normalised Ratio (INR)
:
1.04
Impression: The prothrombin ratio is normal while the INR is decreased
6) Liver Function Test (LFT) (done on 27/08/2008) Objective: To see any liver impairment Total protein
:
6.93 umol/L
Albumin
:
27 g/L
Globulin
:
27g/dL
Albumin/Globulin ratio
:
1.00
Alkaline phosphatise
:
40 U/L
Alanine Transaminase (SGPT)
:
31U/L
Urea
:
1.90 mmol/L
Sodium
:
137 mmol/L
Potassium
:
3.6 mmol/L
Chloride
:
109 mmol/L
Creatinine
:
52 umol/L
Impression: Albumin is decreased
7) Renal Pofile (done on 27/08/2008) Objective: To see any renal impairment
Impression: Values within normal range
8) Widal Test (done on 27/08/2008) Objective: To look for evidence of typhoid fever S. Paratyphi aH flagellar
:
negative
S. Paratyphi bH flagellar
:
negative
S. Typhi dH flagellar
:
negative
S. Typhi O somatic Ag
:
negative
Impression: There was no evidence of typhoid fever
9) Chest X-Ray Objective: to see any lung consolidations and cardiomegaly Result
:
-blunt costophrenic angle -heart was normal in size
Impression: Blunt costophrenic angle (a sign of pleural effusion)
I would also like to propose some other relevant investigations such as: 1) Blood culture, blood film Objective: To look for evidence of malaria 2) Urine dipstick Objective: To look for any severe hypovolemia or any microscopic haemorrhage 3) Urine culture and Sensitivity Objective: To look for any urinary tract infection 4) Sputum Culture and Sensitivity Objective: To look for any upper respiratory infection 5) Endoscopy Objective: To look for any gastric or duodenal ulcer.
MANAGEMENT On arrival at the emergency department, patient had been given intravenous Normal Saline 1000 ml/3 hours and Zantac/Maxalon. Full blood count is also being traced. An hour later, patient is the medical ward. On admission, the patient had been given 5 pints of intravenous Normal Saline which was alternated with 1g KCL. She was also been given medication such as Ranitidine tablets 150 mg twice a day, Duphaston tablets 1 tablet once a day, Ranitidine 150 mg twice a day, Rocephine for 5 days and Flagyl as the patient has diarhea and high spiking fever. Serial observation was done on her i.e. Full Blood Count, Renal Profile, Liver Function Test, Prothrombin Time and Activated Partial Thromboplastin Time (to look for any bleeding tendency) and Dengue IGM. Her full blood count especially the haematocrit level is monitored every 4 to 6 hours or as clinically indicated. Chest x-tray had also been done on her since there were signs of pleural effusion on physical examination. Due to her improvement, especially on the white blood cells count, platelet level and she had already been afebrile, she had been discharged on 31st of August 2008 and was asked to come again to check for her improvement. She was given Amoxy Clavulinic Acid 625mg tablets twice a day, Ceftriaxone 1g Intravenous injection once daily, Metronidazole 200mg tablet and Metronidazole 500m/100ml injection every 8 hours. All her medication is for 5 days.
DISCUSSION Dengue is the most common and widespread arthropod-borne arboviral infection in the world today. The geographical spread, incidence and severity of dengue fever (DF) and dengue haemorrhagic fever (DHF) are increasing in the Americas, South-East Asia, the Eastern Mediterranean and the Western Pacific. Some 2,500 million to 3,000 million people live in areas where dengue viruses can be transmitted. It is estimated that each year 50 million infections occur, with 500,000 cases of DHF and at least 12,000 deaths. Dengue virus is an Arbovirus that belongs to the family Flaviviridae, under the genus Flavivirus. In the past, it was classified under the Group B Arboviruses. It is a small enveloped virus measuring 50 to 60 nm in size containing a single stranded positive sense RNA genome. Dengue virus is transmitted via the bite of Aedes mosquitoes in particular A.aegypti & A.albopictus. In human disease the cycle of transmission involves man-vector-man. The virus is present in blood in early acute phase only, generally for 1-5 days. The incubation period varies between 3 to 10 days with an average of 4-6 days. There are four serotypes of dengue virus (DEN-1, DEN-2, DEN-3 and DEN-4). They areantigenically very similar to each other but different enough to elicit only transient partial cross-protection after infection by each one of them.
Most of the cases are reported among the urban population (70 – 80%) with the highest incidence in the working and school going age group which correlates with the relatively high Aedes Index in construction sites, factories and schools. My patient, who is currently living in Pandan Indah, a place which has a high incidence of dengue infections before and is a known fogging area for few times. Thus, the incidence of having dengue infection is higher. There are a number of criteria for the clinical diagnosis of dengue infection. However, not all the criteria need to be present at the same time. 1. high continuous fever of 3 days or more 2. headache, backache and retro-orbital pain 3. abdominal pain, vomiting, loose stools 4. petechial haemorrhage and/or spontaneous bleeding 5. rash – generalised flushing/maculopapular 6. hepatomegaly 7. fall in platelet count that precedes or occurs simultaneously with a rise in the haematocrit 8. normal WBC or leukopenia with relative lymphocytosis 9. normal ESR (<20mm first hour) 10. shock Dengue virus infection may present in four different clinical syndromes: 1. Undifferentiated fever 2. Classic dengue fever 3. Dengue Haemorrhagic Fever [DHF] 4. Dengue Shock Syndrome [DSS] I will focus the discussion of my patient on dengue haemorrhagic fever Dengue Haemorrhagic Fever (DHF) The critical stage is reached at the end of the febrile phase of illness; accompanying or shortly after a rapid drop in temperature varying degrees of circulatory disturbances occurs. This phase rarely lasts longer than 48 hours. The following must all be present: 1. Fever, or history of acute fever, lasting 2-7 days, occasionally biphasic. 2. Haemorrhagic tendencies, evidenced by at least one of the following: a. a positive torniquet test b. petechiae, ecchymoses, or purpura c. bleeding from the mucosa, gastrointestinal tract, injection sites or other locations 3. Thrombocytopenia (100,000/mm3 or less) 4. Evidence of plasma leakage due to increased vascular permeability, manifested by at least one of the following: a. haemoconcentration (equal to or greater than 20% above average for age, sex and population) b. a drop in haematocrit following volume replacement equal to or greater than 20% of haematocrit at presentation. c. signs of plasma leakage evidenced by pleural effusion, ascites and hypoproteinemia.
Other clinical manifestations suggestive of DHF are a. hepatomegaly which may be tender b. circulatory disturbance In my patient, there were features of dengue infection. She had high continuous fever of 3 days or more, headache, backache and retro-orbital pain, abdominal pain, vomiting, loose stools, fall in platelet, initially leukopenia but went to the normal WBC count in later stage. The reasons I diagnosed her as having dengue haemorrhagic fever since there was fever which lasted for about more than 10 days. There was also haemorrhagic tendency which was per-vaginal bleeding (intermenstrual bleeding). She also had thrombocytopenia. Besides, on examination and x-ray, there was sign of plasma leakage which was signs of pleural effusion. On examination, lung percussion was dull at the lower zone on both sides. The vocal fremitus, air entry and vocal resonance were reduced at the lower zone on both sides. Moreover, there was a blunt costophrenic angle on chest x-ray. Patient must meet all the criteria before being hospitalised. The criteria are continuous fever more than 3 days, lethargy, restlessness, generalised flushing, excessive tiredness, dehydrated, abdominal discomfort, haemorrhagic manifestations, plasma leakage and evidence of circulatory failure/shock such as rapid and weak pulse, cool, mottled or pale skin or changes in mental status, restlessness and lethargy. In dengue patient, we should monitor the blood pressure, urine flow, white blood cells count and platelets. The treatment for dengue infection, patient should be started on intravenous fluid which is 0.9% sodium chloride (normal saline) [30- 50 ml/kg/day], KCL supplement as required. However, caution is needed in elderly/cardiac disease. In diabetics patient only normal saline must be used. The haematocrit level, vital signs and urine output (hourly) must be monitored closely. The pleural effusion occurs during the phase of plasma leakage. It decreases thoracic compliance and functional residual capacity leading to hypoxemia and increased work of spontaneous breathing. Thus, massive pleural effusions can be prevented by judicious replacement of intravascular volume. Most cases of bleeding in DHF occur as a result of prolonged shock secondary to inadequately corrected plasma leakage. There is a category of patients with pre-existing peptic ulcers who develop haemorrhage in the course of DF. However, there is no consensus on how these patients should be treated.
