Dengue hemorrhagic fever

Rule In
Headache
fever
(10-6daysptc)
Epigastric pain
Loose stools
Vomiting
Bilateral conjunctival
suffusion

Rule out
Calf pain / bilateral leg
pain
CBC
WBC 16.713.45
PT 11.5secs normal

No urine output
Plt. Ct 6172
Hct 35.221.7
Tachycardic
Icteric sclerae
Jaundice
Grade 1 bipedal edema
BUN 61
AST 41U/L
ALT 44U/L
aPTT 43.1sec

Our first differential diagnosis is dengue hemorrhagic fever.

Dengue infection is a systemic and dynamic disease. It has a wide clinical spectrum that
includes both severe and non-severe clinical manifestations. The illness begins abruptly and is
followed by the three phases -- febrile, critical and recovery.
According to the WHO, during febrile phase, patients typically develop high-grade fever
suddenly. This acute febrile phase usually lasts 27 days and is often accompanied by facial
flushing, skin erythema, generalized body ache, myalgia, arthralgia and headache.
Some patients may have sore throat, injected pharynx and conjunctival injection/suffusion?.
Anorexia, loose stools, nausea and vomiting are also common. Hence we ruled in fever,
headache, loose stools, and vomiting.
Dengue also has the designation of break bone fever because of the fever along with severe
myalgia, back pain and retro orbital pain. Therefore, we ruled out calf pain and bilateral leg pain
because the myalgia experienced in dengue is usually generalized and not limited to a specific
area in the body only.
The liver is often enlarged and tender after a few days of fever. The stretching of the glissons
capsule brought about by the enlarging liver causes epigastric pain. So we also ruled in
epigastric pain.

We ruled out the patients WBC count of 16.7 x 10^9/L because according to WHO guidelines,
the earliest abnormality in the full blood count is a progressive decrease in total white cell count,
which should alert the physician to a high probability of dengue. Our patient WBC was above
normal.
Those who improve after defervescence (after fever) are said to have non-severe dengue and
recovers. But some patients progress to the critical phase of plasma leakage. During critical
phase, around the time of defervescence, when the temperature drops to 37.538oC or less
and remains below this level, usually on days 37 of illness, an increase in capillary permeability
in parallel with increasing hematocrit levels may occur. This marks the beginning of the critical
phase. T
he period of clinically significant plasma leakage usually lasts 2448 hours. The degree of
increase above the baseline hematocrit often reflects the severity of plasma leakage. So we
ruled in the patients decreased platelet count of 61 x 10^9/L on the first hospital day and still a
decreased platelet count during the second hospital day with a value of 72 x 10^9/L. The
patients hematocrit was also decreasing with a value of 35.2 and 21.7 x 10^9/L on the first and
second hospital days respectively, hence we ruled it in.
We also consider tachycardia as a ruling in factor ----- as dengue vascular permeability
progresses, hypovolemia worsens and results in shock. It usually takes place around
defervescence, usually on day 4 or 5 (range days 37) of illness, preceded by the warning
signs. During the initial stage of shock, the compensatory mechanism, which maintains a normal
systolic blood pressure, also produces tachycardia and peripheral vasoconstriction with reduced
skin perfusion.
We also ruled in icteric sclerae, jaundice, Grade 1 bipedal edema, anuria together with BUN of
61 AST of 41U/L and ALT 44U/L because in severe dengue fever, there is severe organ
impairment (acute liver failure, acute renal failure, encephalopathy or encephalitis, or
cardiomyopathy) or other unusual manifestations that may cause the said laboratory findings,
signs, symptoms presented by our patient.
We ruled hemoptysis in. Patients with severe dengue may have coagulation abnormalities, but
these are usually not sufficient to cause major bleeding. When major bleeding does occur, it is
almost always associated with profound shock, in combination with thrombocytopenia. But when
massive bleeding does occur, even without prolonged shock, it may be seen in instances when
acetylsalicylic acid (aspirin), ibuprofen or corticosteroids have been taken. If we are to recall the
HPI, the patient self medicated with ibuprofen for fever. Lastly in dengue, there is prolonged PT
and aPTT; hence we ruled in the patients prolonged aPTT and ruled out PT since it is within
normal limits.

Viral Hepatitis
Rule In
Nausea
Vomiting
Myalgia
Jaundice
Epigastric pain

Rule Out
bilateral conjunctival suffusion
No history of blood transfusion
No history of neonatal hepatitis

Increased AST & ALT

Increased bilirubin
Our 2nd differential diagnosis is viral hepatitis, because some of its early symptoms are
consistent with the symptoms of the patient. The prodromal symptoms of acute viral
hepatitis are systemic and quite variable. Constitutional symptoms of anorexia, nausea and
vomiting, fatigue, malaise, arthralgias, myalgias, headache, photophobia, pharyngitis,
cough, and coryza may precede the onset of jaundice by 12 weeks. For Hepatitis A and E,
patients manifest with loose stools. In the icteric period of viral hepatitis, jaundice starts to
appear and it may or may not be accompanied by fever. The liver becomes enlarged and
tender and may be associated with right upper quadrant pain and discomfort. The serum
aminotransferases aspartate aminotransferase (AST) and ALT show a variable increase
during the prodromal phase of acute viral hepatitis and precede the rise in bilirubin level.
Rarely, individuals with acute infections with HAV and HBV develop fulminant hepatitis
wherein the liver fails due to severe inflammation. In our patient, there are evidences of liver
failure in the laboratory findings and his course in the ward.
However, we can rule out viral hepatitis because towards the end of his course, he did not
manifest with any neurologic symptoms like confusion or coma, due to the livers failure to
detoxify chemicals. Cerebral edema, brainstem compression and intracranial hypertension
are common terminal events of acute hepatitis. Another reason to rule out viral hepatitis is
that bilateral conjunctival suffusion was seen in the patient. This is a pathognomonic sign of
early Weils disease, which is caused by Leptospira interrogans. It is characterized by
redness of the conjunctiva that resembles conjunctivitis, but does not involve inflammatory
exudates. Also, our patient does not have a definite history of any of the modes of
transmission for viral hepatitis, which are fecal-oral route, sexually transmitted, parenteral or
perinatal.
To definitively diagnose a patient with viral hepatitis, antibodies to the hepatitis viruses and
viral proteins or genetic material must be evaluated.
Typhoid Fever
Rule In
Fever
Headache

Rule Out
Diffuse abdominal pain
No history of ingestion of contaminated food
or water

Myalgia
Nausea
Vomiting
Diarrhea
Elevated liver function tests
Our 3rd differential diagnosis is typhoid fever, also called enteric fever, which is a potentially
fatal multisystemic illness caused primarily by Salmonella enterica. Patients have relatively
few or no signs and symptoms during the initial incubation stage.
In this series, symptoms on initial medical evaluation include headache (80%), chills (35
45%), cough (30%), sweating (2025%), myalgias (20%), malaise (10%), and arthralgia (2
4%). Gastrointestinal symptoms include anorexia (55%), abdominal pain (3040%), nausea
(1824%), vomiting (18%), and diarrhea (2228%) more commonly than constipation (13
16%). Physical findings include coated tongue (5156%), splenomegaly (56%), and
abdominal tenderness (45%). Early physical findings of enteric fever include rash (rose

spots; 30%), hepatosplenomegaly (36%), epistaxis, and relative bradycardia at the peak of
high fever (<50%).
Nausea, vomiting, and diarrhea occur 648 h after the ingestion of contaminated food or
water. These probably result from secretion of cytokines by macrophages and epithelial cells
in response to bacterial products that are recognized by innate immune receptors when a
critical number of organisms have replicated. Diarrheal stools are usually loose, nonbloody,
and of moderate volume.
A high index of suspicion for this potentially fatal systemic illness is necessary when a
person presents with fever and a history of recent travel to a developing country.
In 1525% of cases, leukopenia and neutropenia are detectable. Other nonspecific
laboratory findings include moderately elevated liver function tests and muscle enzyme
levels.
It is very difficult to diagnose typhoid fever based on symptoms. Therefore, it requires a
definitive diagnosis by the isolation of S. typhi or S. paratyphi from blood, bone marrow,
other sterile sites, rose spots, stool, or intestinal secretions.