CASE PRESENTATION

DENGUE HAEMORRHAGIC FEVER

Presented by :
M. Fahrizal Alkaff
0010035

Counsellor :
H. Tisna Sukarna, dr, SpA, MBA

DEPARTMENT OF PEDIATRIC
MEDICAL FACULTY
MARANATHA CHRISTIAN UNIVERSITY
BANDUNG
2006
I. Patient Identification

Name : Liana Anisa

Age : 7 years, 3 months old
Place and date of birth : Bandung, November 19th 1998
Sex : Female
Consignment from : ER
Diagnosed : DHF
Date of hospitalized : February, 17th 2006
Date of examination : February, 17th 2006
Father : Name : Mr. Kirman Sudrajat
Age : 34 years old
Education : College graduation
Occupation : Employee
Salary : Rp3,000,000 ,-/month
Address : Melonggrena No. 9 RT 5 RW 29 Kel. Cibereum Kec.Cimahi
Selatan, Cimahi
Mother : Name : Mrs. Yeyen Dasiman
Age : 29 years old
Education : High school graduation
Occupation : Housewife
Salary : -
Address : Melonggrena No. 9 RT 5 RW 29 Kel. Cibereum Kec.
Cimahi Selatan, Cimahi
II. Anamnesis
2.1. Heteroanamnesis was given by her mother on February, 17th 2006.
Chief complaint: fever
History of present illness:
Since 5 days before hospitalization, the patient had fever. It was suddenly
high, the fever felt all day long but the temperature much more higher at night than
daytime. The patient also complained headache, myalgia, queasy, and loss his
appetite. Headache at front area of the head and myalgia occurred most at the joint.
Since 3 days before hospitalization, patient went to the doctor and take some
medicine, made the fever becomes up and down. A red spots shown in her chest and
stomach, but doesn’t felt itchy.
Since 2 days before hospitalization, the patient had vomit two times a day.
Every time she throw up the amount of vomit is about a quarter of glass. The vomit
contains water and leftovers from a meal. The patient also had gum bleeding.
Her mother denied fever with convulsion and decrease of awareness.
Mixie : The colour is yellow, normal in frequency and volume
Defecation : Since 5 days before hospitalization the patient only defecate one time, it
was diarrhea with no blood or mucus
Past medical history : The patient had haven’t illness like this
Record of family health : His family denied got sick like this.
Medical effort : The patient had seen a doctor in Cimahi, and told that she had
fever. The doctor gave medicine to went down her temperature,
also Ikadryl® cough syrup and antibiotics.

2.2. Birth History

The patient is the 2nd child from 3 child. No stillbirth and no abortus.
Birth : aterm, spontaneous, directly cry and helped by a doctor.
Birth weight : 3300 grams. Birth length : 51 cm

2.3. Physical and Intelligence Development

Turn over : 4 months
Sitting down : 8 months
 Standing up : 10 months
Talking : 12 months
Walking : 12 months

2.4. Family Members

No Name Age Sex Condition Relationship
Mr. Kirman
1. 34 years Male Health Father
Sudrajat
Mrs. Yeyen
2. 29 years Female Health Mother
Dasiman
Adhi 10 years 2
3. Male Health Brother
Hisyam months
7 years 3
4. Liana Anisa Female Sick Patient
months
4 years 2
5. Firial Alfilah Female Health Sister
month

2.5. Immunizations
Booster Recommended
Vaccine Basic Vaccination
Vaccination Vaccination
BCG √ (scar + ) - - - HiB : none
Polio √ √ √ - - - MMR : none
DPT √ √ √ - - - Hep A : none
Hep B √ √ √ - - - Varicella : none
Measles √ - - - Typhim/typha : none
Inluenzae : none

2.6. Nutrition and Feeding

0 – 4 months : breast feeding on demand
4 – 6 months : breast feeding + cereal milk + fruits + extra milk
6 – 12 months : breast feeding + steamed rice + fruits + extra milk
Quality and quantity : enough
12 - 24 months : breast feeding + rice + fruits + extra milk
Quality and quantity : enough
24 months – now : Family menu

2.7. Past Illnesses

Diarrhea
Cold and cough

2.8. Family history :

Her family denied got sick like this

III. Physical Examination February, 17th 2006

3.1.General appearance
Condition : Moderate sickness
Consciousness : Compos mentis
Activity and position : No force position
General condition : Weak, snivel

3.2.Vital signs
Pulse : 102 times a minute, weak pulse
Respiration : 36 times a minute, abdominothoracal type
Temperature : 37,4 ºC, axillar
Blood pressure : 90/60 mmHg
Rumple Leede : Not performed

3.3. Measuring
Age : 7 years, 3 months
Weight : 20 kg
Height : 118 cm
( 88.89 % standard Weight/Age )
( 96.72 % standard Height/Age )
( 96.15 % standard Weight/Height )
Nutrition status : good (standard Weight/Height )
Circumference of the head : 51 cm
Circumference of the chest : 64 cm
Circumference of the abdomen : 68 cm
Circumference of the upper arms : 22 cm

IV. Systematic examinations

4.1. Skin : icteric - , pale -, cyanosis -, petechiae +, skin’s turgor
was immediately returns to its normal position
4.2. Head
Hair : black, disseminated, not easy to yanked out
Eyes : conjunctiva hyperemic -/-, sclera icteric -/-,
Nose : flare nose-/-, secret -/-, epistaxis -/-, crusta -/-
Ears : simetric, left was equal to right, no discharge
Lips : wet, anemic -, cyanosis -
Mouth : wet mucosa
Gums : bleeding +
Palate : no disparity, icteric -
Tongue : coated tongue -, hiperemis -, tremor –
Pharynx : hyperemic -
Tonsil : hyperemic -, T1 = T1

4.3. Neck
Nuchal rigidity : –
JVP : 5+0 cmH2O
Lymph node : not palpable

4.4. Thorax
Lungs
Inspection : shape and movement was simetric, right was equal to left,
retractions -
Palpation : vocal fremitus right was equal to left
Auscultation : vesicular breath sound +/+, rales -/-, wheezing -/-
Heart
Inspections : ictus cordis was not seen
Palpations : ictus cordis was palpable at ICS 4 linea midclavicularis
sinistra
Percussions : border on top ICS 2 linea parasternalis sinistra
border on left ICS 4 linea midclavicularis sinistra
border on right ICS 3 linea sternalis dextra
 Auscultations : heart sounds regular, shouffle -

4.5. Abdomen :
Inspections : flat
Auscultations : bowel sound + normal
Percussions : tympanic, Traube’s space : tympanic
Palpations : soepel, tenderness +, skin’s turgor was immediately returns
to its normal position
liver palpable ± 3 cm BAC (flat surface, sharp edge, tough
consistency, not painful to press)
spleen unpalpable
kidney unpalpable
4.6. Genital : female, normal
4.7. Anus & Rectal : no disparity
4.8. Extremities : no disparity, cold acral
Upper : left: active, right : active
Lower : left: active, right: active
Joint : no disparity
Muscle : hypertrophy -, atrophy -
Reflex : physiological +/+, pathological -/-
4.9. Neurological Examination
Reflex : physiological +/+, pathological -/-

V. Laboratory finding
17/02/2006 (patient was moved to PICU time : 13.00)
Hb : 11,8 gr/dl
Hct : 35 %
Trombocyte : 28.000 / mm3
Anti Dengue IgM +, IgG +
18/02/06
Hb : 13,4 gr/dl
Hct : 41 %
Trombocyte : 30.000 / mm3
19/02/06 time : 06.20
Hb : 14,2 gr/dl
Hct : 43 %
Trombocyte : 53.000 / mm3
time : 16.45
Hb : 12,5 gr/dl
Hct : 37 %
Trombocyte : 80.000 / mm3
20/02/06
Hb : 11,7 gr/dl
Hct : 36 %
Trombocyte : 125.000 / mm3
17/02/2006
Chest X-Ray : Impression : There was a pleural effusion dextra

VI. Resume
Seven years old girl, with 20 kg body weight, nutritional status good (96.15%
standard Weight/Height ) came to Immanuel Hospital with febris as a chief complain.
Five days before hospitalization, the patient had febris, suddenly high and
continuous, night temperature higher than daytime. The temperature was decrease
using drugs. The patient had headache, myalgia, anorexia and queasy too.
Three days before hospitalization, there was a red spots on patient’s skin.
Two days before hospitalization, the patient had vomit two times a day, each
vomit is about quarter of glass, contains water and food residue. She also had gum
bleeding.
Mixie : the colour is yellow, normal in frequency and volume.
Defecation : since 5 days before hospitalization the patient only defecate one time, it
was diarrhea with no blood or mucus
Past medical history : The patient had haven’t illness like this
Record of family health : his family denied got sick like this.
Medical effort : The patient had seen a doctor in Cimahi, and told that she had
fever. The doctor gave medicine to went down her temperature,
also Ikadryl® cough syrup and antibiotics.

6.1. Physical examination

General appearance
Condition : Moderate sickness
Consciousness : Compos mentis
Activity and position : No force position
General condition : Weak, snivel
Vital signs
Pulse : 102 times a minute, weak pulse
Respiration : 36 times a minute, abdominothoracal type
Temperature : 37,4 ºC, axillar
Blood pressure : 90/60 mmHg
Rumple Leed : not performed

6.2. Systematic Examination

Skin : petechiae (+), rash (-), pale (-)
Head
Eyes : conjunctiva hyperemis -/-, sclera icteric -/-
Ear Nose Throat : epistaxis -/-, secret -/-, krusta -/-
Mouth : wet mucosa, coated tongue (-), gum bleeding (+)
Thorax : shape and movement simetric right = left, retraction (-)
Pulmo : VBS +/+, Rh -/-, Wh -/-
Cor : regular heart sound, shouffle (-)
Abdomen : flat, soepel, BS (+) normal, liver palpable ± 3 cm BAC (flat
surface, sharp edge, tough consistency, not painful to press)
spleen and kidney unpalpable
Genital : female, normal
Extremities : No disparity, cold acral
Neurological Examination : Physiological reflex +/+
Pathological reflex -/-

6.3. Laboratory finding

17/02/06 18/02/06 19/02/06 20/02/06
06.20 16.45
Hb (g/dL) 11.8 13.4 14.2 12.5 11.7
Hct (%) 35 41 43 37 36
Tc (/mm3) 28.000 30.000 53.000 80.000 125.000
17/02/2006 (patient was moved to PICU time : 13.00)
Anti Dengue IgM +, IgG +
17/02/2006
Chest X-Ray : Impression : There was a pleural effusion dextra
VII. Diagnosis
Differential Diagnosis Additional Diagnosis
Dengue haemorrhagic fever grade III Pleural effusion dextra

Working diagnosis Nutritional status :

Dengue haemorrhagic fever grade III Good (98% standard
Weight/Height)
Additional diagnosis :
Pleural effusion dextra

VIII. Suggested Further Studies

- Blood: Hb, Hct, Trombocyte, Leucocyt
- IgM, IgG AntiDengue
- Hemaglutination Inhibition Test
- Chest X-Ray : lateral position

IX. Planning Therapy

1. Non Medicamentous
- O2 1-2 l/minute
- Fluid : Ringer Lactat 20 gtt / minute (17/02/06-21/02/06)
- Trombocyte, Whole Blood and FFP transfussion
- Diet : Soft food

2. Medicamentous
- Adona 50 mg in Ringer Lactate 500 cc IV (17/02/06-21/02/06)
- Fixef 2x500 mg IV (17/02/06-21/02/06)
- Kalfoxim 2x500 mg IV (17/02/06-21/02/06)
- Transbroncho 3x1 cth (17/02/06-21/02/06)
- Imunos 2 x 1 cth (17/02/06-21/02/06)
 - Lasix 10 mg (17/02/06)
- Longcef 2 x 1 cth (20/02/06-21/02/06)
- Igastrum 3x1 cth (20/02/06-21/02/06)

X. Prognosis
Quo ad vitam : dubia ad bonam
Quo ad functionam : dubia ad bonam

XI. Discussion
The Diagnosis of DHF Grade III based on :
Anamnesis :
 Five days, suddenly high fever and continue
 Headache and myalgia
 Weak, anorexia, queasy, vomit
 Petechie, gum bleeding
Physical Verification :
 The patient looks snivel
 Weak pulse, tachycardi, tachypneu
 Hepatomegaly
 Cold acral

Laboratory Finding
- Trombocytopenia
- Chest X-Ray : there was right pleural effusion

XII.REFERENCES

DENGUE HAEMORRHAGIC FEVER

Introduction
Dengue virus is an arthropod borne virus belonging to genus flavivirus, family
flavividae. There are four serotypes called DEN-1, DEN-2, DEN-3, DEN-4. Infection
with one serotype provides lifelong immunity for homologous infection but no croos
protection against infection with other serotype. Aedes aegypty as the principle vector
in India. It is a small black and white tropical masquito. It rests indoors and bites
humans in daytime. It lay eggs in water collected in artificial countainers like buckets,
coolers, flower pots. Its incubation period is about 10-12 days.

Pathophysiology
Exact mechanism of DHF/DHS is not clear, two theories, one, the secondary infection
or immune enhancement hyapotesis. This hypotesis implies that patient
experiencing a second infection with a heterogeneous dengue virus serotype has a
significantly higher risk for developing DHS and DSS. Preexisting heterologous
dengue antibody reconizes the infecting virus and forms an antigen antibody complex,
which is then bound to and internalized by immunoglobulin Fc receptors on the cell
membrane of leukocytes, expecially macrophages where virus is free to replicate. This
antibody dependent enhancement (ADE) enhances the infection and replication of
dengue virus in cells of the mononuclier cell lineage. These cell produce and secrete
vasoactive mediators in response to dengue infection, which causes increase vascular
permeability leading genome may include increased virus replication and viremia,
virulence (severity of deases), and epidemic potential. Cytokines and chemical
mediators such as tumor necrosis factor (TNF), INTERLEUKIN-1 (IL-1), IL-2, IL-6,
platelet activation factor (PAF), complement activation products C3a and C5a, and
histamine may play a role.

Manifestations
A. Asymptomatic-
B. Symptomatic-(i) Undifferentiated Fever, (ii) Dengue Fever (a) Without
Hemorrage (b) With Unusal Hemorrage. (i) DHF without shock (ii) DHF with shock.

Symptoms
Fever usually starts after 2-7 days after masquito bites. It is associated with mascular
or maculopapular rash. Vomiting, diarhoea, abdominal pain, convulsions, altered
sensorium, headache, retro-orbital pain, arthralgia are usually associated.
Hepatomegaly, splenomegaly, bradycardia, lyphadenopathy is usual findings. In DHF
the hemorrage starts by third day. It is characterised by positive torniquet test (Hess
test), epistaxis, hematemesis, skin/mucosal bleeds, melana. Thrombocytopenia (less
than 1,00,000 per cmm) and evidence of plasma leak are characteristic of DHF. The
plasma leak is to be monitored by more than 20% rise in hematocrit for age, more
than 20% drop in hematocrit following treatment with fluids as compared to base line.
DSS includes all about and above and signs of circulatory failure manifested by rapid
and weak pulse, narrow pulse pressure, hypotension for age.

Grading the severity

DF/DHF Grade Symptoms Laboratory

DF Fever with two Thrombocytopenia,
more: headache, Occ Leukopenia,
retro-orbital pain, No plasma loss
myalgia,arhralgia

DHF I Above plus Plat less than

Tourniquet test 100000, Hct rice >
20%
DHF II Above plus bleed Plat less than
 100000, Hct rice >
20%
DHF III Above plus Plat less than
circulatory failure 100000, Hct rise >
20%
DHF IV Profound shock Plat less than
100000, Hct rica >
20%

DHF Grade III and IV are also called as Dengue Shock Syndrome (DSS)

Diagnosis
Laboratory diagnosis is made on demonstration of fourfold or greater rise in specific
antibody which can be detected. By various serological tests e.g. hemagglutination
inhibitation, complement fixation, neutralization test, ELISA or G-ELISA Virus
isolation methods such as mammalian cell culture and masquito inoculation are very
expensive and time consuming and are not routinely available. Reverse transciptase
PCR, hybridization probes for nucleic acids and immunohistochemistory are newer
techniques for diagnosis

Prevention
In the absence of effective vaccine, preventation is largery dependent on vector
control

Treatment
There is no specific antiviral therapy is only important. Antipyretics, good diet, fluid
and rest is to be taken care. Paracetamol is preferred antipyretic

TREATMENT OF DENGUE HAEMORHAGIC FEVER

Medical therapy:
Gift the O2 (2-4 liter/minute)
Plasma Volume exchange (kristaloid isotonis RL / NaCl 0,9 %)
20 ml / weight given fast (bolus in 30 minutes)

Evaluation for 30 minute, is the syok handeled
Check the vital sign every 10 minute
Write the electrolyte while the electrolyte given

If the shock overcome If the shock not overcome

 Conciousnous good Conciousnous went down
Hard pulse Pulse slow/not palpable
Pulse pressure > 20 mmHg Pulse pressure < 20 mmHg
There is no dyspnoe/sianosis Respiratory distress/sianosis
Warm extrimity Cold skin & extremity
Enough diuresis 1 ml/weight/hour Check
Electrolyte and drops Continue the electrolyte 20 ml/weight/hr
10 ml/weight/hour add the koloid/plasma Dextran/FFP 10 -
20 (max 30) ml/weight/hour
Corection asidosis
Tight evaluation evaluation in one hour
Vital sign
Bleeding sign shock handeled
Diuresis If shock not overcome
Hb, Ht, Tc  
Ht  Ht /
Stabil in 24 hour  
 Fresh blood Koloid
Become 3 ml/weight/hour tranfusion 10 ml/weight 20 ml/weight

IVFD stop not more than 48 hour After the shock overcome
If the thrombositopeni severe (<30.000/mm) or there is bleeding and there is sign of
bleeding, gift thrombosit tranfusion.

XII. FOLLOW UP

DATE FOLLOW UP DOCTOR’S ORDER

17/02/06 S : body felt cold -RL for 20 gtt/min
11.00 O : weak, pulseless, right VBS not -Adona 50 mg in RL 500
equal to the left cc IV
T: 37,4 °C -Fixef 2x500 mg IV
-Cito:
Lab : Lab : Hb, Hct, Tc,
Hb : 11,8 IgM/IgG dengue,
Hct : 35 widal, CXR
Tc : 28.000 Tc transsfusion (2 bags)
IgM (+) and FFP (2 bags)
IgG (+)
 13.00 PICU

18.35 dr. Tisna’s advice :

-Kalfoxim 2x500 mg

20.10 S: fussy
O : CM, fussy
T : 36 ° C
P : 102x/min
R : 30x/min
Sat. O2 : 99 %
ENT : flare nose -
Pulmo : VBS +/+, Rh ±/±, Wh -/-,
dullness +/-, retraction -
Cor : BP: 83/56mmHg, regular,
shouffle (-)
Abdomen : flat, soepel, painful to
press at RUQ, BS (+)N,
H/L 4 cm BAC
Urine : -
21.10 Reported to dr. Tisna about CXR
results. Said that he will come to visit
21.45 Cough (+), pulse felt (+) -more often observation
-Transbroncho 3x1 cth
-Imunos 2x1 cth
-allowed to drink

22.20 -There’s no Tc for B blood groups at dr. Tisna’s advice:

PMI -prepared Whole Blood
-little gum bleeding 200-250cc. If that fresh,
give Lasix 10mg first
18/02/06 S: defecation (+)
08.00 O : CM, cough (+) dr. Tisna’s advice :
T : 37,4 ° C -try to eat cooked rice
Lab : P : 98x/min -Lab :
Hb: 13,4 R : 25x/min Hb, Hct, Tc
Hct: 41 Skin : petechie + -Tc transfusion (2 bags)
Tc: 30.000 Eyes : conj. anemic -/-
ENT : flare nose -
Pulmo : VBS +/+, Rh ±/±, Wh -/-,
dullness +/, retraction -
Cor : regular, shouffle (-)
Abdomen : dome-shaped, painful to
press, H/L 3 cm BAC
Ext. : warm
Input : 2305cc
Output : 1202cc
21.08 S: calm dr. Tisna’s advice :
O : CM -Tc transsfusion (2 bags).
T : 35,6 ° C Order 2 bags more if the
P : 91x/min price less than fifty
R : 36x/min thousand rupiah
Sat. O2 : 99 %
Skin : petechie -
ENT : flare nose -
Pulmo : VBS +/+, Rh ±/-, Wh -/-,
dullness +/-, retraction -
Cor : BP: 109/87mmHg, regular,
shouffle (-)
Abdomen : flat, soepel, not painful to
press, BS (+)N, H/L 4 cm
BAC
Urine : +

19/02/06
07.00 Lab :
Hb : 14,2
Hct : 43
Tc : 53.000
07.16 dr. Tisna’s advice :
-repeat tests for Hb, Hct,
Tc

08.10 S: calm
O : CM
T : 36 ° C
P : 101x/min
R : 30x/min
Sat. O2 : 93 %
ENT : flare nose -
Pulmo : VBS +/+, Rh +/-, Wh -/-,
dullness +/, retraction -
Cor : BP: 108/77mmHg, regular,
shouffle (-)
Abdomen : flat, soepel, not painful to
press, BS (+)N, H/L 4 cm
BAC
Urine : +

17.00 Lab : dr. Tisna’s advice :

Hb : 12,5 -cancel Tc
Hct : 37 transfusion
Tc : 80.000 -plan to moved from
PICU
 -continue therapy

21.00 S: calm
O : CM, moderate sickness
T : 36,7 °C
P : 85x/min
R : 36x/min
Sat. O2 : 95 %
ENT : flare nose -
Pulmo : VBS +/+, Rh +/-, Wh -/-,
dullness +/-, retraction -,
Cor : BP: 108/87mmHg, regular,
shouffle (-)
Abdomen : a little bit dome-shaped
and stiff, not painful to
press, BS (+)N, H/L 4 cm
BAC
Ext. : warm
Urine : +

21.40 Lab : dr. Tisna’s advice :

Tc : 50.000 -continue therapy
-at six o’clock tomorrow
morning, get Hb, Hct, Tc
checked. If everything
okay, moved from PICU
20/02/06
07.50 S: calm, eat her breakfast, defecation + dr. Tisna‘s advice:
O : CM, mild to moderate sickness -could move to regular
T : 36.6 °C room (Abednego)
Lab. : P : 82x/min -Longcef 2x1 cth
Hb : 11,7 R : 25x/min -Igastrum 2x1 cth
Hct : 36 Sat. O2 : 100 %
Tc : 125.000 Eyes : conj. anemic -/-
ENT : flare nose -
Pulmo : VBS +/+, Rh -/-, Wh -/-,
dullness -/-, retraction -
Cor : BP: 107/86mmHg, regular,
shouffle (-)
Abdomen : dome-shaped, epigastric
pain +
Ext. : warm
Defecation : +

Input: 1961cc
Output: 2710cc

13.40 S: calm PATIENT

O : CM
T : 36.8 °C MOVED TO
P : 85x/min
R : 25x/min ABEDNEGO
Sat. O2 : 96 %
Eyes : conj. anemic -/-
Pulmo : VBS +/+, Rh -/-, Wh -/-,
dullness -/-, retraction -
Cor : BP: 109/88mmHg, regular,
shouffle (-)
Abdomen : dome-shaped, epigastric
pain +
Ext. : warm

21/02/06 : PATIENT GO HOME