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Case Write Up - Dengue Fever
Case Write Up - Dengue Fever
PHASE II
PAEDIATRIC POSTING
CLINICAL CASE WRITE-UP
POSTING : PAEDIATRICS
SUPERVISOR : AP DR. SALMI ABD RAZAK
A. HISTORY TAKING
Name : Nur Farah Ilyana Binti Ahmad
Registration no. : HRPZ252877
Age : 11 years old
Gender : Female
Race : Malay
Address : Melor, Kelantan
Informants : Mother
Diagnosis : Dengue Fever Without Warning Signs
Underlying illness : Asthma
Date of Admission : 1/1/2018
Date of Clerking : 2/1/2018
Chief Complaint
The patient presented with persistent high-grade fever for 4 days of duration prior to admission.
History Of Presenting Illness
She was previously well and active before until 5 days prior to the admission, she complained of
having recurrent painful headache which was pulsating in nature spreading all over her head
associated with retro – orbital pain. She often cries due to the throbbing pain and her activity was
limited for each episode. The following day, she developed a persistent high-grade fever for 4
days before the admission, associated with chills but no rigors. The patient also noted
erythematous, raised and itchy rash formed on her right upper limb and only lasted during the
first 2 days of its presentation. Moreover, there had been reduced in her appetite and daily oral
intake ever since her illness.
During the 2nd day of fever, she was brought to KK and was discharged with syrup paracetamol,
however, the symptoms persists.
On further questioning, she also had been vomiting only for one day, more than 5 times in
frequency containing food and fluid. It was non-bilious with no presence of blood. There’s also
presentation of loose stool for one episode which was large in amount, also no blood nor mucus
noted.
Besides that, the patient also complaint of having muscle aches and joint pain especially at the
lower limbs and on her back that she had been feeling of uneasiness and been unable to move
freely.
On the 4th day of fever, the patient was brought again to KK, there, blood sample was taken and
tested, and the mother claimed that the GP told her that Farah was having very a low platelet
count. Hence, she was then referred to HRPZ and admitted due to suspect for dengue.
There was a positive history of recent travelling to dengue area where patient had been staying in
her grandmothers’ house during the holiday season for 3 weeks and claimed that there was a
recent fogging activity in early December in that area.
Otherwise, there were no abdominal pain, no conjunctivitis, no persistent vomiting, no mucosal
bleeding, no recent jungle – trekking or water activity and no family members presented with the
same symptoms.
Systemic Review
Developmental Milestone
The developmental milestone is currently normal according to her age. She started to roll prone
to supine at the age of 7 months, crawling at 8 months, stand with support at 9 months, walking
with support at 11 months and without support at 12 months of age. As for fine motor, she able
to self – feed at 8 months of age, pincer grasp at 9 months and scribble at 12 months. For
language, she started to babble at 8 months, able to speak one word with meaning at 11 months,
and able to speak 2 to 3 words in a sentence at 2 years of age. Lastly, she had stranger anxiety
during 12 months of age. Currently, she is appropriately active at home and in school and able to
maintain a very good relationship with her family and fellow colleagues. There is no
developmental delay so far and she claimed to be very active in school sports especially in
athletics. Futhermore, she is also good academically in every subject in class.
Family History
45 40
y/o y/o
20 19 15 11 10 8 y/o 6 y/o
y/o y/o y/o y/o y/o
Farah is the 4th child out of 7 siblings of a non – consanguineous marriage. Her father is a
businessman who has no known medical illness while her mother is a housewife who also has
underlying asthma. She has strong family history of asthma which including all her siblings have
asthma except the youngest child. Otherwise, there is no family history frequent miscarriage or
neonatal death, no known other chronic illness runs in the family such as diabetes, hypertension
and tuberous sclerosis.
Social History
Farah lived with her family in a house with adequate basic amenities such as electricity, well-
water supply and food. The mother claimed to have no any financial problems in the family.
Diet History
Farah is currently on adult diet consumption and she has loss of appetite since sickness. She has
no known food allergy so far.
SUMMARY OF HISTORY
Farah, 11 years old Malay girl presented with persistent high-grade fever for 4 days of duration
with presence of severe headache, retro – orbital pain, muscle ache and joint pain. She also had
history of vomiting and loose stools for one day that subsided spontaneously. Moreover, she had
been staying in her grandmother’s house during this recent school holiday season for 3 weeks
and claimed that there was a recent fogging that was held during early December in that area.
Otherwise, there is no abdominal pain, no persistent vomiting, no mucosal bleeding, no
conjunctivitis, no recent jungle – trekking or water activity and no other family members
presented with the same symptoms.
B. PHYSICAL EXAMINATION
General Examination
On inspection, Farah was lying supine, alert, conscious and ill – looking. She was not in
respiratory distress and noted breathing rate were 30 breaths per minute. There were no gross
deformity, no dysmorphism noted. Her hydrational and nutritional were clinically adequate.
There was a branula attached on the dorsum of left hand.
Vital sign :
Pulse rate : 98 beats/min, regular rhythm, good volume.
Respiratory rate : 30 breaths/min
Blood pressure : 112/68 mmHg
Temperature : 38.5 ̊ C
Anthropometry
Age : 11 years old
Height : 142 cm (on 25th percentile)
Weight : 31.4 kg (on 10th percentile)
Upper limbs
a. Palms were warm, dry and pink.
b. No finger clubbing
c. No peripheral cyanosis
d. Capillary refill was good, < 2 seconds
e. No palmar erythema
f. No thenar or hypothenar muscle wasting
Lower limbs
a. No pitting edema
b. Posterior tibial & dorsalis pedis pulses were palpable
Specific Examination
NEUROLOGICAL EXAMINATION
On inspection, both upper and lower limb were symmetrical, there was no abnormal posture, no
abnormal movement, no muscle wasting, no muscle hypertrophy, no muscle fasciculation, no
neurocutaneous sign and no scars.
Cranial nerve:
I Normal
II Normal pupillary light reflex
D. Cerebellar Examination
a. No dysarthria
b. No dysmetria
c. Pendular knee jerk was normal
d. No cerebellar ataxia
e. Normal gait
f. Negative Romberg’s sign
RESPIRATORY EXAMINATION
Inspection:
a. Chest wall was rising symmetrically with each respiration
b. Chest wall expansion was symmetrical in all lung zones
c. No intercostals recessions
d. No use of accessory muscles during breathing
e. No surgical scars
f. No skin discoloration
g. No dilated veins
Palpation:
a. Chest expansion is symmetrically normal
b. No thrills upon breathing
c. Tactile fremitus was resonance.
Percussion:
a. Percussion note was resonance at both upper and middle zones of lungs.
b. Liver and spleen dullness present
Auscultation:
a. Normal and equal air entry was heard over the upper, middle and lower zones
both lungs and no additional sounds heard.
b. Vocal fremitus was resonance in all lung zones
CARDIOVASCULAR EXAMINATION
Inspection:
No precordial bulge, no pectus carinatum, no pectus excavatum
Palpation:
a. Apex beat was palpable at left fifth intercostal space, at medial to mid-clavicular
line.
b. No parasternal heave
c. No thrill
Auscultation:
a. S1, S2 with normal intensity, no murmur was heard over mitral, tricuspid,
pulmonary and aortic areas. There was no murmur heard at apex beat and
subclavian areas as well.
ABDOMINAL EXAMINATION
Inspection:
a. Abdomen moved symmetrically with each respiration
b. It was non-distended.
c. The umbilicus was centrally located and inverted.
d. There was a well healed scar at the right inguinal region
e. No dilated veins, no visible pulsation and no skin discoloration.
Palpation:
a. Superficial palpation:
Abdomen was soft and non-tender.
b. Deep palpation:
No mass could be felt over all the nine quadrants.
Liver was not palpable.
Spleen was not palpable
Kidneys were not ballotable.
Percussion:
a. Liver span was measured 10cm.
Auscultation:
a. Bowel sound was present with normal intensity.
b. No renal bruit.
SUMMARY OF EXAMINATIONS
Examination of this patient revealed that she was still febrile. Otherwise, other neurological,
respiratory, cardiovascular and abdominal examinations were normal.
C. PROVISIONAL DIAGNOSIS
D. DIFFERENTIAL DIAGNOSIS
1. Leptospirosis
2. Typhoid fever
Positive Findings Negative Findings
Fever with chills No progressive fever
Vomiting No constipation
Loose stool No abdominal pain
No rose spots
No hepatosplenomegaly
No intestinal bleeding
3. Malaria
4. Chikungunya
E. INVESTIGATIONS
Interpretation :
There might be no infection at all or the infection is still in its 1st week.
Serology may be negative in the first 5 days of illness
IgM and IgG often positive during the 2nd week of illness
Result : (1/1/2018)
Positive
Interpretation :
There is presence of viral antigen hence, it may be dengue virus infection.
Result : (3/1/2018)
Hb : 130 (115 – 155 g/L)
TWBC : 1.81 (4.5 – 13.0 X 10^9/L)
RBC : 4.86 (4.0 – 5.2 X 10^12/L)
MCV : 83.1 (77 – 95 fl)
MCH : 26.7 (25 – 33pg)
MCHC : 32.2 (31 – 37g/dL)
HCT : 40.4 (35 – 45%)
Platelet : 72 (150-450 X 10^9/L)
Neutrophils : 0.87 (1.5 – 8.0 X 10^9/L)
Lymphocytes : 0.65 (1.2 – 5.2 X 10^9/L)
Interpretation :
Hemoglobin level is normal.
There is leukopenia which may indicates virus – induced destruction or
inhibition of myeloid line.
Both neutrophils and lymphocytes are decreased.
The platelet count is markedly low, bleeding tendency is likely, and this
might be due to destruction of peripheral platelet or bone marrow
megakaryocytes by viruses.
Hematocrit level is normal, there is no dehydration or plasma leakage so
far.
Interpretation :
There is slightly reduced in serum Sodium and Potassium concetration.
Interpretation :
There are increase in ALP and AST value yet normal ALT.
1. Coagulation Profile
Reason : To look for haemorrhagic sign.
G. MANAGEMENT
Goals:
Treat fever
Supportive management
5. Anti-pyretic
Syrup paracetamol 500g PRN to relieve fever
H. DISCUSSION
After the incubation period, the illness begins abruptly and will be followed by three phases:
febrile, critical and recovery phase.
Day of illness 3 to 7 days 3 to 7 days 1 to 5 days
Phase Febrile Critical Convalescence
-Monitor
-Monitor
haemodynamic status,
haemodynamic status,
respiratory status and
respiratory status and -Monitor
neurological status 2-4
neurological status 4-6 haemodynamic status,
hourly. If in shock, 15-
hourly. respiratory status and
30 minutes until
stable, then 1-2 hourly. neurological status 4-6
hourly.
3. Iv fluid therapy should also be considered in patients who are vomiting, severe loose
stools and not tolerating orally.
4. The normal maintenance requirement for iv fluid therapy in such patients could be
calculated.
5. Frequent adjustment of maintenance fluid regime is needed during the critical phase.
6. If the fluid infusion rate exceeds more than the maintenance requirement, the
infusion rate should be reviewed within 2-4 hours.
7. In patients with persistent warning signs with increasing or persistently high HCT,
the graded fluid bolus may be initiated with caution.
8. Frequent monitoring of clinical and laboratory parameters must be carried out every
2-4 hours until patients improve.
9. Aim for urine output of 0.5-1.0 ml/kg/hr.
10. A rising HCT indicates on-going plasma leakage and will require an increase in the
iv fluid infusion rate.
11. If patients deteriorate and progress to shock
a. Iv fluid therapy is the mainstay of treatment for dengue shock.
b. Colloid may be preferable as the fluid of choice in patients with intractable
shock in the initial resuscitation because seem to restore the cardiac index and
reduce the level of HCT faster
12. Reduce or consider discontinuation of iv fluid therapy when patients begin to show
signs of recovery usually after 24-48 hours of defervescence, or the HCT drops in a
stable patient.
I. PROGRESS REPORT
During her presentation at A&E at 6 pm, she was given tablet paracetamol to reduce the
temperature and the fever drops gradually. Later the next morning, the fever was spiking again
and persist until the next morning. Within that time interval, she was given tepid sponging and
tablet paracetamol and the fever subsided only slightly and temporarily. During the 3 rd day of
admission, the febrile phase ended where she no longer in feverish state and start to improve in
oral intake. There’s no vomiting, loose stools or abdominal pain so far. She finally discharged
from HRPZ during the 7th day of admission.
J. PROGNOSIS
Generally, the prognosis is favourable. She was discharged with no complications and recovered
fully.
K. ETHICAL ISSUES
There are a few ethical issues surrounding the management of the patient. For example,
confidentiality of the child’s medical condition. As sometimes it is very important to promote
respect for the patient, but it is necessary to breach the confidentiality, where it is felt that the
child may be at risk if no one is alert and does not react accordingly in time. As such, the school
is usually informed so that a medical emergency can be adequately managed.
Moreover, the importance of empathy during communication even though some questions can be
very sensitive. Some patients’ families may be less likely to offer honest answers and may be
unreceptive to entertaining the possibility of an intervention. Knowing different ways of asking
about tobacco usage, for example, can help in getting the necessary information without
alienating the respondent. While sensitive, the information is needed for accurate diagnosis and
intervention. Adherence to interventions for sensitive topics (e.g., smoking cessation, alcohol
abuse) may present special challenges for the health care provider. A good communication plays
an important role in such conditions.
Question:
What are the effects of corticosteroids in children with dengue-related shock?
Clinical Answer:
There is insufficient randomized controlled trial evidence to judge the effects of corticosteroids
in children with dengue-related shock.
Very low-quality evidence suggests that corticosteroids may have no benefit in terms of
mortality, need for blood transfusion, duration of hospital stay, pulmonary hemorrhage or
convulsions when compared with placebo/no steroids in children with dengue infection who had
been admitted to hospital suffering from dengue-related shock. Three small trials seemed to
report inconsistent results regarding the duration of shock, but data were sparse. All of the
analyses would have been too underpowered to detect differences between groups, even if these
were present.
Background
Dengue is a common and important mosquito-borne viral infection. In many low- and middle-
income countries it is endemic and is an important public health problem. Severe dengue is an
important cause of death in children. There is no specific treatment for dengue, but observational
studies suggest corticosteroids may have a benefit in dengue-related shock, and some people
believe corticosteroids may prevent the progression to severe illness if given early in the course
of the illness.
Objectives
To compare treatment of dengue with and without use of corticosteroids or placebo in relation to
preventing shock-related death and disease progression in children and adults.
Search methods
We searched the Cochrane Infectious Disease Group Centralized Register; CENTRAL;
MEDLINE; EMBASE; and LILACS, up to 6 January 2014. We screened reference lists and
contacted the relevant study authors for additional information where required.
Selection criteria
Randomized controlled trials or quasi-randomized controlled trials comparing corticosteroids
with placebo or no corticosteroids in patients diagnosed with dengue-related shock, or patients in
an early symptomatic state of dengue with positive serology.
Data collection and analysis
Two researchers independently screened eligibility of records, extracted data and assessed
quality of the studies. We presented findings in meta-analysis and summary of findings tables
and evaluated the quality of evidence using GRADE.
Main results
We included eight studies enrolling 948 participants in this review.
Paitents with dengue-related shock
Four studies enrolled children younger than 15 years with dengue-related shock at hospitals in
Southeast Asia and evaluated intravenous corticosteroids. The trials did not detect an effect on
death (four trials, 284 participants, very low quality evidence), the need for blood transfusion
(two trials, 89 participants, very low quality evidence), pulmonary haemorrhage (one trial, 63
participants, very low quality evidence), convulsions (one trial, 63 participants, very low quality
evidence), or duration of hospitalization (one trial, 63 participants, very low quality evidence).
The body of evidence is too small to confidently prove or exclude clinically important effects.
Furthermore, the trials are more than 20 years old with several methodological limitations.
Patients with dengue at an early stage
Four studies enrolled 664 children and adults with dengue at an early stage of infection (without
shock) in Columbia, India, Sri Lanka and Vietnam. In these participants there were no evidence
of effects of oral or intravenous corticosteroids on mortality (four trials, 664 participants, low
quality evidence), or on the development of complications of severe dengue such as shock (two
trials, 286 participants, very low quality evidence), severe bleeding (two trials, 425 participants,
very low quality evidence), severe thrombocytopaenia (one trial, 225 participants, very low
quality evidence), ascites (one trial, 178 participants, very low quality evidence) and intensive
care unit (ICU) admissions (two trials, 286 participants, very low quality evidence).
Authors' conclusions
The evidence from trials using corticosteroids in dengue is inconclusive and the quality of
evidence is low to very low. This applies to both the use of corticosteroids in dengue-related
shock and for dengue at an early stage. There is insufficient evidence to evaluate the effects of
corticosteroids in the treatment of early stage dengue fever and dengue-related shock outside of
the context of a randomized controlled trial.
M. REFERENCES