Case Presentation Dengue Fever

Proper Case Presentation for Dengue Fever, Prevention, Treatment and everything else. Prepared by Dr Zain Khan, Doctor at Liaquat College of Medicine and Dentistry

2. Clinical Medicine
Case Presentation
Atif Rahim
Nasreen Akhter
Zain Ul Abidin

3. History
Mrs. Nishat
60 years old Female
Housewife
Gulistan E Joher, KHI
Admitted in DSH on 14/11/2015 via ER
C/O
Fever
Headache For 3 Days
Malaise

4. HOPC
According to my patient she was in usual state of
health 3 days back when she started having Abrupt
onset high grade continuous fever documented at
103 F, Associated with chills, headache,
Generalised body ache and Easy Fatiguability, NO
Aggreviating and Relieving Factors.
Temp mildly paracetamol but recurred.
↓
Persistent above symptoms brought Patient to the
Hospital

5. Contd..
No h/o
Polyarthralgia
Rash
Abdominal pain/swelling
Hematemesis/melena/Mucosal bleeds
Yellowish discoloration of mucosa & skin
Altered consciousness/Seizures
Hematuria/oliguria
Chest pain/palpitations/breathlessness
Cough with expectoration

6. Contd…
Past History
Not contributory
Personal History
not smoker/ No other addiction
Occupation
Housewife
Family History
Not contributory
Socioeconomic History
Patient lives in her own 2 rooms, ventilated house
With her husband And 3 children, use tap water.

7. On Examination
My Patient was Lying comfortably on the bed, was well oriented
with time place and person.
Vitals
BP – 100/70 mmhg
Pulse – 94/min
RR – 28/min
Temp – 102
0
F

8. O/E
On General Physical Examination My Patient is of
Moderate built & nourishment, She has a Fever at
102 F, She is mildly Tachypneic, Not dyspneic.
Besides that no abnormal finding on GPE.

9. Contd..
Systemic Examination
CVS
JVP not raised
S1, S2+
No additional sounds
No murmurs

10. Contd…
RS
Tachypneic
Normal Vesicular Breathing Sounds
No added sounds
Abdomen
Non tender
No organomegaly/free fluid
BS +
CNS
No Functional Neurological Disorders

11. Differential Diagnosis
Dengue Fever
Malaria
Typhoid
Viral Hepatitis

12. Investigations
•CBC
•MP
•Dengue Serology

13. Investigations
13/11/15 – done outside
Hb – 13.6
TC – 3500
DC – P-55/L-42/E-3
ESR – 5/8
Platelet – 80,000
RBS – 97
Urea – 27
Creatinine – 0.7
Sodium – 136
Potassium – 3.6
Smear for MP – negative
14/11/15 – DSH
Hb – 13.6
TC – 3400
DC – P-45/L-52/E-3
PCV – 39
ESR – 3/7
Platelet – 70,000
RBS – 94
Urea – 21
Creatinine – 0.8
Sodium – 139
Potassium – 3.8

14. MP Test
Negative
Dengue IgM & IgG
Positive

15. Final Diagnosis
Dengue Fever

16. Management
Tab Panadol 2+2+2
IV Ringer Lactate

17. Dengue Fever

18. History of Dengue Fever
The Word Dengue is derived from the Swahili
phrase "Ka-dinga pepo", meaning "cramp-like
seizure caused by an evil spirit
The first record of a case of probable dengue
fever is in a Chinese medical encyclopedia from
the Jin Dynasty (265–420 AD) which referred to a
“water poison” associated with flying insects
The first confirmed case report dates from 1789
and is by Benjamin Rush, who coined the term
"breakbone fever" because of the symptoms of
myalgia and arthralgia.

19. Dengue Fever
WHO says some 2.5 billion people, two
fifths of the world's population, are now
at risk from dengue and estimates that
there may be 50 million cases of dengue
infection worldwide every year.
epidemic in more than 100 countries

20. Dengue fever
genus Flavivirus,
family Flaviviridae
also known as breakbone
fever.(bonecrusher disease)
-Dandy Fever
Aedes aegypti main mosquito
vector

21. Distribution
Endemic in more than
100 tropical and
subtropical countries
Pandemic began in
Southeast Asia after WW
II with subsequent global
spread
Several epidemics since
1980s
Distribution is
comparable to malaria

22. Manifestations of dengue virus
infection:
ASYMPTOMATIC
SYMPTOMATIC
Undifferentiated
Fever
Dengue Fever
Dengue
Haemorrhagic
Fever
Without haemorrhagic
With unusual
haemorrhagic
No shock
DSS

23. Virology
Flavivirus family
Small enveloped
viruses containing
single stranded
positive RNA
Four distinct viral
serotypes (Den-1,
Den-2, Den-3, Den-4)

24. Dengue Viruses
Four closely related single-stranded RNA Dengue viruses (DEN-
1, DEN-2, DEN-3 and DEN-4)
Each serotype provides specific lifetime immunity, and short-
term cross-immunity (A person can be infected as many as
four times, once with each serotype)
All serotypes can cause severe and fatal disease

25. Pathophysiology
Transmitted by the
bite of Aedes
mosquito (Aedes
aegypti)
Incubation 3-14 days
Acute illness and
viremia 3-7 days
Recovery or
progression to
leakage phase

26. Dengue Mosquito
Aedes aegypti is the most important dengue
mosquito
It breeds in collections of water close to dwellings
Common breeding sites are;
-Domestic water storage containers - tanks, jars,
drums, flower vases with water
-Roof gutters /sun shades
-Used tyres, discarded tins, cans, pots, yogurt cups,
polythene bags, tree axils &
- Many more places where rain watercollects

27. The most common epidemic vector of dengue in the world is
the Aedes aegypti mosquito. It can be identified by the white
bands or scale patterns on its legs and thorax.

28. Replication and Transmission
of Dengue Virus (Part 1)
1. Virus transmitted
to human in mosquito
saliva
2. Virus replicates
in target organs
3. Virus infects white
blood cells and
lymphatic tissues
4. Virus released and
circulates in blood
3
4
1
2

29. Replication and Transmission
of Dengue Virus (Part 2)
5. Second mosquito
ingests virus with blood
6. Virus replicates
in mosquito midgut
and other organs,
infects salivary
glands
7. Virus replicates
in salivary glands
6
7
5

30. Dengue Clinical Syndromes
Undifferentiated fever
Classic dengue fever
Dengue hemorrhagic fever
Dengue shock syndrome

31. Undifferentiated Fever
May be the most common
manifestation of dengue
Prospective study found that 87%
of students infected were either
asymptomatic or only mildly
symptomatic
Other prospective studies
including all age- groups also
demonstrate silent transmission

32. Clinical Characteristics
of Dengue Fever
Fever
Headache
Muscle and joint pain
Nausea/vomiting
Rash
Hemorrhagic manifestations

33. Hemorrhagic Manifestations
of Dengue
Skin hemorrhages:
petechiae,
purpura, ecchymoses
Gingival bleeding
Nasal bleeding
Gastro-intestinal bleeding:

hematemesis, melena,
Hematuria
Increased menstrual flow

34. Clinical Case Definition for
Dengue Hemorrhagic Fever
Fever, or recent history of acute fever
Hemorrhagic manifestations
Low platelet count (100,000/mm
3
or less)
Objective evidence of “leaky capillaries:”
elevated hematocrit (20% or more over
baseline)
low albumin
pleural or other effusions
4 Necessary Criteria:4 Necessary Criteria:

35. Clinical Case Definition for
Dengue Shock Syndrome
4 criteria for DHF
Evidence of circulatory failure manifested indirectly by all of the
following:
Rapid and weak pulse
Narrow pulse pressure (£ 20 mm Hg) OR hypotension for age
Cold, clammy skin and altered mental status
Frank shock is direct evidence of circulatory failure

36. Physical Exam
Nonspecific findings
Conjunctival
injection, pharyngeal
erythema,
lymphadenopathy,
hepatomegaly (20-
50%)
Macular or
maculopapular rash
(50%)

37. Laboratory Findings
Leukopenia
Thrombocytopenia (<100,000)
Modest liver enzyme elevation (2-5x nml)
Serology:
•Acute phase serum IgM (+6-90 days) ELISA
•Acute and convalescent IgG (99% sens,
96% spec)
•Hemagglutination inhibition assay (HI) is
gold standard. Paired acute and
convalescent HI assay, positive if >4 fold
titer rise

38. Treatment
No specific therapy
Supportive measures:
adequate hydration
acetaminophen (if no liver dysfunction)
avoid ASA and NSAIDs
DHF or DHF w/ shock:
IV fluid resuscitation and hospitalization
blood or platelet transfusion as needed

39. Traditional and emerging
treatments
Emerging evidence suggests that
mycophenolic acid and ribavirin inhibit
dengue replication.

40. Brazilian traditional
medicine,-cat's claw herb

41. Malaysia,-natural medicine. Mas
Amirtha, Semalu & Kolostrum
Mas Amirtha – Two Capsules 3 times A Day
Mas Semalu  – Two Capsules 3 times A Day
Mas Kolostrum – Two Capsules 3 times A Day

42. Philippines -tawa-tawa herbs

43. Sweet potato tops juice

44. Mortality/Morbidity
Treated DHF/DSS is associated with a 3%
mortality rate.
Untreated DHF/DSS is associated with a
50% mortality rate.

45. Advice
Stay in air-conditioned or well-screened
housing
Reschedule outdoor activities
Wear protective clothing
Use mosquito repellent
Reduce mosquito habitat

46. Mosquito control:
Options available
“Mosquitoes take
about 7 days to
complete life
cycle.
The first three
Stages: eggs,larva
and pupa are
aquatic.
Therefore, the
best way to
prevent mosquito
breeding is
to remove
stagnant clear
water”

47. THANK YOU