DENGUE

FACTORAN, MICHELLE M.
“Dengue is a mosquito-borne viral infection
causing severe flu-like illness and, sometimes
causing potentially lethal complication called
severe dengue.”
“Dengue virus (DEN) comprises of four
distinct serotypes (DEN-1, DEN-2, DEN-3 and
DEN-4) which belong to the genus Flavivirus,
family of Flaviviridae.”
“Aedes aegypti mosquito is the main vector
that transmits the viruses that cause dengue.
The viruses are passed on to humans through
the bites of an infective female Aedes
mosquito, which mainly acquires the virus
while feeding on the blood on of an infected
person.”
“A total of 307,704 dengue patients were admitted in different hospitals nationwide
from January 1 to September 14, based on the DOH dengue surveillance report.

The number was higher by 142,783 cases compared to the same period in 2018.
Fatalities also went up to 1,247 from 742 last year.

The DOH said dengue cases exceeded the epidemic threshold in the Ilocos region,
Central Luzon, Calabarzon, Mimaropa, Bicol, Western Visayas, Eastern Visayas,
Zamboanga peninsula, Northern Mindanao, Socsksargen, National Capital Region and
Bangsamoro Autonomous Region in Muslim Mindanao.

The DOH added incidence of the mosquito-borne disease in Central Visayas and
Davao region has exceeded alert threshold. “
“Calabarzon accounted for the highest number of dengue cases with
49,661 followed by Western Visayas with 49,068.

The National Capital Region posted the third highest number of dengue
cases with 23,251 followed by Central Luzon with 23,046. “
“The DOH said Western Visayas recorded the highest number of deaths
with 214 followed by Calabarzon with 152 and Metro Manila with 122.

Children aged five to nine years were the most affected with a total of
69,549 cases. Males accounted for the bulk of the cases with 161,319. “
CASE PRESENTATION
General Data

• L.M.A.L.
• 17 years old
• Male
• Single
• Born on October 26, 2002 in Camarines Sur
• Filipino
• Roman Catholic
• Meycauayan, Bulacan
Chief Complaint

• Nose bleeding
History of Present Illness

4 days PTA
• Onset of undocumented fever
• 4 episodes of vomiting of previously ingested food about 1 cup per bout
• Dizziness
• Weakness
• Body malaise
• Self-medicated with Paracetamol 500mg tablet, 2 tablets every 12 hours
which afforded temporary relief
History of Present Illness

3 days PTA
• Undocumented fever
• Occasional dizziness
• Generalized body weakness
• Body malaise
• Self-medicated with Paracetamol 500mg tablet, 2 tablets every 12 hours
which afforded temporary relief
History of Present Illness

During the interim, symptoms were persisted. Patient took Paracetamol for
temporary relief. Still no consult done.
History of Present Illness

Few hours PTA

• Fever of 37.8C
• 5 episodes of vomiting of previously ingested food of about half a cup per
bout
• Abdominal pain on epigastric area
• Nose bleeding
• Private Clinic -> Dengue test was done and showed positive result -> advised
for transfer to hospital of choice.
History of Present Illness

At the ER
• Blood pressure was palpatory 90
• Cold clammy skin
• Abdominal pain on epigastric area
Past Medical History
• No previous history of hospitalization, surgery, previous accidents/trauma, or blood
transfusion.
• No illnesses such as asthma, heart disease, kidney disease, pulmonary disease,
hypertension, diabetes mellitus, tuberculosis were noted.
• No known allergy to any food or medication noted.
• Patient had unrecalled immunization history. Patient was given with Dengvaxia vaccine.
Maternal and Birth History
• 23 year old G2P2 (2002)
• Normal Spontaneous Delivery at Camarines Sur Provincial Hospital
• Full term at 37 weeks AOG
• Regular prenatal check up done at Camarines Sur Provincial Hospital
• No maternal illnesses such as hypertension, DM, UTI, thyroid diseases were noted.
• No fetomaternal complications were noted.
Family History
• (+) Hypertension - paternal
• (-) Diabetes
• (-) Asthma
• (-) Tuberculosis
• (-) Cancer
• (-) Thyroid disorder
Personal and Social History
• Patient lives in a bungalow type of house with 3 windows and 1 door
• Maynilad supplies their household water
• Mineral water for drinking
• Out-of-school youth
• Online gaming and basketball
• 0.5 pack years smoker
• Occasional alcoholic drinker
• Denies use of illicit drugs
Nutritional History
• Patient was breastfed until 3 weeks mixed with unrecalled milk formula.
• Patient is fond of eating rice, meat and vegetables.
Review of Systems
General: (-) weight loss, (+) poor appetite, (-) delay in growth
Skin: (-) rash (-) pigmentation (-) dryness (-) acne (+)pruritus
HEENT: (-) oral discharge (+) nasal discharge (-) aural discharge (-) cervical lymphadenopathy
Respiratory: (-)dyspnea, (-) cough (-) noisy breathing
Cardiovascular: (-) cyanosis (-) murmur
Gastrointestinal: (-) diarrhea (-) constipation (-) jaundice
Genital: (-) tea colored/ reddish urine
Musculoskeletal: (-) joint pain (-) edema
Neurologic:(-) paralysis, (-) sleep apnea
Physical Examination
Vital Signs:
BP: 90/70 mmHg HR: 97 bpm RR: 18 cpm T: 37.8C, O2 Sat: 98%

Weight: 54.5 kg Height: 159 cm BMI: 23.5kg/m2 Z-score: 0

General Survey: awake, alert, no gross deformities, ambulatory, not in cardiorespiratory
distress
Skin: brown, flushed, cold clammy skin, dry, elastic with good skin turgor, no lesions
HEENT: normocephalic, anicteric sclera, pink palpebral conjunctiva, clear nasal discharge, no
aural discharge, no tonsilopharyngeal congestion, no cervical lymphadenopathy
Physical Examination
Chest And Lungs: symmetrical chest expansion, clear breath sounds, no retractions, no lagging
Cardiovascular: adynamic precordium, normal rate, regular rhythm, no murmur
Abdomen: flat, soft, (+) epigastric tenderness, (+) abdominal guarding, no organomegaly
Musculoskeletal: no gross deformities, intact motor and sensory, no fasciculations, no atrophy,
no tremors
Extremities: no gross deformities, no cyanosis, no edema, CRT 3 secs
Neurological: conscious, coherent, oriented to time, place and person, intact memory
Laboratory Results Brought by the Patient
CBC with PC Result Normal Value
WBC 3.00 L 5.00- 10.0 x 10 ^9 /L
Neutrophil 0.46 0.40-0.75
Lymphocytes 0.39 0.20-0.45
Monocytes 0.14 0.02-0.06
Eosinophils 0.1 0.01-0.04
Basophils 0 0.0-1.0
Hemoglobin 192 H 113-130 g/L
Hematocrit 0.54 H 0.35-0.40
Platelet 30 L 150-450 x 10 ^ 9/L

Dengue Duo Result

IgM Negative
IgG Positive
24
 Salient Features Laboratory Findings
• Intermittent fever • Leukopenia
• Abdominal pain (epigastric area) • Thrombocytopenia
• Vomiting • Elevated hematocrit
• Body weakness • Dengue IgG positive
• Body malaise
• Epistaxis
• Cold clammy skin
• Flushed skin
• Petechial rash upon torniquet test
• BP: Palpatory 90
• Dengvaxia recepient
Differential Diagnosis
DENGUE FEVER
Pertinent Positive Pertinent Negative
• Fever • Diarrhea
• Headache
• Body malaise
• Epigastric tenderness
• Mucosal bleeding
• Hypotension
• Hypothermia
• Flushed skin

YELLOW FEVER
Pertinent Positive Pertinent Negative
• Fever • Faget sign (bradycardia)
• Body malaise • No history of travel in South America and Africa
• Epigastric tenderness
• Mucosal bleeding
• Hypotension
• Hypothermia
Differential Diagnosis
CHIKUNGUNYA
Pertinent Positive Pertinent Negative
• High-grade fever • Saddle-back fever
• Myalgia • Conjunctival suffusion
• Flushed skin • Photophobia
• Joint pain

LEPTOSPIROSIS
Pertinent Positive Pertinent Negative
• Fever • Rigor
• Nausea and Vomiting • Muscle pain localized to calf and lumbar areas
• Headache • Photophobia
• Hemorrhagic features
Clinical Impression
Severe Dengue with Shock (Dengue Hemorrhagic Fever Grade III)
At the er
• Patient was admitted to SMR. Vital signs which BP: palpatory 90, CR: 88,
RR: 18, T: 35.6C, O2 sat: 99%
12/2/2019 • Day 4 of Illness, Day 0 Afebrile
(6:30 PM)

• IVF: PNSS, fast drip 600cc, then reassess.

• Labs: CBC with PC, Dengue Duo, Serum Electrolytes, BUN, Crea, AST, ALT
• Meds: Omeprazole 40mg/IV OD
• O2 mask at 10LPM
 12/2/2019 Result Normal Value
WBC 4.2 L 5.00- 10.0 x 10^9 /L 12/2/2019 Result Normal Value
Neutrophil 50.4 37-72 BUN 8.68 H 2.5-6.5 mmol/L
Lymphocytes 39 20-50 CREA 113.1 70-115 mmol/L
Monocytes 15.4 0-14 ALT 499.9 H 0-45 u/L
Eosinophils 1 0-0.6 AST 1040.4 H 0-40 u/L
Basophils 0 0-1 Na 131.4 L 136-142 mmol/L
Hemoglobin 192 H 140-160 g/L K 5.14 H 3.8-5 mmol/L
Hematocrit 0.548 H 0.40-0.54 Cl 96.7 95-103 mmol/L
RBC 6.7 4.5-5.5 x10 ^12 /L Ionized Ca 1.06 L 1.12-1.32 mmol/L
MCV 82.3 80-94 fL
MCH 28.4 27.5-33.2 pg
MCHC 35 32-36 g/dL
Platelet 30 L 150-440 x 10^9/L

30
At the er
• BP:100/80mmHg, cold extremities, improved
12/2/2019 pulses, CRT >3 secs
(7:30 PM)

• IVF: PNSS, fast drip another 600cc, then reassess.

• Labs: PT and PTT
12/2/2019 Result Normal Value
Protime 13.8 H 9.6-12 secs
% Activity 80 70-150 secs
INR 1.2 <1.5 secs

PTT
aPTT 46.6 H 24.3-32.7 secs

32
At the er

12/2/2019
•BP: 100/70 mmHg
(7:47 PM)

•IVF: PNSS, 410 cc per hour, then

reassess.
Course in the ward
• Patient is awake, afebrile, good pulses, CRT<2
12/2/2019 secs, urine output of 800cc, (+) melena.
(7:47 PM)

• For blood transfusion.

• Revise IVF to 174cc/hr.
• Start Dobutamine 7cc + D5W 93cc = 100cc to run at
5cc/hr.
• Give Vitamin K 5mg + 4ml sterile water SIVP over 30
minutes.
Course in the ward
• Patient is awake, afebrile, good pulses, CRT<2 secs, urine
12/2/2019 output of 800cc, (+) melena.
(7:47 PM)

• For blood transfusion.

• Revise IVF to 174cc/hr.
• Start Dobutamine 7cc + D5W 93cc = 100cc to run at
5cc/hr.
• Give Vitamin K 5mg + 4ml sterile water SIVP over 30
minutes.
 Course in the ward
12/2/2019 Result Normal Value
BUN 8.68 H 2.5-6.5 mmol/L
CREA 113.1 70-115 mmol/L 12/3/2019 (12:00 AM)
ALT 499.9 H 0-45 u/L • Start N-Acetylcysteine 600mg
AST 1040.4 H 0-40 u/L
tablet, 1 tablet every 6 hours
Na 131.4 L 136-142 mmol/L • Repeat Serum electrolytes
every 12 hours
K 5.14 H 3.8-5 mmol/L
• Repeat ALT, AST OD
Cl 96.7 95-103 mmol/L
Ionized Ca 1.06 L 1.12-1.32 mmol/L
Course in the ward
• Day 5 of Illness, Day 0-1 Afebrile
12/3/2019
• No headache, still with melena, good pulses, CRT
(08:00 AM) <2secs, BP: 100/60 mmHg.

• Diet for age.

• IVF: PNSS 1L to run for 174 cc/hr (3)
• Repeat CBC with PC, Serum Electrolytes, ALT, AST
• WOF: Signs of bleeding and hypotension
 12/3/2019 Result Normal Value
WBC 6.4 5.00- 10.0 x 10^9 /L
Neutrophil 62.3 37-72
Lymphocytes 29.8 20-50
12/3/2019 Result Normal Value
Monocytes 6.2 0-14
ALT 240.5 H 0-45 u/L
Eosinophils 0.6 0-0.6
AST 529.2 H 0-40 u/L
Basophils 1.1 H 0-1
Na 135 L 136-142 mmol/L
Hemoglobin 175 H 140-160 g/L
K 4.24 3.8-5 mmol/L
Hematocrit 0.503 0.40-0.54
Cl 106.7 H 95-103 mmol/L
RBC 6H 4.5-5.5 x10 ^12 /L
MCV 84.1 80-94 fL
MCH 29.1 27.5-33.2 pg
MCHC 35 32-36 g/dL
Platelet 16 L 150-440 x 10^9/L

38
Course in the ward
• Day 6 of Illness, Day 1 Afebrile
• No signs of bleeding, good pulses, CRT <2 secs, BP 100/70
12/4/2019
(10:50 AM) mmHg

• Diet for age.

• IVF: PNSS 1L to run for 125 cc/hr (M)
• Repeat CBC with PC, Serum Electrolytes, ALT, AST
• WOF: Signs of bleeding and hypotension
 12/4/2019 Result Normal Value
WBC 11.2 H 5.00- 10.0 x 10^9
/L 12/4/2019 Result Normal Value
Neutrophil 55.1 37-72 ALT 240.8 H 0-45 u/L

Lymphocytes 38.1 20-50 AST 282.7 H 0-40 u/L

Na 133.4 L 136-142 mmol/L
Monocytes 5.7 0-14
K 4.11 3.8-5 mmol/L
Eosinophils 0.4 0-0.6
Cl 105.8 H 95-103 mmol/L
Basophils 0.7 0-1
Hemoglobin 160 140-160 g/L
Hematocrit 0.465 0.40-0.54
RBC 5.6 H 4.5-5.5 x10 ^12 /L
MCV 82.7 80-94 fL
MCH 28.5 27.5-33.2 pg
MCHC 34 32-36 g/dL
Platelet 15 L 150-440 x 10^9/L
40
Course in the ward
• Day 7 of Illness, Day 2 Afebrile
• No signs of bleeding, good pulses, CRT <2 secs, BP 100/70
12/5/2019
(08:00 AM) mmHg

• Diet for age.

• IVF: PNSS 1L to run for 125 cc/hr (M)
• Repeat CBC with PC, Serum Electrolytes, ALT, AST
• WOF: Signs of bleeding and hypotension
 12/5/2019 Result Normal Value
WBC 8.8 5.00- 10.0 x 10^9
/L 12/5/2019 Result Normal Value
Neutrophil 39.7 37-72 ALT 188.2 H 0-45 u/L
Lymphocytes 44.3 20-50 AST 188.2 H 0-40 u/L
Monocytes 13.2 0-14 Na 139.9 136-142 mmol/L
Eosinophils 2.3 H 0-0.6 K 4.07 3.8-5 mmol/L
Basophils 0.5 0-1 Cl 108.9 H 95-103 mmol/L
Hemoglobin 149 140-160 g/L
Hematocrit 0.422 0.40-0.54
RBC 5.1 4.5-5.5 x10 ^12 /L
MCV 83.2 80-94 fL
MCH 29.4 27.5-33.2 pg
MCHC 35 32-36 g/dL
Platelet 31 L 150-440 x 10^9/L

42
Course in the ward
• Day 8 of Illness, Day 3 Afebrile
• Patient complains of headache, no signs of bleeding, good
12/6/2019
(09:30 AM) pulses, CRT <2 secs, BP 140/90 mmHg

• Diet for age.

• Discontinue inotropes.
• Discontinue IV fluids.
• Increase oresol intake to 2-3 L/day
• Repeat CBC with PC.
Course in the ward

• No headache, no signs of bleeding, comfortable, afebrile,

12/6/2019 good pulses, CRT <2 secs, BP 120/80 mmHg
(7:55 PM)
 12/6/2019 Result Normal Value
WBC 7.8 5.00- 10.0 x 10^9 /L

Neutrophil 34.3 L 37-72

Lymphocytes 43.8 20-50
Monocytes 16.9 H 0-14
Eosinophils 4.5 H 0-0.6
Basophils 0.5 0-1
Hemoglobin 138 140-160 g/L
Hematocrit 0.389 L 0.40-0.54
RBC 4.7 4.5-5.5 x10 ^12 /L

MCV 83.7 80-94 fL

MCH 29.7 27.5-33.2 pg
MCHC 36 32-36 g/dL
Platelet 121 L 150-440 x 10^9/L
45
Course in the ward
• Day 9 of Illness, Day 4 Afebrile
• Patient has good appetite. No headache, no signs of
12/7/2019 bleeding, comfortable, afebrile, good pulses, CRT <2
(9 AM) secs, BP 120/80 mmHg

• Patient may now go home.

• Patient was advised to avoid strenuous activities for
4 weeks.
• Follow-up at Pedia OPD after 1 week.
 Temperature
38

37.5

37

36.5
Temperature

36

35.5

35
Day 4 Day 5 Day 6 Day 7 Day 8 Day 9
 WBC
12

10

6
WBC

0
Day 4 Day 5 Day 6 Day 7 Day 8 Day 9
 Platelet Count
140

120

100
Axis Title

80
Platelet Count
60

40

20

0
Day 4 Day 5 Day 6 Day 7 Day 8 Day 9
 Hematocrit
0.6

0.5

0.4

0.3
Hematocrit

0.2

0.1

0
Day 4 Day 5 Day 6 Day 7 Day 8 Day 9
Diagnosis of Dengue
SEVERE DENGUE WITH SHOCK
DO’S IN THE MANAGEMENT OF DENGUE
DON’TS IN THE MANAGEMENT OF DENGUE
DISCHARGE CRITERIA FOR DENGUE