Case
01
Dengue Hemorrhagic Fever
COMMON TROPICAL INFECTION — TROPICAL MEDICINE SYSTEM
FAKULTAS KEDOKTERAN UNIVERSITAS PADJADJARAN
2016 - 2017Block title Tropical Medicine
Week theme ‘Common Tropical Infection
case ttle + Dengue Hemorrhagic Fever (DHF)
case pages
General Learning Objective _: The purpose of this week is to discuss etiology, the signs and
symptoms, epidemiology, pathophysiology, diagnosis,
complication, management, prevention, and control of DHF
Case objective for the student:
By the end of the week the students will be able to explain the:
Characteristics of dengue virus
Epidemiology
Pathophysiology
Signs and symptoms
Diagnosis
Laboratory examination for diagnosis
Complication
Management
Prevention and control of DHF
PEN OTA wN >
(case synopsis:
Denny, a 10-year-old boy was presents to emergency department with high fever that last for 5|
days with abrupt onset. The symptom was accompanied by headache, myalgia, arthralgia, and|
hemorrhagic manifestations. Physical examination revealed high fever, hepatomegaly, petechiae,
land positive tourniquet test. Laboratory findings revealed thrombocytopenia. During)
hospitalization he experienced shock, pleural effusion, a drop in platelet count, and @ rise of]
lhematocrit level more than 20%. Prompt and appropriate volume replacement result in|
luneventful recovery. HI test showed a secondary infection of Dengue virus infection. The final
diagnosis is DHF secondary infection with Dengue Shock Syndrome as complication. The patient]
lwas fully recovered and discharged, The case was reported to district health authority.
Reference for the student:
1. WHO. Comprehensive guidelines for prevention and control of dengue and dengue
haemorrhagic fever. Revised and expanded edition. World Health Organization 2011
2. Halstead S.B. Dengue Fever and Dengue Hemorrhagic Fever. In : Behrman, R.E; Kliegman R.M.
and Jenson H.B (eds.). Nelson textbook of Pediatrics, 17 ed., Saunders, International ed.,
Philadelphia, Pennsylvania, 2004: 1092 - 1093
3. Woodward, T. F. The Fever Pattern as a Diagnostic Aid. In : Mackowiak, P.A (ed.), Fever : Basic
‘Mechanism and Management, 2" ed., Lippincott-Raven, Philadelphia-New York, 1997 : 215 ~
236
4, Jawetz, Melnick & Adelberg's Medical Microbiology, 27" Edition, Geo F Brooks, Karen C
Carroll, Janet $ Butel, Stephen A Morse, Timothy A Mietzner, A Lange Medical Book, Mc
Graw Hill, International Edition, 2016
Reference for the tutor:
1. WHO. Comprehensive guidelines for prevention and control of dengue and dengue
haemorrhagic fever. Revised and expanded edition. World Health Organization 2011
2. Halstead S.8, Dengue Fever and Dengue Hemorrhagic Fever. In : Behrman, R.E; Kliegman R.M.
and Jenson H.B (eds). Nelson textbook of Pediatrics, 17 ed., Saunders, International ed.,
Philadelphia, Pennsylvania, 2004: 1092 - 1093
‘Woodward, T. F. The Fever Pattern as a Diagnostic Aid. In : Mackowiak, P.A (ed.), Fever : Basic
Mechanism and Management, 2” ed., Lippincott-Raven, Philadelphia-New York, 1997 : 215 —
236
4, Jawetz, Melnick & Adelberg’s Medical Microbiology, 27" Edition, Geo F Brooks, Karen C
Carroll, Janet $ Butel, Stephen A Morse, Timothy A Mietzner, A Lange Medical Book, Mc
Graw Hil, International Edition, 2016
5. Gubler DJ, Kuno G, Dengue Hemorrhagic Fever. CAB International, New York, 1997Tutorial 1 Page 1
[You are a fourth year of medical student in ER department in RS Ujung Berung. Denny, a 10-year,
lold boy, presents to you with high fever last for 5 days with abrupt in onset, the body
itemperature range from 38.9 to 39.5°C, it’s occurs all day and night. On the 3" day the body
Itemperature decreased to 37.5-38°C. But on the next day elevated again as it was occurred cn]
the previous days.
Identify the patient's problem!
Generate a hypothesis for the problem!
What further information/investigations maybe helpful for the management of Denny
illness?
Identify the patient's problem
a. The students are supposed to discuss at least problems of:
b. Fever: high, last for 3 days, abrupt in onset, high, biphasic in pattern
Generate hypothesis for the problem
Guiding question: what is the cause of the problem?
Fever, 2 change in the normal regulation of body temperature set point, literally a
resetting of the thermostat, is one of the changes in homeostatic setting that occurs
during the acute phase response to inflammatory stimuli, To figure out the cause of
the illness, for many centuries, clinical diagnosis has been made or strongly
suggested by the history, the present helpful physical findings, and observation of
the patient. In respect of fever, helpful clues come from the type of onset (abrupt
or slow), the duration, the pattern of fever, and the febrile curve following
institution of specific treatment. Even not absolutely correct, a specific infection
tends to associate with the characteristic pattern of fever.
The type of febrile patterns traditionally grouped according to the definition listed
below.
1. Continuous (sustained) fever with slight remissions not exceeding 2.0°F/ 1°C in
remittance. Within this group fall fevers caused by lobar and gram-negative
types of pneumonia, rickettsial diseases, typhoid fever, central nervous system
disorders, tularemia, and falciparum (malignant tertian) malaria,
Intermittent (hectic, quotidian, “picket fence") fever with wide fluctuations,
usually normal or low in the morning with a peak at 4:00 to 8:00 pm. This
group includes fever caused by localized pyrogenic infections and bacterial
endocarditis; chills and leucocytosis are usually present. Malaria (commonly
with leucopenia) may present as quotidian (daily spike), tertian, (spike every
third day), or quartan (spike every fourth day) types. in acute brucellosis, fever
is often intermittent, with sweating associated with leukopenia or @ normal
leukocyte count, A double quotidian pattern with two dally spikes occurs
sufficiently often to be helpful in salmonellosis, miliary tuberculosis, double
‘malarial infections, and gonococcal and meningococcal endocarditis.
Tertian and quartan intermittent febrile pattern occur in malaria, these cyclic
patterns occur regularly and are consistent with the parasites’ repetitive cycles
of multiplication.
3. Remittent fever, the fluctuation of body temperature is also wide, more than
1°C, the difference between remittent and intermittent fever, is that in the
former, the lowest temperature never reach normal body temperature. The
fever usually low in the morning and higher in the late evening. This pattern
can be found in the first week of typhoid fever.
4, Saddleback (biphasic) fever, with several days of fever, a gap of reduced fever
fof about 1 day, and then several additional days of fever. This type
characterizes dengue and yellow fever, Colorado tick fever, Rift Valley fever,
and viral infections such as influenza, poliomyelitis, and lymphocytic
choriomeningitis.