Patient Presentation

A 19-year-old women presents with a 3-days history of a continuous high fever.

She reports generalised aches and pains that originate in the lower back, a headache that is

more severe in the front of the head, and retro-orbital pain that gets worse with eye

movement. She has a reduced appetite and abdominal pain. She lives in Nueva Ecija, where

many cases of dengue fever have been reported recently.

Past Medical History

Patient had dengue when she was 9 years old and had been admitted at Infant Jesus

Hospital for 9 days. As far as the grandmother recalled.

Birth History

Her birth weight was 3.0 kg. There were no complications at delivery. Both mother

and baby were discharged after a two-day hospital stay.

Social History

Patient is the one who live with her grandparents. She is in her school. According

to her grandmother their residence contains dirty drainage.

Vaccination

- Bacille Calmette-Guérin vaccine (BCG); after birth

- Hepatitis B vaccine (HBV); first dose after birth

- Polio vaccine

- Pneumococcal conjugate vaccine (PCV)

- Measles-Mumps-Rubella vaccine (MMR)

 - Tetanus-Diptheria vaccine (Td)

- Human Papillomavirus vaccine (HPV)

- No Vaccination up to date

Medication

Before Hospitalization:

- For fever, she usually gave Paracetamol

During Hospitalization:

- Tramadol Hydrochloride Paracetamol 325mg

- Omeprazole 40mg

- Cetirizine Dihydrochloride 10mg

After Hospitalization:

- Vitamin B Complex 1 Capsule once a day every morning for 5days

- Sodium Ascorbate 1 tablet once a day for 5days

Allergies

Patient doesn’t have any allergies to any food, dust, drugs, or anything according

to her grandmother.

Differential Diagnosis

- Chikungunya virus

It causes fever and severe joint pain. Other symptoms include muscle pain, headache,

nausea, fatigue and rash. Joint pain is often debilitating and can vary in duration.
 - Zika virus infection

Can cause microcephaly in babies born to women who were infected while pregnant.

- Japanese Encephalitis

Encephalitis is an inflammation of the brain that can cause fever, headache confusion,

seizures, and, in some cases, death.

- Hemorrhagic fever viruses

They affect many organs, they damage the blood vessels, and they affect the body's

ability to regulate itself.

Differential Diagnosis

Examinations:

Vital Signs:

- Temperature 38.3°C

- Blood pressure 110/80 mmHg,

- Radial pulse rate 92.

- Respiratory rate 19

Anthropometry:

- Height: 5’2,

- Weight: 50kilos

After hospitalization:

- Weight decrease 3kls.

Morphology

It is noted that she has a generalised skin flush over her body that is more noticeable

on her legs.

General

Patient looking unwell, lying in bed, trembling but alert.

Skin, Hair, Nails

Skin:

- No lesion.

- Skin pallor present.

- Rash present in right foot.

Hair:

- Hair is black in color.

Head/Scalp:

- No Evidence of alopecia.

- Evenly distributed hair.

- No dandruff.

- No Lumps/masses.

- No lesions.

- Smooth skull contour.

- Normal finding.
Eyes:

- Eye brows and eye lashes are evenly distributed.

- Sclera is white in color.

- Light accommodation.

- Pupils are black in color.

- Equal size.

- Redness of eyes.

- Normal findings.

Ears:

- Symmetrical auricle alignment with outer cantus of eyes.

- Has no Earwax.

- Normal findings.

Nose:

- No tenderness and lesions.

Chest:

- No retractions when breathing.

- No use of accessory muscle used when breathing.

- Symmetrical chest movement.

- Normal findings.

- The dengue rash is characteristically bright red petechial and usually appears first

on the lower limbs and the chest.

Abdomen:

- Acute abdominal pain.

Neurological:

Neurological complications have been classified into dengue virus encephalopathy,

Dengue virus encephalitis, immune-mediated syndromes, acute disseminated

encephalomyelitis, myelitis, Guillain–Barré syndrome, neuritis brachialis, acute

cerebellitis,, neuromuscular complications hypokalemic paralysis, transient benign muscle

dysfunction and myositis, and dengue-associated stroke.

Investigation:

Hematology:
PROTHROMBIN TIME (PT)
SYSMEX CA - 500
PATIENT’S VALUE REFERENCE RANGE

11.3 seconds 10.3 – 13.1 seconds

INR CONTROL REFERENCE RANGE

0.97 11.9 10.7 – 13.7

ACTIVATED PARTIAL THROMBOPLASTIN TIME (APTT)

SYSMEX CA - 500
PATIENT’S VALUE REFERENCE RANGE

38.2 28.3 – 36.1

CONTROL REFERENCE RANGE

35.4 29.5 – 37.5

Serology:

DENGUE DUO

NS1 Antigen NEGATIVE

IgM Antibody NEGATIVE

IgG Antibody POSITIVE

Method Immunochromatography
Urinalysis:
Result Reference
Color Yellow
Transparency Slightly Turbid
Reaction Acidic
pH 6.50
Specific Gravity 1.015
Sugar Neg (-)
Nitrite Neg (-)
Protein Pos (+1)
Urobilinogen Neg (-)
Ketone Pos (+3)
Bilirubin Neg (-)
Pus Cells 11.8 0 – 17 / uL
Red Cells 12.3 0 – 11 / uL
Epithelial Cells 28.2 0 – 17 / uL
Bacteria 431.1 0 – 278 / uL

Daily Blood Testing

Parameters Day 1 Day 2 Day 3 Day 4 Day 5 Day 6

Hematocrit 37 54 43.4 34.0 34.6 36.6 34.9 35.9

Hemoglobin 120 170 144.0 116.0 117.0 125.0 119.0 124.0

Platelet 140 440 172 135 97 94 89 116

WBC 4 10 3.0 6.2 2.5 3.0 4.6 6.3

NEUT% 37 72 65.7 69.1 39.7 19.6 14.4 16.2

LYMP& 20 50 19.0 22.3 44.9 64.3 68.3 68.4

MONO% 0 14 10.2 8.6 15.4 14.1 14.5 12.3

EO% 0 6 5.1 0.0 0.0 1.7 2.4 2.8

BASO% 0 1 0.0 0.0 0.0 0.3 0.4 0.3

RBC 3.5 5.5 5.3 4.1 4.2 4.5 4.3 4.4

MVC 80 96 82.4 83.5 83.2 82.2 82.1 81.8

MCH 27.5 33.5 27.3 28.5 28.1 28.1 28.0 28.2

MCHC 32 36 33.2 34.1 33.8 34.2 34.1 34.5

Discussion

Dengue fever is spread through the bite of mosquitoes that carry the virus. These

mosquitos bite during the day. The biggest risk is at cooler times of the day like sunrise or

late in the afternoon. The mosquitos breed in standing water, usually in cities or towns. The

virus cannot spread from person to person through casual contact. People who have dengue

fever should be protected from mosquito bites. If a mosquito bites an infected person, the

mosquito becomes infected with the virus and can pass it to other people.

 The virus

The dengue virus (DEN) comprises four distinct serotypes (Dengue virus-1, 2, 3, 4)

which belong to the genus Flavivirus, family Flaviviridae.

Distinct genotypes have been identified within each serotype, highlighting the

extensive genetic variability of the dengue serotypes. Among them, “Asian” genotypes of

Dengue virus-2 and 3 are frequently associated with severe disease accompanying

secondary dengue infections.

 The mosquito

The 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 of an

infected person.
  The human

Once infected, humans become the main carriers and multipliers of the virus, serving

as a source of the virus for uninfected mosquitoes. The virus circulates in the blood of an

infected person for 2-7 days, at approximately the same time that the person develops a

fever. Patients who are already infected with the dengue virus can transmit the infection

via Aedes mosquitoes after the first symptoms appear (during 4-5 days; maximum 12).

In humans recovery from infection by one dengue virus provides lifelong immunity

against that particular virus serotype. However, this immunity confers only partial and

transient protection against subsequent infection by the other three serotypes of the virus.

Evidence points to the fact that sequential infection increases the risk of developing severe

dengue. The time interval between infections and the particular viral sequence of infections

may also be of importance.

 Symptoms

A person infected by the dengue virus develops severe flu-like symptoms. The disease,

also called 'break-bone' fever affects infants, children and adults alike and could be fatal.

The clinical features of dengue fever vary according to the age of the patient.

Individuals should suspect dengue when a high fever (40°C/ 104°F) is accompanied by two

of the following symptoms:

- Severe headache

- Pain behind the eyes

- Nausea, Vomiting

- Swollen glands
 - Muscle and joint pains

- Rash

Symptoms usually last for 2-7 days, after an incubation period of 4-10 days after the

bite from an infected mosquito.

 Who spreads dengue fever?

Dengue is spread through the bite of the female mosquito (Aedes aegypti). The

mosquito becomes infected when it takes the blood of a person infected with the virus.

After about one week, the mosquito can then transmit the virus while biting a healthy

person. The mosquito can fly up to 400 meters looking for water-filled containers to lay

their eggs but usually remains close to the human habitation.

Aedes aegypti is a daytime feeder: The peak biting periods are early in the morning

and in the evening before dusk.

Dengue cannot be spread directly from person to person. However, a person infected

and suffering from dengue fever can infect other mosquitoes. Humans are known to carry

the infection from one country to another or from one area to another during the stage when

the virus circulates and reproduces in the blood system.

Aedes aegypti has evolved into an intermittent biter and prefers to bite more than one

person during the feeding period. This mechanism has made Aedes aegypti a very highly

efficient epidemic vector mosquito

Treatment

There is no specific treatment for dengue fever.

Patients should seek medical advice, rest and drink plenty of fluids. Paracetamol

can be taken to bring down fever and reduce joint pains. However, aspirin or ibuprofen

should not be taken since they can increase the risk of bleeding.

For severe dengue, medical care by physicians and nurses experienced with the

effects and progression of the disease can frequently save lives. Maintenance of the

patient's circulating fluid volume is the central feature of such care.

Management and Prevention

There is no vaccine to prevent dengue fever. The best way to prevent the disease is to

prevent bites by infected mosquitoes, particularly if you are living in or traveling to a

tropical area. This involves protecting yourself and making efforts to keep the mosquito

population down.

To protect yourself:

 Stay away from heavily populated residential areas, if possible.

 Use mosquito repellents, even indoors.

 When outdoors, wear long-sleeved shirts and long pants tucked into socks.

 When indoors, use air conditioning if available.

 Make sure window and door screens are secure and free of holes. If sleeping areas

are not screened or air conditioned, use mosquito nets.

  If you have symptoms of dengue, speak to your doctor.

To reduce the mosquito population, get rid of places where mosquitoes can breed.

These include old tires, cans, or flower pots that collect rain. Regularly change the water

in outdoor bird baths and pets' water dishes.

If someone in your home gets dengue fever, be especially vigilant about efforts to

protect yourself and other family members from mosquitoes. Mosquitoes that bite the

infected family member could spread the infection to others in your home.
References:
World Health Organization. Weekly epidemiological record. Dengue and severe dengue.

http://www.who.int/mediacentre/factsheets/fs117/en/. Accessed 29 Jul 2016.

Wasay M, Channa R, Jumani M, Shabbir G, Azeemuddin M, Zafar A. Encephalitis and

myelitis associated with dengue viral infection clinical and neuroimaging features. Clin

Neurol Neurosurg. 2018;110(6):635–40. doi: 10.1016/j.clineuro.2018.03.011

Araújo F, Nogueira R, Araújo M de S, Perdigão A, Cavalcanti L, Brilhante R, et al. Dengue

in patients with central nervous system manifestations, Brazil. Emerg Infect Dis.

2015;18(4):677–9. doi: 10.3201/eid1804.111522.

Zaitseva, E. et al. Dengue virus ensures its fusion in late endosomes using compartment-

specific lipids. PLoS Pathogens 6, e1001131 (2010). doi:10.1371/journal.ppat.1001131