HISTORY TAKING FOR FEVER

NS, 20 year old, presented with fever for 4 days associated with vomiting and diarrhoea
for 2 days.

FEVER

S
O Dengue
• Sudden onset of high grade fever

Febrile Phase Anorexia, nausea, vomiting, facial

flushing, body ache, myalgia,
arthralgia & headache.
Mild hemorrhagic manifestation:
positive tourniquet test & petechiae,
PV bleed usually in young adult, GIT
bleed.
Others include: Sore throat,
conjunctival injection.sz

Look out for dengue encephalopathy

Critical Phase After 3rd day- Plasma Leakage
T drops to less than 38 degree
SHOCK Clinical deterioration occur
BLEEDING Last for 24-48H
ORGAN IMPAIRMENT Plasma leakage leads to
hemoconcentration and hypovolemia

Sequelae: may recover or may lead to

compensated/decompensated shock
Look out for warning signs
Organ dysfunctions: Hepatitis,
Myocarditis, Encephalitis.
Recovery Phase Plasma leakage stops followed by
reabsorption of extravascular fluid
Hemodilution occur
IV therapy should be stopped to avoid
hypervolemia & pulmonary edema

General wellbeing improves: appetite

returns, GIT symptoms abate, diuresis
ensues, hemodynamically stable
Skin: Classical ‘island of white in the
sea of red’, generalized pruritus

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 Leptospirosis
• Biphasic clinical course:

Acute/Septicemia Phase 1 week

Immune Phase Antibodies produced and leptospires
excreted in urine (6days -1 month)

Malaria
• High fever (40-41 degree) & followed by prolonged asymptomatic period

Cold Stage Dramatic rigors- patient shakes

visibly
Hot Stage T>40 degree, restless, vomit &
convulse
Sweating Stage Fever abates & patient fall asleep

C Dengue
• Rapid drop of temperature usually on the 3rd day of illness

Leptospirosis
• fever for 1 week, drop in temperature for 1 week, and temperature may
rise up again.

Malaria
• Cyclical: Tertian (P. Vivax, P. Ovale & P Falciparum) & Quartan (P.
Malariae)
• Tertian: Fever spikes every 48 hours
• Quartan: Fever spikes every 72 hours
• P. Falciparum usually irregular intervals

R
A Dengue:
• Live/travel to dengue prone area
• When is the last fogging?
• Fever & 2 of the following:
- Nausea, vomiting
- Rash
- Muscle aches, joint pain
- Retro-orbital pain
- Any warning sign-

WARNING SIGNS
• Abdominal pain
• Persistent vomiting/diarrhea >3x/day
• Restlessness, Lethargy
• Altered conscious level
• Clinical fluid accumulation
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 • Mucosal bleed
• Tender liver

Severe Dengue:
• Severe plasma leakage leads to Dengue Shock Syndrome, fluid
accumulation causing respiratory distress
• Severe bleeding
• Severe organ involvement: impaired consciousness

Leptospirosis:
• Any water recreational activities
• Exposure to rodents at home
• Occupation: agricultural sectors, sewerage workers, livestock handlers,
pet shops workers, military personnel, disaster relief workers
• Headache, myalgia particularly over calf & lumbar region, arthralgia,
conjunctival suffusion, anuria/oliguria, jaundice, hemorrhages from
intestines and lungs, rash, GI symptoms such as nausea, vomiting,
abdominal pain, diarrhea

Malaria:
• Jungle Trekking
• Travel history

Severe Malaria:
• Altered consciousness, not tolerating orally, convulsion, deep breathing,
respiratory distress, jaundice, spontaneous bleeding
T Dengue
• 2-7 days
•
Leptospirosis
• fever usually 1 week

Malaria
• High fever for 6-10 hours

E Reliever: PCM, tepid sponging

S

F Changed in activity, too weak to move, absent from work

P Worsened?
Dietary Any change in oral intake to look for dehydration
Intake
Urine Output Any change to look for dehydration

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TRO DDX

Food poisoning • Vomiting

• Diarrhoea
• Abdominal pain
• History of taking outside food
• Anyone else experiencing the same thing
Acute gastroenteritis • Fever
• Vomiting
• Diarrhoea
• Epigastric pain
Acute appendicitis • Fever
• Vomiting
• Diarrhoea
• RIF pain

PHYSICAL EXAMINATION

General Examination

Shock:

Normal Compensated Shock Decompensated Shock

Conscious Conscious Change of mental status
CRT <2s CRT>2s Mottled skin, CRT
Warm & pink Cool extremities prolonged
Peripheral pulses: good Peripheral pulses: weak & Cold, clammy extremities
volume thread Peripheral pulses:
Vital signs: normal Vital signs: feeble/absent
Urine Output: normal PR- tachycardia Vital signs:
BP- normal, narrowing pulse PR- severe tachycardia
pressure BP- hypo, narrowed pulse
RR- Tachypnea pressure <20mmHg
Urine Output: reduced Oliguria/anuria
Intense thirst

Look for signs of respiratory distress: usage of accessory muscles (SCM, scalene), abdominal
muscles, recessions, nasal flaring
Look for signs of anemia: palmar crease pallor, subconjunctival pallor
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Skin: any rash, petechiae
Eyes: jaundice, conjunctival injection, subconjunctival pallor
Mouth: hydrational status- cracked lips, mucous membrane, coated tongue, gum bleed,
central cyanosis
Throat: injected

Abdominal System: Abdominal pain, liver tenderness and enlargement >2cm, ascites
Respiratory System: Look for signs of pleural effusion/pulmonary edema

PROVISIONAL DIAGNOSIS
Dengue fever day ____ of illness in febrile/critical/recovery phase with/without warning
signs (hemoconcentration) and in/not in decompensated/compensated shock

INVESTIGATIONS

Disease Monitoring Test

FBC Dengue
Febrile phase: Normal
Critical phase: Leucopenia,
thrombocytopenia, HCT increase (marker of
plasma leakage)

HCT:
Male <60 y/o – 46%
Male >60 y/o – 42%
Female all age – 40%

Malaria
Normal with lymphopenia
Severe: Neutrophilia
Hb drops: Normocytic Hypochromic
anemia, <8 g/dL
Thrombocytopenia
LFT Liver involvement: raised in transaminases

Leptospirosis
Raised serum bilirubin

Malaria
serum bilirubin raised with mild elevation
of liver enzyme, low albumin
RP Urea and creatinine – AKI
Any electrolyte imbalances: Hyponatremia,
hypocalcemia in malaria
Coagulation Profile Coagulopathy
ABG Respiratory failure in Leptospirosis

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 Metabolic Acidosis: plasma bicarbonate of
<18 mmol/L in Malaria
LDH Elevated in Malaria
DXT <3 mmol/L in Malaria
CRP Elevated in Malaria
CXR For suspected vascular leakage
GXM/GSH Requiring transfusion

Diagnostic Test

Dengue Rapid Combo Test

- Detect presence of virus and ab
simultaneously
- Read within 15-20 mins
- Useful during early phase & later
stage when the ab begin to rise
- Detect presence of NS1 antigen,
IgM and IgG

Dengue antigen serology test by ELISA

• NS1 antigen (3-5days)
• IgM >5 days
• IgG >7 days
Leptospirosis • Microscopic Agglutination Test
(MAT)
• PCR: within 10 days of onset
• Culture for leptospires: blood
sample within 7 days of onset &
urine sample after the 10th day of
illness
• Detection of leptospires in tissues
using immunohistochemical
staining.
Malaria Blood film: thin & thick smear

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 - GOLD STANDARD
- If initial negative then repeat
another 2 samples or more
especially at the peak of fever
PCR - blood film fails
Rapid diagnostic Test - for acute malaria

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MANAGEMENT

Dengue

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When to discharge Dengue patient

1. Afebrile for 24 hours without anti pyretics

2. Good appetite, improved clinically
3. Adequate urine output
4. Stable hematocrit level
5. At least 48 hours since recovery from shock
6. No respiratory distress
7. Platelet count greater than 50,000 cells/microL

Leptospirosis

PHARMACOLOGICAL Adult

Severe: IV Penicillin QID for 5-7 days

Less severe: T Doxycycline BD for 5-7 days
Other alternatives: Tetracycline, Ampicillin,
Amoxicillin

Monitor & supportive care

Paediatrics

Moderate to severe: IV Penicillin G QID for

7 days (used in caution in impaired renal
function)
Alternative: >8 y/o- T Doxycycline BD for
7 days (can cause permanent discolouration
of teeth)
<8 y/o- T Ampicillin QID for 7 days/ T
Amoxicillin TDS/QID for 7 days

PROPHYLAXIS Pre Exposure (High risk exposure to

potentially contaminated sources)

- T Doxycycline 200 mg STAT

then weekly throughout the stay
- T Azithromycin 500mg STAT
then weekly throughtout stay
(given in pregnant women and
those with doxycycline allergies)

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Malaria

Plasmodium Falciparum (uncomplicated) Riamet 6 doses for 3 days

Taken with fatty meal
1st dose followed by 2nd dose 8H later then 1
dose BD for the following two days
According to weight

Alternative: Artesunate
Plasmodium Falciparum (severe) IV Artesunate 2.4mg/kg at 0H, 12H, 24H &
daily until day 7
+ T Doxycycline 100mg BD

Criteria for Severe Malaria

1. Impaired consciousness/seizure
2. AKI
3. Shock
4. Hypoglycemia <2.2 mmol/L
5. Pulmonary oedema
6. Hb <8 g/dL
7. Spontaneous bleeding
8. Acidosis, ph <7.3
9. Hemoglobinuria
10. Parasitaemia >10%

General Management of Severe Malaria

1. Admit to ICU/HDU
2. IV Artesunate STAT -> administered for at least 24H before switching to oral
3. Close observations of vital signs, GCS
4. Look out for APO (cx in P Knowlesi & Falciparum)
- I/O monitoring
- IV fluids given according to weight
- No rapid boluses
- Dehydration be managed with cautious & monitor urine output -> >1ml/kg/hr
5. Dropping in GCS -> look for meningitis
6. Broad spectrum antibiotic if patient has secondary infection
7. High fever: tepid sponging & PCM

Prophylaxis

1-2 days before departure -> Doxycycline

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