DENGUE HEMORRAGHIC FEVER

WITH WARNING SIGN

Supervised by : dr. Dewi Shandi Laila, M. Ked. Ped, Sp.A

Deya Seisora Ismet

Dilla Ayuni
Rike Despriyani

Clinical Clerkship of Pediatric Department

Medicine Faculty of Riau University
RSUD ARIFIN ACHMAD RIAU PROVINCE
2019
BACKGROUND

Aedes (Stegomyia)
Caused by DENGUE VIRUS aegypti/
DEN-1,DEN-2,DEN-3,
(genus Flavivirus, family
DEN-4 Aedes (Stegomyia)
Flaviviridae)
albopictus

•Karyanti MR. Diagnosis dan tatalaksana terkini dengue.Jakarta: Departemen Ilmu Kesehatan Anak, RSUP Cipto Mangun Kusumo FKUI.Divisi
Infeksi dan Pediatri tropik.2014; 1.
•Djunaedi D. Demam berdarah dengue (DBD). Malang: Universitas Muhammadiyah; 2006.
BACKGROUND

59.047 with
50-100 milion cases of DF 444 death
(which is 250-500 thousands 126.675 with Riau : 1.928
was DFH) with 24.000/years 1.229 death with 15
mortality. death
156.052 case
with 1.396
death

•WHO, Dengue: Guideline for Diagnosis, Treatment, Prevention and Control. New Edition. Geneva: World Health Asosiation; 2009.
•Kementrian Kesehatan Republik Indonesia. Pusat data dan informasi Kementrian kesehatan Republik Indonesia. Situasi DBD di Indonesia. Jakarta;2016.
•Departemen Kesehatan RI. Data kasus DBD per bulan di Indonesia tahun 2010, 2009 dan 2008. Jakarta.
•Kementrian Kesehatan Republik Indonesia. Profil Data Kesehatan Indonesia Tahun 2017. Jakarta; 2018.
PATHOGENESIS

Secondary heterologous dengue infection

Viral replication Anamnestic antibody respons

Virus-antibody Complex

Platelet aggregation Activated of Complement

Destruction of platelet coagulation activation
in RES Release of platelet Activation of
factor III Hageman factor Anaphylatoxin
Trombositopenia
Consumptive coagulation Kinin system
(DIC)
Increased
Decreased clotting Kinin Capillary
factors permeability
FDP increased
Platelet function
disturbance Massive bleeding Shock
SHOCK
THE COURSE OF DENGUE ILLNESS
DENGUE CRITERIA
Case Report
Appearance
PRIMARY SURVEY
Tone : Active
Interactability : Responds
Airway clear
Consolability : relaxed
Look : good eye contact
Speech : clear Breathing Spontaneous, RR : 20x/i
Expertise : normal
Circulating Pulse : 100x/i,
Work of Breathing
Abnormal sound (-) Disability composmentis, Temperature : 36,5 ’C.
Retraction (-) nasal flare (-)
Expertise : normal Epistaxis
Exposure

Circulatiaon :
Cyanotic (-) pallor (-) motlet
skin (-)
Case Report
Patient Identity

Name/MR Number : An. VKH / 01006888

Age : 9 years 2 months

Father / Mother : D / SH

Sex : Female

Address : Pemuda street gg. Masjid

Date of admission : January 27th 2019

Date of examination : January 29th 2019

Anamnesis
 Chief Complaint :

 Epistaxis since 12 hours before admission

12 hours before admission

4 days before admission
- Sudden fever with high temperature
continiously.
- Reffering with antipyretic but increased then.
- Headache, retroorbital pain, arthralgia, fatigue,
decreased appetite
- He was brought out to the clinic and was given
an antipyretic.
- Nausea and vomiting
- Fever with no recovery and has been occurred for 4
days
- Epistaxis came out a bit (fresh red)-
- Epigastric pain
- Worsening fatigue neither appetite
- Pooping normal limit (no black color, no pain, 1 times
a day)
- Urinate normal limit (no pain, last pee 2 hours before
admission)
- Rumple leed test (+) in hospitalized
Anamnesis
•Past medical history :
• Patient never complained about the
same complains
• No epistaxis history
• No hematology abnormality
• No trauma history
• Family’s medical history
• Family’s member never complained
about the same complains.
•Parent’s history :
• Father : enterpreneur
• Mother : housewife
•Pregnancy history :
• Aterm, spontaneously, midwife.
• Meal history
• Breast milk : 0-1 year
• Companion breast milk: 6 month – 1 year
• Solid food : 1 year - now
• Immunization history
• Incomplete immunization (Hep B and Morbili
vaccine)
• History of growth and development
• Birth weight : 3000 gram, Birth length : 52 cm
• Weight now : 26 kg, Length now : 127 cm
• Crawling : 7 months
• Standing : 11 months
• Walking : 12 months
• Speaking : 12 months
Physical examination
General appearance : Moderate Illness
Awareness : Composmentis

Vital signs:
- Blood pressure : 110/80 mmHg
- Pulse : 100 x/min
- Respiratory rate : 20x/min
-Temperature : 36,5ºC
- Nutrition : - Height : 127 cm
- Weight : 26 kg
- Head Circumference: 52 cm
- Arm Circumference: 18 cm
IBW : 27 kg
Nutritional status : (ABW / IBW) x 100%
(27 / 27) x 100% = 100% (normal)
Physical Examination

Normocephal, ear and nose Pale conjunctiva (-), yellow

within normal limit. sclera (-),
Mouth: normal Light reflex (+/+), isochoric
pupil  2 mm,

Inspection: symmetrical chest wall

movement left and right, retraction
(-)
Palpation: symmetrical vocal
fremitus left and right lung
Percussion: resonant in both lungs
Neck stiffness (-) Auscultation: Vesicular (+ / +),
Neck and axilla lymph ronkhi (-/-), wheezing (-/-)
nodes enlargement (-)

Inspection : Ictus cordis was invisible

Palpation : palpable in the left midclavicle line, ICS V
Percussion : no cardiomegaly
Auscultation: S1 S2 regular (+), murmur (-), gallop (-)
Physical Examination

Warm, CRT <2 seconds, Inspection : Flat, scar (-), venectation (-)
oedema(- /-), Auscultation : bowel sound (+) 8 times a minute
cyanosis (- / -) Palpation : supel, hepatomegaly 1 cm below
Petechie (+) costal arc, 7cm below proc. xypoideuus,
blunt edges, firm consistency, tenderness
(+), splenomegaly (-)
Percussion: Timpani (+), shifting
Male, normal forms, dullness (-)
congenital anomalies (-)

Warm, CRT <2 seconds,

oedema(- /-),
cyanosis (- / -)
Laboratorium finding

Imunoserologi 26 Januari 2019 RS Ibnu Sina Imunologi 26 Januari 2019 RSUD AA

Salmonela typosa O 1/80 IgG Dengue Reaktif

Salmonela typosa H 1/80 IgM Dengue Reaktif

27 Januari 2019
Hemoglobin : 14,7 g/dl Basofil : 0.4 % MCV : 78.6 fL
Leukocyte : 4.67 10’3/µL Eosinofil : 0.0 % MCH : 27.1 pg
Trombocyte : 18 10’3/µL Neutrofil : 31.3 % MCHC : 34.4 g/dl
Hematocryte : 42,7 % Limfosit : 55.0 %
Eritrocyte : 5,43 10’6/µL Monosit : 13.5 %
 Conclusions from the ilness history
• Continuously fever since 4 days before
admission
• Headache, retroorbital pain, arthralgia,
mialgia
•Epistaxis
• Abdominal pain
•Decreased appetite
• Fatigue

Conclusions of the physical examination and lab test:

• Epigastric pain
• Hepatomegaly (1 cm below costal arc, 7cm below proc.
xypoideuus, blunt edges, firm consistency.)
• Rumple leed (+)

Blood routines:
•Trombocitopenia
•Leucopenia
•Limfositosis
•Monositosis
•IgG and IgM dengue reactive
Working Diagnosis
Dengue Hemorrhagic Fever with warning sign

Nutrition Diagnosis: Good Nutrition

Plan of Examination
Blood routines / 24 hours (conditional)

Vital signs observation

Rontgen thorax
Therapy
Medicamentosa :
- In Emergency:
IVFD Ringer Laktat 250cc/3hours (30 dpm makrodrip)
Omeprazole injection 1 x 15 mg
- Hospitalization:
IVFD Ringer Laktat 3cc/kgBW/hour (26 dpm makrodrip)
Paracetamol tablet 4 x 375 mg
Injeksi omeprazole 1 x 25 mg

Nutrition
= RDA x IBW
= 50 x 26 kg
= 1.300 Kkal
Carbohydrate = 910 KKal (227,5 gr)
Protein = 260 KKal (65 gr)
Lipid = 130 KKal (15 gr)

Quo ad vitam : Bonam

Prognosis Quo ad fungsionam : Bonam
Follow Up 27 Januari 2019
headache (+), retroorbital pain (+), arthralgia (+), abdominal pain (+), epistaxis (-), nausea (-), vomite (-)
S
GA : Moderate illness Lab :
Awareness : Composmentis Input: 2.504,25 cc • Hb : 14,7 g/dl
T: 36,5 ‘C Output: ±1.446 cc • Ht : 42,7 %
RR : 22 x/i Balance: + 1.058,25 cc • Leukosit : 4.67 10’3/μL
HR : 96 x/i
Dieresis: 1,2 cc/jam • Trombosit : 18 10’3/μL
BP : 100/90 mmHg
O Epitaxis (-)

Ekstremitas
Petechiae (+) eksremitas superior
CRT < 2 Second
Warm

A Dengue Hemorraghic Fever with Warning Sign

• Vital signs observation
• Input and output observation
• Blood routines and albumin
P •
•
IVFD Ringer Laktat 3cc/kgBB/jam (26 dpm macrodrip)
Paracetamol tablet 4 x 375 mg
• Injeksi omeprazole 1 x 25 mg
Follow Up 28 Januari 2019
Arthralgia (+), Fever (+) headache (+), epistaxis (-), nausea (-), vomite (-)
S
GA : Moderate illness Lab :
Awareness : Composmentis Input:2.604,25 cc • Hb : 12,2 g/dl
T: 37,5 ‘C Output:± 1.786 cc • Ht : 36,2 %
RR : 28 x/i Balance: + 818,25 cc • Leukosit : 5,61 10’3/μL
HR : 88 x/i
BP : 100/80 mmHg
Dieresis: 1,6 cc/jam • Trombosit : 20 10’3/μL
O Epitaxis (-) • Albumin : 3.5 g/dL

Ekstremitas
Petechiae (+) eksremitas superior
CRT < 2 Second
Warm

A Dengue Hemorraghic Fever with Warning Sign

• Vital signs observation
• Input and output observation
• Blood routines
P • IVFD Ringer Laktat 3cc/kgBB/jam (26 dpm macrodrip)
• Paracetamol tablet 4 x 375 mg
• Injeksi omeprazole 1 x 25 mg
Follow Up 29 Januari 2019
Fever (-), headache (-), retroorbital pain (-), arthralgia (-), abdominal pain (-), epistaxis (-), nausea (-), vomite (-)
S
GA : Moderate illness Lab :
Awareness : Composmentis Input:2.754,25 cc • Hb : 13,1 g/dl
T: 37 ‘C Output: ±1.786 cc • Ht : 38.5 %
RR : 24 x/i Balance: + 968,25 cc • Leukosit : 5.70 10’3/μL
HR : 80 x/i
BP : 100/90 mmHg
Dieresis: 1,6 cc/jam • Trombosit : 54 10’3/μL
O Epitaxis (-)

Ekstremitas
Petechiae (-)
CRT < 2 Second
Warm

A Dengue Hemorraghic Fever with Warning Sign

• Vital signs observation
• Home caring
P
 DISCUSSION
Acute onset of Pain Nausea and Positive rumple
fever of 2 to 7 vomitus leed
days duration • Headache,
• retroorbital pain • Vomiting for a • Positive rumple
• Sudden fever • arthralgia while after leed
since 4 days eating
• Mialgia
before • Epigastric pain
admission

Hemorrhagic Liver enlargement Platelet count ≤100 Evidence of plasma

manifestations 000 cells/mm3 leakage

• Epistaxis came • Hepatomegaly 1 • Platelet • Decrease >20%

out a bit cm below costal : 18.000 /ul Hematocryte
• Petechie arc, 7cm below post rehidration
proc.
xypoideuus

•Karyanti MR. Diagnosis dan tatalaksana terkini dengue.Jakarta: Departemen Ilmu Kesehatan Anak, RSUP Cipto Mangun Kusumo FKUI.Divisi Infeksi dan Pediatri
tropik.2014; h. 1-13.
•WHO, Dengue: Guideline for Diagnosis, Treatment, Prevention and Control. New Edition. Geneva: World Health Asosiation; 2009. h. 3-55.
•World Health Organization. Comprehensive guidelines for prevention and control of dengue and dengue haemorrhagic fever. Revised and expanded edition.
India: World Health Organization. 2011. h. 1-56.
•Soedarmo SSP, Garna H, Hadinegoro SR, Satari HI editors. Buku ajar infeksi pediatri dan tropis. Ed 1st. Jakarta: Badan penerbit IDAI; 2008. h.143-67
•Chen K, Pohan HT, Sinto R. Diagnosis dan terapi cairan pada demam berdarah dengue. Medicinus. 2009;22 (1), 3-7
•Center for Disease Control and Preventation. Dengue clinical case management e-learning: tourniquet test [cited 2019 Jan 30].
Available from: https://www.cdc.gov/dengue/training/cme/ccm/page73112.html.
•Soedarmo SSP, Garna H, Hadinegoro SR, Satari HI editors. Buku ajar infeksi pediatri dan tropis. Ed 2nd. Jakarta: Badan penerbit
IDAI; 2010. h. 155-81.
DISCUSSION

Temperatur
Hemoglobin
Hematokrit
Trombosit
Leukosit

Hari 1 Hari 2 Hari 3 Hari 4 Hari 5 Hari 6 Hari 7

Temperatur 36.5 37.5 37
Hemoglobin 16 14.7 12.2 13.1
Hematokrit 48.4 42.7 36.2 38.5
Trombosit 15 18 20 54
Leukosit 5.08 4.67 5.62 5.7
 DISCUSSION
Transform lymphocytes and
monocytosis Reactive IgM or and
IgG anti dengue

• Lymphocytosis and
• Reactive IgG and
monocytosis IgM anti dengue

ALL THE SIGNS ABOVE

DHF WITH WARNING SIGN

•World Health Organization. Comprehensive guidelines for prevention and control of dengue and dengue haemorrhagic fever. Revised and expanded edition. India: World Health Organization. 2011. h. 1-56.
•Prihadi DN, Yuniarti T, Manggus A. Monositosis dan Limfositosis Merupakan Faktor Risiko Demam Berdarah Dengue pada Anak. MKB. 2009; 41(4):201-6.
•Hadinegoro AR, Kadim M, Davaera Y, Idris NS, Ambasari CG, editors. Update Management of Disease and Gastrointestinal Disorder. Jakarta: Departemen Ilmu Kesehatan Anak FKUI-RSCM;
2012. h. 16-39.
DISCUSSION
Albumin was checked in
the second day of
treatment

Not recommended

Suggestion : The test

should be checked at the
first day of treatment to
prove of plasma leakage
manifestation.

•World Health Organization. Comprehensive guidelines for prevention and control of dengue and dengue haemorrhagic fever. Revised and expanded edition. India: World Health
Organization. 2011. h. 1-56.
 DISCUSSION

Treatment

250 cc in 3 hours Paracetamol tablet Injeksi omeprazole

4 x 375 mg 1 x 25 mg
• IVFD Ringer
Laktat
3cc/kgBW/hour
(26 dpm
makrodrip)

•Ghazala Z, Anuratha HV, Shifamurthy MC. Pattern of management and outcome of dengue fever in pediatric in-patients in tertiary care hospital:A prospective observation study.
IJBCP. 2014; 3(3): 536.
•World Health Organization. Comprehensive guidelines for prevention and control of dengue and dengue haemorrhagic fever. Revised and expanded edition. India: World Health
Organization. 2011. h. 1-56.
THANK YOU