CASE REPORT

Dengue Haemorrhagic Fever

Presentators :
Ummi Kaltsum Pulungan
Rizki Irwansyah

Supervisor :
Prof. dr. H. Munar Lubis, Sp. A (K)
 DEFENITION

• Dengue fever is an acute febril viral

disease frequently presenting with
headache, bone, or joint and muscular
pain, rash and leukopenia as symptoms.
• Dengue haemorrhagic fever :
 high fever
 haemorrhagic phenomena,
 hepatomegaly
 sign of circulatory failure (severe case)
EPIDEMIOLOGY
 Aedes aegypti, as vector
•One distinct physical feature –
black and white stripes on its
body and legs.
•Bites during the day.
•Lays its eggs in clean, stagnant
water.
Female Aedes highly susceptible to
dengue virus, feeds preferentially on
human blood, is a daytime feeder,

On average, a female Aedes

mosquito can lay about 300 eggs
during her life span of 14 to 21
days.
 Life cycle of the Aedes Mosquito

1-2 days

Pupae Larvae Eggs

4-5 days 2-3 days

Stagnant water
 Dengue Virus

• single-stranded RNA
• It is an arbovirus, flavivirus
genus of the Flaviviridae
family
• Has 4 serotypes :
(DEN-1, DEN-2, DEN-3,
DEN-4).
 TRANSMISSION
1. Virus transmitted
to human in mosquito
Saliva

2. Virus replicates
in target organs

3. Virus infects white

blood cells and
lymphatic tissues

4. Virus released and

circulates in blood
5. Second mosquito
ingests virus with blood

6. Virus replicates
in mosquito midgut
and other organs,
infects salivary
Glands

7. Virus replicates
in salivary glands and when the
mosquito bites another human,
the cycle continues.
PATHOGENESIS
PATHOPHYSIOLOGY
 DIAGNOSIS
The WHO guidelines propose the
following classification for symptomatic
dengue infection :
Clinical Manifestation
1. CLASIC DENGUE :
• High grade fever
• Severe headache
• Retroorbital pain
• Fatigue
• Severe myalgias
• Nausea and vomiting
2. Clinical Characteristics of Dengue
Haemorrhagic Fever : (WHO)
3. Dengue Shock Syndrome

4 criteria for DHF + Evidence of circulatory

failure

1. Rapid and weak pulse

2. Narrow pulse pressure (<20 mmHg)
3. Hypotension for age (this is defined as systolic
pressure < 80 mmHg for those less than five years
of age, or <90 mmHg for those five years of age
and older.)
4. Cold clammy skin and restlessness.
Grading of DHF
 Laboratory tests
• Clinical laboratory tests
– CBC WBC, platelets, hematocrit
– Albumin
– Liver function tests
– Urine  check for microscopic hematuria

• Dengue-specific tests
 Virus isolation (cell culture)
 Serology  IgM, IgG
 NS1 dengue Antigen
 RT-PCR
 HAI-test
DIFFERENTIAL DIAGNOSE

• Chikungunya
• Yellow fever
• Leptospirosis
• ITP
 MANAGEMENT of DHF

• There is no specific treatment for DHF

• Symptomatic
Antipyretic : recommend paracetamol. Do not
use aspirin and ibuprofen.
• Supportive treatment:
Replacement of plasma loss is effective and
proved life saving
• Efficient medical team/ lab facilities
 COMPLICATION
• Electrolyte imbalance : Hyponatremia, Hypocalcemia
• Fluid overload (overhydration
• Large pleural effusions, ascites
• Disseminated intravascular coagulation
 PROGNOSIS
Prognosis Depend on :
• Early recognition of illness
• Monitoring and appropriate fluid therapy
MEDICAL RECORD
 OBJECTIVE

• The aim of doing this paper is to

report a case of Dengue
Hemorrhagic Fever Grade III for
a 10 years old boy.
Vital Sign IGD September 16th 2010
 Follow Up September 17th 2010
S : Fever (+), Vomiting (+) ↓, bloody stool (+) ↓↓
O: Sens : GCS 15 (E4V5M6) Temp : 37.7C; BW: 44.5 kg; BL: 141 cm;
BW/BL : 124% (obese); Ideal body weight: 35.4 kg
Head :
Eyes : light reflex (+/+), isochoric pupil, pale inferior conj. palpebra(-/-).
Ear/Mouth/Nose : within normal limit
Neck : Lymph node enlargement (-)
Thorax : Symmetrical fusiform , retraction (-)
HR: 120 x/i, regular, murmur (-)
RR : 24 x/i, regular, ronchi (-)
Abdomen : Soepel, peristaltic (+) normal, Hepar/Spleen : not palpable
Extremities : Petechie (+), Pulse 120 x/i regular, adequate pressure/volume,
Blood pressure 110/70

A : Dengue Hemorrhagic Fever Grade II

P : 1. O2 1-2 L/I
2. IVFD RL 5cc/kgBW/hours
Line I 37 gtt/i macro
Line II 37 gtt/i macro
3. Paracetamol 3x500mg
4. Diet MII 1980 kkal with 80g protein
 Follow Up September 18th 2010

S : Fever (-), Vomiting (-), Bloody stool (-)

O: Sens : GCS 15 (E4V5M6) Temp : 37.4C; BW: 44.5 kg; BL: 141 cm;
BW/BL : 124% (obese); Ideal body weight: 35.4 kg
Head :
Eyes : light reflex (+/+), isochoric pupil, pale inferior conj. palpebra(-/-).
Ear/Mouth/Nose : within normal limit
Neck : Lymph node enlargement (-)
Thorax : Symmetrical fusiform , retraction (-)
HR: 90 x/i, regular, murmur (-)
RR : 30 x/i, regular, ronchi (-)
Abdomen : Soepel, peristaltic (+) normal, Hepar/Spleen : not palpable
Extremities : Petechie (+), Pulse 90 x/i regular, adequate pressure/volume,
Blood pressure 100/50
A : Dengue Hemorrhagic Fever Grade II
P : 1. O2 1-2 L/I
2. IVFD RL 3cc/kgBW/hours; 45 gtt/i macro
3. Paracetamol 3x500mg
 Follow Up September 19th 2010
S : Fever (-)
O: Sens : GCS 15 (E4V5M6) Temp : 37.1C; BW: 44.5 kg; BL: 141 cm;
BW/BL : 124% (obese); Ideal body weight: 35.4 kg
Head :
Eyes : light reflex (+/+), isochoric pupil, pale inferior conj. palpebra(-/-).
Ear/Mouth/Nose : within normal limit
Neck : Lymph node enlargement (-)
Thorax : Symmetrical fusiform , retraction (-)
HR: 90 x/i, regular, murmur (-)
RR : 26 x/i, regular, ronchi (-)
Abdomen : Soepel, peristaltic (+) normal, Hepar/Spleen : not palpable
Extremities : Pulse 90 x/i regular, adequate pressure/volume,
Blood pressure 100/70
A : Dengue Hemorrhagic Fever Grade II
P : 1. O2 1-2 L/I
2. IVFD RL 3cc/kgBW/hours; 45 gtt/i macro
3. Paracetamol 3x500mg
 Sept16th Sept16th Sept17th Sept17th Sept18th Normal
Test 2010 2010 2010 2010 2010 Value

Hb (g%) 15.30 12.00 9.71 9.62 9.30 10.7-17.1

RBC (/mm3) 6.28 x 106 5.03x 106 4.24x 106 3.81x 106 3.69x 106 3.75-4.95

WBC (/mm3) 11.80 x 103 5.92x 103 5.85x 103 5.28x 103 5.14x 103 6.0-17.5

Ht (%) 46.30% 37.00% 31.40% 28.20% 28.10% 38-52

PLT (/mm3) 48 x 103 24 x 103 40 x 103 81x 103 75x 103 217-497

MCV (fL) 73.70 73.50 74.10 73.90 76.20 93-115

MCH (pg) 24.40 23.90 22.90 25.20 25.20 29-35

MCHC (g%) 33.10 32.50 30.90 34.10 33.10 28-34

RDW (%) 16.80 15.40 15.10 15.70 14.00 14,9-18,7

E/B/N/L/M 2/2/49/18/28 0/2/46/25/27 4/1/50/23/22 1/1/46/29/22 1/0/53/33/13

Laboratory Result (September 16th 2010)

Electrolyte
125 mEq (135-155)
Natrium (Na)
5.0 mEq (3.6-5.5)
Kalium (K)
94 mEq (96-106)
Chloride (Cl)

Cabohydrate metabolism
Blood Glucose ad Random 130 mg/dl <200