CASE PRESENTATION - 4

Day 3 onset of fever, 0730amC/O: Fever-3 days Nausea and vomiting Myalgia. O/E Comfortable Pulse 98/min BP=

98/60mmHg T=37.5 Lungs -clear

26/M/F, university student, staying at GombakCame back to Kelantan on D2 of feverS/B MA at A&E, DH

Given IV fluid 1pint N/S fast. Repeat BP 102/60 Plan: FBC Allow discharged (before review of

FBC)

Q1: What is the pitfall in the management ?

District Hospital Day 5 (1430, 31 hours

defervecence)(Referral letter)Admitted yesterday. C/O: fever for 4 days , vomiting and abdominal pain headache and fainting episodes No bleeding No diarrhoea

2 siblings also had fever. Still at home.

Cont……. Admitted for 24 hours. BP =80-90/50-

60mmHg, HR=105/min

Leptospirosis TRO dengue

IV fluid 1pint N/S bolus followed by 5 pint N/S over 24 hours

IV C Penicillin 2.0 mega 6hourly

Referred for persistent thrombocytopenia

IX 1730 2200

WCC 8.3 8.9

Hb 13.2 14.1

Hct 38.4 42.0

Platelet 7 5

Urea 12.0

Lactate 11.2

INR 1.8

APTT 112

IX (Day 5)

0830 1200

WCC 7.8 7.1

Hb 14.5 16.6

Hct 44.0 50.0

Platelet 56 13

Urea 9.0

Lactate

INR

APTT

Q2: Comment on the referral letter?

Q3: Comment on diagnosis

Q4: How would you manage?

Q5: What other investigations would you request?

GH: Day 5 (1630,33 hours defervecence)

Has PV bleed. 4 pads soaked today Examination: Obese wt 79kg Alert but restless Afebrile BP 80/60 PR 98/min RR 22/min SPO2:98% on O2 nasal

prong Generalized macular rash

Lungs: clear Abdomen: soft , mild tenderness Hess test: POSITIVE

Assessment : DSS

Fluid resuscitation: 10ml/kg bolus given for 2 cycles (1L N/S then 1L voluven). Continued with 1.5 IV fluid maintenance.

ABG: PO2 105 PCO2 25 HCO3 15mmol/l

Day 5 (22.00, 37 hours defervesence)

More restless. BP 146/110mmHg Pulse 105/min RR 25/min. SpO2 95% on

HFL Lungs: Rhonchi. Bilateral pleural

effusion Abdomen: Distended and tender.

Ascites present Left ankle- bruises

Day 5 (22.30)

Chest X ray: Bilateral pleural effusion and collapsed consolidation of left lower lobe

ABG: PO2 130 PCO2 21 HCO3 13mmol/l

GXM -3 pint packed cell 6hourly FBC/BUSE Blood C&S Echocardiogram: good LV

function EF 68%

IX 1730 2200

WCC 8.3 8.9

Hb 13.2 14.1

Hct 38.4 42.0

Platelet 7 5

Urea 12.0

Lactate 11.2

INR 1.8

APTT 112

IX 1730 2140

WCC 8.3 8.9

Hb 13.2 14.1

Hct 38.4 42.0

Platelet 7 5

Urea 12.0

Lactate 11.2

INR 1.8

APTT 112

Q6: Discuss on hemodynamic status of this patient?

Q7: Would you transfuse blood and blood products?

Day 5 (23.30) BP 82/60 Pulse 112/min RR 30/min Treatment: IVD 2 pints NS/2H (6ml/kg /hour)

2 pints packed cell transfused Refferred to anesthetist: NO BED IN

ICU Q7: How would you manage the

patient?

Day 6 (0230)

More restless and tachypnoeic

Ventilated in HDW Urine output: 20ml/hour

Assessment: DSS with ARF and acute liver failure (transaminitis and coagulopathy)

IX 1730 2200

WCC 8.3 8.9

Hb 13.2 14.1

Hct 38.4 42.0

Platelet 7 5

Urea 12.0

Lactate 11.2

INR 1.8

APTT 112

IX 1730D5

2140D5

0100D6

WCC 8.3 8.9 17.8

Hb 13.2 14.1 13.0

Hct 38.4 42.0 41

Platelet 7 5 7

Urea 12.0 13

Creatini

300

Lactate 11.2

INR 1.8

APTT 112

AST 1213

ALT 2303

Day 6 (0900)Transferred to ICU Noted blood clots from

the ETT and RT-coffee ground aspirate

Bleeding from nasal and oral cavity and from the puncture sites

BP=105/55 HR 98/min. Urine output (20ml/h) ABG: pH 7.096 pCO2

18.4 pO2 192.9 HCO3 5.5 BE -24.2

IX 1730 2200

WCC 8.3 8.9

Hb 13.2 14.1

Hct 38.4 42.0

Platelet 7 5

Urea 12.0

Lactate 11.2

INR 1.8

APTT 112

IX 2140D5

0100 0600D6

WCC 8.9 17.8 22.8

Hb 14.1 13.0 10.0

Hct 42.0 41.0 28

Platelet 5 7 7

Urea 13 23

Creatini

300 480

Lactate 11.2 11.3

INR

APTT

AST 1213

ALT 2303

CVVHDF commenced Blood transfusion: 4 pints PC, 4u

platelet, 4u FFP Fluid therapy reduced to 500ml/24

hours Referred to gastro team

Day 7 (0230)

Assessment: DSS with ARF and acute liver failure (transaminitis and coagulopathy)

IX 1730 2200

WCC 8.3 8.9

Hb 13.2 14.1

Hct 38.4 42.0

Platelet 7 5

Urea 12.0

Lactate 11.2

INR 1.8

APTT 112

IX 1100D6

1500D6

2200D6

WCC 18.3 18.9 17.8

Hb 12.0 12.1 11.0

Hct 34.4 42.0 33.1

Platelet 27 25 27

Urea 8.0 7.8 6.5

Creatinine

120

Lactate 4.0

INR 1.6

APTT 71

AST 1713

ALT 1203

Q9: Did you agree with the gastro referral?

Q10: Why did you think the patient deteriorated despite stable BP?

Day 8(Recovery phase:1000)

BP:100/50mmHg on NA infusion. T 35C HR 102/min. Temp=36C. Ventilated.

Anuric. CXR: worsening pleural effusion, ARDS

features ABG: Ph 6.9, PCO2 58 P02 90 HC02 9 WCC 3.84 Hb 12.2 HCT 36.2 Platelet 16 Hematologist: 2 cycles DIVC regimes

and IV tranxanemic acid.

Day 8(1800) General condition deteriorating further: BP lowish despite 4 max intropes Bleeding from oral and nasal cavity, ETT Generalized oedema, peripheral cyanosis Pupils fixed and dilated Confirm death at 2025h Cause of death: DENGUE SHOCK

SYNDROME

Day 9 (0930)

Dengue IgM: (D5) borderline

Blood C&S: D5: No growth D7:Kleb Pneum Urine C&S: D7 Kleb Pneum TA C&S: Kleb Pneum

IX 1730 2200

WCC 8.3 8.9

Hb 13.2 14.1

Hct 38.4 42.0

Platelet 7 5

Urea 12.0

Lactate 11.2

INR 1.8

APTT 112

IX D8 0600

1000 1600

WCC 5.21 3.84 4.1

Hb 11.6 12.1 9.0

Hct 34.4 36.0 27.1

Platelet 25 15 27

Urea 6.0 6.8 6.5

Creatini

90

Lactate 3.7

INR 1.6 1.8

APTT 71 60

AST 1868

ALT 833

Q9: Can you comment on borderline Dengue IgM serology?

FINAL CAUSE OF DEATH

DENGUE SHOCK SYNDROME WITH

SEPTICAEMIA