Dengue Fever with Warning Signs

Objectives

To identify warning signs seen in Dengue Fever

To manage a case of Dengue Fever with warning signs

General Data

• J.M.G• 6 years old• Male• Pasig City

Chief Complaint

• Fever of 2 days duration

HPI

• (+) Fever, highest recorded temperature: 39.7C

• No other signs and symptoms noted

2 days PTA

HPI

• (+) Episodes of fever unrelieved by paracetamol

• Accompanied by headache• One episode of loose stools• One episode of vomiting• Decreased appetite

Day of Consult

ER Consult

HPI• HR 118 RR 24 T 38.8 BP 90/60• CBC was done• Dengue NS1 done: (+)• Flushed• Slightly sunken eyeballs, moist

mucosa• Clear breath sounds• Regular cardiac rhythm• Soft non- tender abdomen• Full and equal pulses

At the ER

Admission

Review of Systems

• Headache• No cough and colds, no weakness, no joint

pains, no difficulty of breathing, no nausea or vomiting, no abdominal pain, no change in stool color

Past Medical History• Asthma, last attack 2013, no maintenance

medications• No known allergy to food and medication

Family History

• Hypertension (paternal)• Diabetes Mellitus• Asthma

Birth and Nutritional History

• Born full term via NSD to a 26 year old G1P1• Birth weight 2.58 kg (AGA)• No perinatal/neonatal complications

• Not breast fed, Enfalac, Weaned by 6 months, • Current diet consist of rice, meat, fish and

vegetables

At the Floors

General Survey: Conscious, alert, coherent, not in cardiorespiratory distress

• Ht: 143 cm• Wt: 38.5• BP: 100/60• HR: 106• RR: 24• Temp: 38.1 C

• HEENT: anicteric sclerae, pink palpebral conjunctiva, no TPC, no nasal discharge, (-) CLADs,

• Chest/Lungs: symetric chest expansion, clear breath sounds, no rales and wheezes

• Adynamic precordium, Apex beat 4th ICS MCL, normal rate, regular rhythm, no murmurs

• ABDOMEN: Flat, normoactive bowel sounds, soft, (–) tenderness, (-) masses

• Extremities: full and equal pulses, (-) edema, (-) cyanosis, good skin color and turgor, CRT<2 sec

• Skin: no rashes, no petechiae

Salient Features

• 7/M• 2 day history of fever• (+) headache• No recurrence of vomiting or loose stools• No bleeding, no rashes, no petechiae• No hemodynamic compromise• Dengue NS1 (+)

Admitting Diagnosis

Dengue Fever without Warning signs ( WHO 2010)

Day 4 in the hospital (Day 5 of illness)

S> Day 1 afebrileNo recurrence of epistaxis(+) abdominal painNo vomiting episodes

O> Awake, comfortable, flushedClear breath soundsRegular cardiac rhythm(+) abdominal tenderness

epigastric, no liver enlargement Full and equal pulses, warmextremities, CRT< 2 sec

A> Dengue Fever with Warning Signs

P> Increase hydration to 5- 7 cc/kg/hrSerial CBC monitoringSGOT, SGPTEsomeprazoleChest Xray

FOR PICU TRANSFER

Day of Illness Hgb Hct WBC Platelet Count

Day 2 134 40 4.4 157

Day 3 128 38 3 116

Day 4a 135 42 1.7 110

Day 4b 151 45 3.7 72

Day 5a 156 47 3.7 70

Day 5b 158 48 43.2 70

Day 5c 159 48 4.6 70

Day 5d 152 46 5 70

Day 6a 155 47 5.2 94

Day 6b 147 43 4.1 96

Day 7 92 27 2.8 120

Na 130 (135-145) Crea 0.47 (0.52- 0.72)K 4 (3.5- 5.1) SGPT 228 (9-68)iCal 4.64 (4.48 – 5.28) SGOT 314 (5-34)

Chest Xray

Pleural Effusion, RIGHT

CASE definition: WHO 2010, Interim PPS 2010

Dengue w/o warning signs

Problems at the PICU

• Hemoconcentration Fluid support Serial CBC monitoring

• Pleural effusion Fluid titration

Management: Group B: (with warning signs)in hospital

Treatment:Increase oral fluid intakeIV fluids (0.9% saline, LR)

Monitor: Temperature Pattern

Fluid intake and lossesUrine outputWarning signsHCT, platelet, WBC

Indications for Hospital Discharge

• Absence of fever for 24 hours (without anti-fever therapy) and return of appetite

• Visible improvement in clinical picture• Stable hematocrit• 3 days after recovery from shock• Platelets ³ 50,000/mm3

• No respiratory distress from pleural effusions/ascites

Sources

• WHO Dengue Guidelines on Treatment, Diagnosis, Prevention, and Control 2009

• Philippine Pediatric Society interim guidelines on Dengue 2010