ppt dengue hany
TRANSCRIPT
CASE REPORTDengue Fever
Presenters: - Okmaronab Febriza (080100375) - Hanidya fazwat (080100381)Supervisor : dr. Lily Irsa, SpA (K)
DEPARTMENT OF PEDIATRICSHAJI ADAM MALIK GENERAL HOSPITAL
FACULTY OF MEDICINEUNIVERSITAS SUMATERA UTARA
2012
Dengue fever is disease that cause by one of the four serotype of dengue virus (den-1, den-2, den-3, den-4).
DEFINITION & ETIOLOGY
Dengue fever is transmitted from human to human by the mosquito aedes aegypti.
- Family: flaviviridae- Genus: flavivirus- ɸ = 50 nm
1968 First reported in Surabaya
1980
Spread across the country in Indonesia
EPIDEMIOLOGY
pathogenesis
pathophysiology•Vasculopathy
•Thrombocytopenia and platelet dysfunction
•Coagulopathy
•Evidence of plasma leakage
CLINICAL MANIFESTATIONS FEBRILE PHASE
TAKEN PLACE FOR 3-7 DAYS
FEVER : ≥ 38,50 C
HEADACHE
VOMITING, MYALGIA AND JOINT PAIN
CRITICAL PHASE Increasing hemoconcentration, hypoprotein, pleural effusion,
ascitesSkin bleeding, mucosal bleeding
(gastrointestinal or vaginal)
Moderate to severe thrombocytopenia
RECOVERY PHASE
CLINICAL MANIFESTATION
S
Diagnose
Acute febrile illnes with two or more of the following manifestation
Headache, Retro-orbital, Myalgia, Rash, Haemorrhagic manifestation, leukopenia
• Dengue Haemorrhagic fever• Fever• Haemorrhagic tendencies• Thrombocytopenia (100.000 cell per mm 3 • A rise in the haematocrit equal than 20%• A drop in the haematocrit following volume replacement
treatment equal to or • greater than 20% of baseline• Sign of plasma leakage
• Dengue fever
Complete Blood CountHaematrocritHaemoglobinThrombocyteLeucocyteBleeding timeaPTTPTT
Laboratory Finding
Virus IsolationRT-PCRDetection of antigensIgM/IgG ratioIgA
Further Examination
DF/DHF Grade Symptoms Laboratory
DF Fever with two or more of the
following sign : headache, retroorbital
pain, myalgia, arthralgia
leukopenia occasionally.
Thrombocytopenia, may be
present,no evidence of plasma
loss
DHF I Above sign plus posisitve tourniquet
test
Thrombocytopenia < 100.000,
Hct rise ≥ 20%
DHF II Above sign plus spontaneous bleeding Thrombocytopenia < 100.000,
Hct rise ≥ 20%
DHF III Above sign plus circulatory failure
(weak pulse, hypotension, restlessness)
Thrombocytopenia < 100.000,
Hct rise ≥ 20%
DHF IV Profound shock with undetectable
blood pressure and pulse
Thrombocytopenia < 100.000,
Hct rise ≥ 20%
Grading
Differential Diagnose
chinkungunya
Scarlet fever
malaria
leptospirosis
Thypoid and typhus
Influenza
measles
Treatment of dengue infection
Dengue FeverBed restAdequate NutritionSymptomatic :
Oral fluids sent homeIntravena fluidsParacetamol
Suspect of Dengue Infection
18
High fever, < 7 daysMalaise, no ARI
Emergency signs (-)Emergency signs (+)
ShockSeizureEncephalopathyBleeding
Tourniquet test
Positive Negative
Inpatient
One day observation
Observe for 24 hoursSymptoms & lab
Leucocyte < 4.000/uL
Normal leucocyte
+ Thrombocyte < 100.000/uL+ Rise of Ht > 10%
OutpatientControl until fever(-)Advice the parent
Fever persist > 3 daysCheck Hb, Ht, leucocyte & thrombocyte
Treatment of DHF without shockFluid
Drink 2 litre/day to prevent dehydrationMineral water, juice, oralit
SymptomaticGive antipiretic if high fever or history of febrile
seizure occured. Suggestion is paracetamol. Asetosal & ibuprofen are contraindicated
DiazepamDomperidon 1 mg/kgBB, 3 dose, 1-2 daysH2 blocker (ranitidine, cimetidine)Antibiotic is not givenSteroid is not effective
19
Treatment of DHF without shock (DHF grade I and II)
20
Able to drink Unable to drinkVomit
Drink 2 L/dayParacetamolAnticonvulsive, if necessary
Infuse D5%:NaCl 0,9% = 3:1Maintenance dripsCheck Hb, Ht, thrombocyte every 6-12 hoursEvaluate the symptoms & lab
Signs of shockDiuresisBleeding
Hb, Ht, thrombocyte every 6-12 hours
Discharge Improve Worsen Change to RL D5%
21
Treatment of DHF grade I and IIInitial fluid 6 – 8 ml/kg/hour
RLD5% or RAD5%
Monitor the vital signsHb, Ht, thrombocyte every 6-12 hours
Improvement
No Improvement
Not agitatedStrong pulseStable BPHt decreaseDiuresis 1 ml/kg/hour
AgitatedRespiratory distressHR increaseHt increasePulse pressure < 20mmHgDiuresis <1 ml/kg/hrFluid decrease
to 5 ml/kg/hourFluid increase to
10-15 ml/kg/hour3 ml/kg/hour
Stop in 24-48 hours
Unable vital signs
Evaluate in 12-24 hours
Treatment of DSS
22
SHOCK
O2 2-4 L/minIsotonic fluid 20 ml/kg/hour
RL/RA/NS
in 30 min
Evaluate in 30 minute, has the shock resolved?
Yes No
Adjust the fluid
Monitor
Stable
Stop the fluid not more than 48 hours after the
shock has resolved
Continue the RL+ Kolloid+ Correct acidosisEvaluate in 1 hourShock has
resolvedNot
resolvedHt
Decrease Increase
Transfusion
Inotropic
Kolloid
No improvement
23
Environment-drain the tub or water reservoirs at least once
a week-replace or drain the vase-bury the cansBiological-use of larvae-eating fishChemical-fogging using malathion and fenthion or abate
powder in water reservoirs
Prevention
COMPLICATION
encephalopathyIntra
cranial
bleeding
Liver failure and renal failur
e
Central nervous system
C A S E
D, 3 years old, male, weight 17 kg, was admitted to Haji Adam Malik Hospital at the Infection Unit Pediatric Department on May 28th 2012 with the main complaint fever. This occurred since 2 days ago, high fever tipical, temperature get lower after the medicine given but fever still remain, seizure (-), freezing (-). While the first time get fever, followed by swollen eyes, fever get worst at night. Cough(+), flu (-), dypsneu (-), disfagia (-). vomit (+) 2 times this morning, volume of vomit is ¼ glass of water. Spontantly bleeding history : epistaksis(+), bleeding gum (-), black feaces (-), rash found on the hand and foot, BAK and BAB (+) N.
History of previous illness : coughHistory of previous medication : Paracetamol
Physical Examination :
Presence Status :
Compos Mentis, Temperature : 38,2ºC, Body Weight : 17kg, Dyspnea (-), Edema (-), Cyanosis (-), Icteric (-), Anemic (-)
Head : Eye : light reflexes (+/+), isochoric pupil, pale inferior conj. palpebra (-/-). Ear/Nose/Mouth: normal.
Neck :Lymph node enlargement (-).
Thorax :Symmetrical fusiform , retraction (-)
Physical Examination :
HR: 90 bpm, regular, murmur (-)
RR : 24 bpm, regular, rales (-) Abdominal :
Soepel, peristaltic (+) N, liver and spleen not palpable, maculopapular erythematous rash (-)
Extremities :Pulse = 90 bpm, regular, adequate pressure/volume, warm acral, maculopapular erythematous rash (-) in superior and inferior dextra and sinistra extremities.
Urogenital :Male, within normal limit
Differential Diagnosis:typhusmeasles, chinkungunya, malaria, leptospirosis, thypoid,
Working Diagnosis:Dengue Fever
Management :
- IVFD RL 50 gtt/ minute micro
- Paracetamol 3x250 mg
- Diet MB 1350 kkal with 35 gram protein
Laboratorium
Test (28-05-2012) Results Normal ValueComplete Blood Count :
Hemoglobin (Hb) 11.60 g% 11.3 – 14.1
Erytrocyte (RBC) 4.40 x 106/mm3 4.40 – 4.48
Leukocyte (WBC) 2.27 x 103/mm3 4.5 – 13.5
Hematocrite 42.90 % 37 – 41
Trombocyte (PLT) 90 x 103/mm3 217 – 497
MCV 70.30 fL 81 – 95
MCH 20.00 pg 25 – 29
MCHC 33.20 g% 29 – 31
RDW 14.10 % 11.6 – 14.6
MPV 9.20 Fl 7.2 – 10.0
PCT 0.19 %
PDW 10.5 fL
LED 45 <15
Test (28-05-2012) Results Normal Value
Cell Count :
Neutrofil 75.10 % 37 – 80
Limfosit 15.50 % 20 – 40
Monosit 9.40 % 2 – 8
Eosinophil 0.00 % 1 – 6
Basophil 0.000 % 0 – 1
Neutrophil absolute 3.21x 103/µL 2.4 – 7.3
Limfosit absolute 0.00 x 103/µL 1.7 – 5.1
Monosit absolute 0.40 x 103/µL 0.2 – 0.5
Eosinophil absolute 0.10 x 103/µL 0.10 – 0.30
Basophil absolute 0.00x 103/µL 0 – 0,1
Carbohydrate Metabolism
Blood Glukose 105,09 mg/dl <200
Electrolyte
Natrium (Na) 134 mEq/L 135-155
Kalium (K) 4.4 mEq/L 3.5-5.5
Klorida (Cl) 101 mEq/L 96-106
Virus
Anti DHF IgM Positive Negative
Anti DHF IgG Negative Negative
Follow Up
Follow Up May 29th 2012
S : Fever (-)
O: Sensorium: compos mentis, temp: 37,4 oC, BP: 130/80 mmHg,
Body weight: 17 kg, BB/TB: 80,75%
Head : Eye: Light reflexes (+/+), isochoric pupillary, palpebra
inferior conjunctival pallor (-/-), Ear/Nose/Mouth: within
normal limit.
Neck : Lymph node enlargement (-).
Thorax : Symmetrical fusiform, retraction epigastrium (-)
HR:86 bpm, reguler, murmur (-)
RR: 28 bpm, reguler, ronchi (-/-)
Follow Up May 29th 2012
Abdominal : Soepel, peristaltic (+) Normal, liver and lien were not
palpable
Extremities : Pulse = 86 bpm, regular, adequate
pressure/volume.
Genitalia : Male, within normal limit
A : Dengue Fever
P : - IVFD RL 50 gtt/ minute micro- Paracetamol 3x250 mg- Diet MB 1350 kkal with 35 gram protein
Test (29-05-2012) Results Normal ValueComplete Blood Count :
Hemoglobin (Hb) 13.10 g% 11.3 – 14.1
Erytrocyte (RBC) 4.50 x 106/mm3 4.40 – 4.48
Leukocyte (WBC) 6.27 x 103/mm3 4.5 – 13.5
Hematocrite 38.50 % 37 – 41
Trombocyte (PLT) 152 x 103/mm3 217 – 497
MCV 88.70 fL 81 – 95
MCH 27.20 pg 25 – 29
MCHC 30.20 g% 29 – 31
RDW 14.10 % 11.6 – 14.6
MPV 9.10 Fl 7.2 – 10.0
PCT 0.19 %
PDW 10.5 fL
LED 45 <15
Test (29-05-2012) Results Normal Value
Cell Count :
Neutrofil 75.10 % 37 – 80
Limfosit 15.50 % 20 – 40
Monosit 9.40 % 2 – 8
Eosinophil 0.00 % 1 – 6
Basophil 0.000 % 0 – 1
Neutrophil absolute 3.21x 103/µL 2.4 – 7.3
Limfosit absolute 0.00 x 103/µL 1.7 – 5.1
Monosit absolute 0.40 x 103/µL 0.2 – 0.5
Eosinophil absolute 0.00 x 103/µL 0.10 – 0.30
Basophil absolute 0.00x 103/µL 0 – 0,1
Carbohydrate Metabolism
Blood Glukose 105,09 mg/dl <200
Electrolyte
Natrium (Na) 138 mEq/L 135-155
Kalium (K) 4.9 mEq/L 3.5-5.5
Klorida (Cl) 104 mEq/L 96-106
Follow Up
Follow Up May 30th 2012S : Fever (-)
O: Sensorium : Compos Mentis, Temperature = 36.5 0C, BP: 120/80 mmHg
Body Weight: 17 kg, BB/TB: 80,75%Head : Face : macula Eritematous (-) Eye : Light reflexes (+/+), isochoric pupillary, palpebra inferior conjunctival pallor (-/-), Ear/Nose/Mouth: within normal limit
Neck : Lymph node enlargement (-).Thorax : Symmetrical fusiform, retraction epigastrial (-),
HR: 84 bpm regular, murmur (-)
RR: 24 bpm, regular, ronchi (-/-)
Follow Up May 30th 2012
Abdominal : Soepel, peristaltic (+) Normal, Liver and Lien were not
palpable,
Extremities : Pulse = 84 bpm, regular, adequate pressure/volume,
warm acral,
Urogenitalia : Male, within normal limit
A : Dengue Fever
P : - IVFD RL 50 gtt/ minute micro- Paracetamol 3x250 mg- Diet MB 1350 kkal with 35 gram protein
Test (30-05-2012) Results Normal ValueComplete Blood Count :
Hemoglobin (Hb) 12.60 g% 11.3 – 14.1
Erytrocyte (RBC) 4.43 x 106/mm3 4.40 – 4.48
Leukocyte (WBC) 8.5 x 103/mm3 4.5 – 13.5
Hematocrite 38.70 % 37 – 41
Trombocyte (PLT) 207 x 103/mm3 217 – 497
MCV 79.30 fL 81 – 95
MCH 23.00 pg 25 – 29
MCHC 33.80 g% 29 – 31
RDW 12.10 % 11.6 – 14.6
MPV 8.20 Fl 7.2 – 10.0
PCT 0.19 %
PDW 10.5 fL
LED 45 <15
Test (28-05-2012) Results Normal Value
Cell Count :
Neutrofil 78.10 % 37 – 80
Limfosit 16.50 % 20 – 40
Monosit 8.40 % 2 – 8
Eosinophil 1.00 % 1 – 6
Basophil 0.000 % 0 – 1
Neutrophil absolute 3.21 x 103/µL 2.4 – 7.3
Limfosit absolute 2.00 x 103/µL 1.7 – 5.1
Monosit absolute 0.40 x 103/µL 0.2 – 0.5
Eosinophil absolute 0.00 x 103/µL 0.10 – 0.30
Basophil absolute 0.00 x 103/µL 0 – 0,1
discussion
Theory Cases
Epidemic dengue is a major public health problem in Indonesia, Myanmar, Sri Lanka, Thailand and Timor-Leste which are in the tropical monsoon and equatorial zone where Aedes aegypti is widespread in both urban and rural areas.
Indonesia is a country located on the equatorial zone.
The initial phase is typically characterized by high temperature (≥ 38,50 C) accompanied by headache, vomiting, myalgia, and joint pain, sometimes with a transient macular rash. Children have high fever but are generally less symptomatic than adults during this phase of the illness. Mild hemorrhagic manifestation such as petechiae and bruising, particularly at venipuncture sites and palpable liver are commonly noted. Laboratory finding mild-to-moderate thrombocytopenia and leucopenia, often with a moderate elevation of hepatic aminotransferase levels. This pahse last for 3 to 7 days, after which most patient recover without complication
main complaint of this patient is fever. This occurred since 4 days ago, high fever tipical, temperature get lower after the medicine was given but fever still remain until now. While the first time get fever. vomitting (+) 2 times this morning, volume of vomit is ¼ glass of water. Leucocytes of this patient 2.27 x 103/mm3 and thrombocyte 90x 103
Patients, D, 3-year-old, male, was diagnosed with dengue fever. A symptomatic treatment to has been conducted to this patient. He has been stabilized, and sent home.
summarry
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