D NGUE WORKSHOP 2015

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OPD – CASE 3

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History• 26 years old Chinese lady• G2P1 at 34 weeks POA• Headache for 3 days

– Throbbing– Fronto-parietal area

• Fever for 3 days with myalgia

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Examination

• Afebrile ( taken PCM)• BP 120/80 mmHg, PR 90/min• Weight 79kg, IBW 64kg• Abdomen

– soft , non tender– Uterus : 34 weeks

• Examination of CVS/Lungs/CNS – normal

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Would you admit this patient?

Possible diagnosis :•Pre-eclampsia•Subarachnoid hemorrhage•Dengue fever/ Viral fever•Tension headache

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Alas ! FBC was not done !

Probable dengue

• Live in/travel to dengue endemic area. • Fever and 2 of the following criteria:• Nausea, vomiting• Rash• Myalgia or arthralgia• Thrombocytopenia• Leucopenia• Any warning signs

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WHO 2009

Fever + Myalgia+Headache

• Must rule out Dengue Fever

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• Since patient was afebrile, she was discharged home with T. PCM

• The next day, she came to ED again,• Complaining of worsening of headache and vomited

x 3 times• BP: 120/70mmHg, PR 100/min, good pulse volume• SPO2 100% on RA• Pink, not jaundice, afebrile• GCS 15/15 but in pain( headache) , no neck stiffness• Lung Clear• PA :no tenderness

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What is your diagnosis ?

FBC •WBC : 4. ,Hb 12.2 , HCT 36.3, Platelet 29•Dengue rapid test kit : not available !

•G2P1 , at POA 36/52•Dengue fever , day 4 of illness•In defervescence phase•With warning signs ( vomiting)

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What would you do next ?

• Inform FMS immediately• Transfer patient to Emergency room for close

monitoring• Hourly BP/PR monitoring• Observe GCS• Start IV drip • Refer patient to the nearest hospital

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Are you worried about “headache and vomiting” ?

1. Symptoms of Dengue fever2. Need TRO meningitis / encephalitis3. TRO pre-ecclampsia , BUT BP : not high4. Intracranial bleeding secondary to

thrombocytopenia

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Atypical presentations of Dengue

• Diarrhoea• Myocarditis• Encephalitis• Myositis• Hepatitis• Acute abdomen • Severe bleeding without plasma leakage• Haemophagocytic syndrome

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Dengue with warning signs

• Contacted Physician and ED Physician Oncall Hospital AA, accepted the case

• Ambulance not available at that point in time!Observe patient at Emergency room• Start fluid regime : Dengue with warning signs• Observe “headache” and GCS• Hourly BP/PR

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How much fluid to give?• Fluid management in dengue with warning

signs– Obtain baseline HCt– IVD 5-7mls/kg/hr for 1 to 2 hours, then– Reduce to 3-5mls/kg/hr for 2 to 4 hours, and then– Reduce to 2-3mls/kg/hr or less according to

clinical response

• If clinical parameters worsened , and Hct is rising, increase the infusion rate

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InvestigationsD49am

D4 11am

D51pm

Hb 12.5 12.2 13.2

Hct 36.2 36.3 39.7

Wbc 4.0 3.6 3.2

platelet 52 29 25

BPPR

120/8090, good volume

124/8088, good volume

130/8494, good volume

Any other information ? Antenatal booking : Baseline platelet 245 ,000 Baseline Hct : not stated

D4

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What is your diagnosis at this juncture ?

G2P1 at POA 27/52•Day 4 illness( D1 defervescence), •with warning signs ( HCT, Platelet )•hemodynamically stable

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What are the warning signsListen : Mucosal bleed( 4 symptoms) Abd pain Persistent vomiting Restless/lethargy

Examine : Tender enlarged liver( 2 signs) Third space loss

Lab : ( 1 lab) increase in HCT accompanied by rapid decrease in Platelet count

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Drip regime ?

• Dengue with warning signs hemodynamically stable• Drip regime : should be 5/3/2

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What would you do?1. Fluid resuscitation : 5ml/kg x 2 hours

( 5/3/2 regime) 2. Monitor vital signs hourly3. Monitor urine output

• She was transferred to Hospital AA at 1.30PM, accompanied by a doctor and a nurse

• Continue IVD and BP/PR monitoring in ambulance• Bring alone dengue clerking sheet and vital signs

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What actually happened

• She was only started on IVD 3 pint 24 hours ( not based on body weight) throughout the journey to Hospital AA.

• BP/PR monitored in ambulance but not documented

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Arrived at Hospital AA , 2.30pmD4 1pm

D4 2.45pm

Hb 12.2 13.2

Hct 36.3 39.7

Wbc 3.6 3.2

platelet 29 25

BPPR

120/8090

• Vitals stable• No vomiting, no abd

pain• Headache : reduced• Lung : clear

• IVD reduced to 1x maintenance

=104ml/HIVD 3 pints 24 hours

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104ml/H

Admitted to Dengue ward at 4.30pm

At 5pm•HCT : 42.4%•BP/PR stable•Mild headache, no vomiting•Lungs : clear

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D4 1pm

D4 2.45pm

D55pm

Hb 12.2 13.2 14.4

Hct 36.3 39.7 42.4

Wbc 3.6 3.2 4.3

platelet 29 25 23

BPPR

120/8090

110/8090

What would you do ?

• Hct is in an upward trend, indicates ongoing plasma leakage ( with warning signs)

• IBW 64kg , 1x maintenance = 104ml/H

• Would you give bolus of fluid (10-20ml/kg/H) to bring down the HCT quickly ?

• NO !ID HSB 2015

Rising HCT with warning signs , stable BP: Correct the rising HCT by increasing the

maintenance drip ( 5/3/2 Regime)

Fluid resuscitation :When patient is in shock / impending shock10ml/kg compensated Shock20ml/kg decompensated Shock

Overzealous fluid resuscitation promote 3rd space loss Pleural effusion fluid overload

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Fluid regime for patient with warning signs

Fluid regime :•Should be 5/3/2 regime • Reassess patient at the end of each fluid regime, ect

at second hours of 5ml/kg/H• Increase fluid infusion rate if HCT is rising or patient

is hemodynamically not stable

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D5 of illness, day 2 critical phase

D4 5pm D5 12am D5 6am

Hb 13.2 14.4 15.0

Hct 39.7 42.4 43.8

Wbc 3.2 4.3 6.7

platelet 25 23 14

Day 2 desfervescence, with warning signs ( epigastric pain) , VS stable

She complained of epigastric pain since 3 amBP 110/70 PR 80 good volumeCRT<2sPA : Tender epigastric regionLung : Bilateral pleural effusion

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Management – D5Day 5, day 2 desfervescence : 1pm • Patient became tachypnoeic• Lung : Worsening pleural effusion • Refer for ICU admission , reasons :

– On-going leakage , need more fluid but this will tip the balance and plunge the patient into respiratory failure

– VBG : HCO3 19.5

• GSH sentID HSB 2015

Fluid regime ?

Dilemma :Respiratory failure secondary to Pleural effusion,Patient may become more tachypnoeic with rapid fluid

resuscitation

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Pleural effusion

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• Patient was transferred to ICU eventually• Dengue IgM D5 – equivocal• Dengue IgM D7 – positive• She was discharged on D11 of of illness• FBC upon discharge (D11)

– Hb 10.4, Hct 30.1– Wbc 7.1– Plat 79

• To review FBC in 1 weeks at clinicID HSB 2015

Dengue serology test

• Dengue IgM is usually positive after day 5-7 of illness. Therefore a negative IgM taken before day 5-7 of illness does not exclude dengue infection.

• If dengue IgM is negative before day 7, a repeat sample must be taken in recovery phase.

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Practical issues in management of dengue during pregnancy

Physiological changes in pregnancy complicate diagnosis and assessment of plasma leakage •Elevation of Hct in dengue is masked by the hemodilution of pregnancy

– Look for evidence of plasma leakage• Haemodynamic instability• Third space fluid accumulation (difficult to recognise)

– Serial Hct is more useful than a single value

•Hct is lowest in the 3rd trimester.

•Baseline blood pressure may be lower. •Heart rate may be higher. •Pulse pressure wider.

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Hematologic changes at term:

• Blood volume increased by 45%.

• RBC volume increased by 15%.

• Hct falls blood viscosity falls

• Pregnant woman may tolerate hemorrhage better than non-pregnant woman, before demonstrating a fall in blood pressure.

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Take Home Message

• Admit all pregnant mothers with possible dengue regardless of the stage of infection.

• Careful in interpreting hematocrit in pregnancy• Baseline Hct will be helpful if available • The period of plasma leakage may be more

prolonged especially if complicated by intrauterine LSCS or delivery during plasma leakage phase if possible.

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• Blood/blood products must be on standby if delivery can not be avoided.

• Baby needs to be observed for possible congenital dengue.

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Take home message

Take home message

• If a dengue patient presented with headache and vomiting, must watch out for encephalitis

• Close monitoring and adequate fluid resuscitation is the key to successful outcome

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THANK YOU

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