D NGUE WORKSHOP 2015

ID HSB 2015

OPD – CASE 4

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Mdm QRS , 45 years old

• Hypertension under KK follow up.

• On T. Amlodipine 5mg OD

• Fever with myalgia and arthralgia

• Day 2 of illness– went to KK , FBC not taken, – Diagnosed as UTRI

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When to suspect dengueFever with two or more of the following manifestations:•- headache•- retro-orbital pain•- myalgia•- arthralgia•- rash•- haemorrhagic manifestations•- leukopenia/ Thrombocytopenia

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What is your comment about the diagnosis?

• Fever + Myalgia + Arthralgia

Diagnosis :

TRO Dengue fever , day 2 fever

Check vital signs

Take FBC

Dengue rapid test ( if available)

Notify as Dengue ID HSB 2015

Deside if admission is required

If admission is not required :

•Provide Home care advice leaflet to patient

•Advise patient to seek treatment if fever persists or presence of warning signs

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• Day 4 of illness – She went to Hospital Apple , as she “was not

feeling well “– 1pint NS was given– She was discharged home . FBC taken , but

result not available

• Day 5 of illness

- she returned to KK – BP 101/76, PR 93, T 39°C, – HCT 43.7, PLT 105, WBC 3.0– Again ,she was given IVD and discharged.

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When is IVD indicated ?

• Patient is dehydrated

• Patient could not tolerate orally

• Presence of warning signs

• Evidence of plasma leakage

• Dengue with compensated shock

• Dengue with decompensated shock

• Severe dengue with bleeding, while waiting for blood transfusion

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• It is NOT a routine to prescribe bolus IVD at clinic.

• Unless patient is being monitored at outpatient observation ward. In this case patient will be observed for a longer period of time. Patient will be reassessed again at regular intervals depends on the drip regime.

• Consider admission if patient requires IVD

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• Day 6 of illness

– Fever had subsided.

– However, she felt unwell.

– She had chest pain , aggravated by inspiration. The pain was more excruciating when she lied supine .

– There was no cough, no palpitation

– No headache

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Day 7 of illness

•She contacted her son, her son brought her to hospital Durian.• BP 116/79, PR 92-104/min, poor volume• SPO2 97% on RA• CVS :heart sounds were muffled• Lungs : clear

• CXR : Cardiomegaly, no pleural effusion• ECG done :– small QRS complex with ST elevation at V4-6

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Blood Investigations• WBC 2.8 , HCT 51.1, Plt 80.

• NS1 : Positive

Diagnosis : Dengue Fever , Day 7 illness, with warning signs ( high HCT, low platelet) , in compensated shock TRO myocarditis

-repeated FBC, HCT 45.8, Hb 15.4, Plt 77.

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• Run fluid 5ml/kg/h

• Repeated FBC, HCT 45.8, Hb 15.4, Plt 77.

• Patient was referred to the nearest specialist hospital

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Arrived at Hospital Coconut

• Patient was alert, but lethargic looking

• With cold clammy peripheries,

• all of her peripheral pulses were not palpable,

• BP : not recordable ,

• PR about 140-160 on cardiac monitor.

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Diagnosis

Diagnosis : Dengue Fever , Day 7 illness, with warning signs ( high HCT, low platelet) , in decompensated shock with peri-myocarditis

• repeated FBC, HCT 45.8, Hb 15.4, Plt 77.

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Decompensated shock !• IVD 20ml/kg/h

• GXM/VBG were dispatched

After first cycle of fluid resuscitation :

• BP 80/60mmHg, PR 140/min, weak pulse

• Lungs: clear,

• CVS: heart sounds : muffled.

ECG: Sinus tachycardia with non specific ST segment elevation. Low voltage complex

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Day 5 Day 710.00pm

Day712.00pm

Day72.30pm

WBC 3.0 2.8 2.8 3.2

HCT 43.7 51.1 45.8 39.2

Platelet 105 80 77 88

HCO3 8.2

BPPR

101/7693

116/79100

BP not recordableRun 20ml/kg

80/60140

CRP and LFT : NormalID HSB 2015

What is your diagnosis

Dengue fever, Day 7 of illness, Day 2 defervesence, decompensated shock with severe metabolic acidosis secondary to

a)Plasma leakageb)Ongoing bleedingc)Cardiogenic shockd)Septic shock

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• Bedside Echo at ED

pericardial fluid collection noted (no left ventricle end diastolic collapse) IVC patent.

• Bedside U/S:

No fluid in intra-peritoneal region, minimal fluid in right pleural space

Troponin T : Positive

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ECG : suggestive of pericarditis

Patient was transferred to ICU

1 Pint WB was transfused while waiting for ECHO

ECHO : LVHGlobal pericardial effusion(0.6cm)No RA/RV collapseNo RWMAEF 58%

Day 710.00pm

Day712.00pm

Day72.30pm

WBC 2.8 2.8 3.2

Hb 18.3 15.2 14

HCT 51.1 45.8 39.2

Platelet 80 77 88

HCO3 8.2

BPPR

116/79100

BP not recordableRun 20ml/kg

80/60140

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Patient was admitted to ICU

• Despite 4 inotropic support, MBP 50-60mmHg

• PR : feeble

• She was intubated and ventilated

• CVVH was commenced. She was anuric with metabolic acidosis.

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VBG

• pH 7.137, pCO2 22.7, pO2 204, HCO3 10.3, SPO2 98.2 ,

lactate 6

Impression :

DHF with myocarditis and pericarditis in Cardiogenic Shock with metabolic acidosis

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Repeated ECHOLVEF 33% Chambers normal size Valves - normal minimal Pleural Effusion seen Global hypokinesia LV wall

She succumbed to illness on day 7 of ICU admission

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Cause of death :

• Severe Dengue with myopericarditis complicated with cardiogenic shock, with multi-organ failure

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Severe Dengue with target organ involvement

• Severe Dengue with myocarditis

• Severe Dengue with hepatitis

• Severe Dengue with encephalitis

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Cardiac complication in Dengue

• Myocarditis is the most common documented cardiac pathology in Dengue infection

• Be aware if patient complains of chest pain , palpitation , shortness of breath

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• Cardiac rhythm disorder may occur in dengue infection :

• AV blocks, VPCs, ect

• Pericarditis can be seen in dengue infection, usually as a form of extension of myocarditis to pericardium

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Dengue and CNS ( encepahlitis)Be aware if patient presents with headache, vomiting , altered sensorium or seizure

If a patient presents with viral encephalitis, rule out dengue fever with CNS manifestation.

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Hepatitis in Dengue Infection:

• Hepatitis is common in patients with DF/DHF and may be mild or severe regardless of the degree of plasma leakage.

• In some cases, liver failure may occur.

• Patients with liver failure have a high propensity to bleed, especially gastrointestinal bleeding

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• Peak transaminase enzyme usually occurred later ( Day 4- 10 of illness) than other complications.

• Clinically severe liver involvement may result in severe bleeding.

• Chronic co-infection with hepatitis B or C may be associated with modestly but significantly increased levels of alanine aminotransferase.

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THANK YOU

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