Tropical Medicine Grand Rounds 2
INMED Conference May 2011
Case Presentation
8 yo Thai male presents Bangkla Christian Hospital (east
central Thailand) with fever for 6 days. Symptoms initially
included fever and chills with headache and generalized
myalgia. Nausea vomiting and anorexia began 2 days ago.
Fever improved some 36 hours ago, but returned even
higher last night along with symptoms of severe fatigue
and listlessness. He has not been able to keep any food or
liquids down for the last 24 hours.
Physical Exam
Acutely ill, well developed young Asian male,
Temp 104.5, Resp rate 32 and shallow, pulse
120, BP 80 / 40
HEENT: conjunctival and pharyngeal injection,
CHEST: diminished BS bilaterally, worse on R
ABD: mild distention, diffusely tender, worse in
epigastrum. Liver edge 3 cm below RCM and
tender
SKIN: diffuse macular rash on chest and abd.
Nurse reports positive T.T.
Lab Tests
CBC: WBC 3100, 45 PMN, 10 B, 35 L, 10 E
Hematocrit 54 %
Platelets 45,000
Malaria Smear Neg
U/A : unable to void
What other Tests ?
? X-Rays/Ultrasound
? Chemistry
? Electrolytes
? Serology or Antibody tests
What is the Dx/DDX ?
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4.____________________________________________________________
What is the Treatment ?
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4.____________________________________________________________
What is the Dx/DDX
Dengue Fever, DHF / DSS ?
Swahili: ki denga pepo, “sudden overtaken
by an evil spirit ” Major outbreak among African slaves in
Caribbean in 1820’s
What is the Treatment ?
Aggressive Volume Replacement
20ml/kg D5NS or RL bolus, 10-20ml/kg/hr
Avoid ASA / NSAIDS
Close monitoring BP, Urine,
Serial HCT
Watch for gross hemorrhage
Virology and Vector
Dengue is an arthropod-borne disease caused by
any one of four closely related viruses. Infection
with one serotype of dengue virus provides
immunity to that serotype for life. A person can be
infected as many as four times, once with each
serotype. Dengue viruses are transmitted from
person to person by Aedes mosquitoes (most
often Aedes aegypti) in the domestic environment.
Endemic in Asia for many years, In the past 20
years, dengue transmission and the frequency of
dengue epidemics has increased greatly in most
tropical countries of the American region
The Culprit !
Aedes aegypti,
Distribution
Symptoms and Signs
Fever
Pain
Anorexia
Abdominal Pain
Nausea and Vomiting
Petechial Rash
Exam
Appearance
Fever range 102 to 105
Tourniquet Test
Liver/Epigastric Tenderness
Lab Findings: CBC, UA special tests
XRAY: Pleural Effusions, Ascites,
Clinical Case Definition for
Dengue Hemorrhagic Fever
4 Necessary Criteria:
Fever, or recent history of acute fever
Hemorrhagic manifestations
Low platelet count (100,000/mm3 or less)
Objective evidence of “leaky capillaries:”
– elevated Hematocrit (20% or more over
baseline)
– low albumin
– pleural effusion or Ascites
Laboratory Tests
in Dengue Fever
Clinical laboratory tests
– CBC--WBC, platelets, Hematocrit
– Albumin
– Liver function tests
– Urine--check for microscopic hematuria
Dengue-specific tests
– Virus isolation
– Serology
Pleural Effusion
PEI = A/B x 100
B
A CENTERS FOR DISEASE CONTROL
AND PREVENTION
Positive Tourniquet Test
Clinical Course
4 to 7 Days
Bimodal Course (? Multiple strains)
Recovery
When to worry:
– Sudden diminished LOC
– Drop in BP
– Anuria
– Sudden drop in temp, especially with low BP
Warning Signs for Dengue
Shock
Alarm Signals:
• Severe abdominal pain
• Prolonged vomiting
Four Criteria for DHF: • Abrupt change from fever
• Fever to hypothermia
• Hemorrhagic manifestations • Change in level of
• Excessive capillary permeability
consciousness (irritability
• 100,000/mm3 platelets
or somnolence)
Initial Warning Signals:
• Disappearance of fever When Patients Develop
• Drop in platelets DSS:
• Increase in Hematocrit • 3 to 6 days after onset of
symptoms
Treatment for Severe Dengue
Careful watch of Vital Signs
Avoid NSAIDS, ASA, STEROIDS
IV Hydration: D5NS or RL: 20ml/kg bolus (15min),
then 10 to 20ml/kg/hr
Monitoring of HCT and Platelet Cnt: Rapid
changes in capillary permeability need rapid
response/adjustment of fluids
“Judicious use of platelets”
“ICU” level care
Post Dengue Syndrome
Depression
Chronic Fatigue
Neuropathy
Arthritis/Arthalgia