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Morning report dengue fever

VIEWS: 18 PAGES: 37

									Case

15y girl presents with five days of fever and headache.
Iguazu Falls Argentina, Brazil, & Paraguay
HEADS Assesment
HEADS Assesment

      Age                  Young                        Sarcastic
                     LAHW; travel; safety         LAHW, travel, safety
Home
                      (chemicals, stairs)           (guns, persons)

Eats (ins/outs)     Feeds, voids, stooling                Diet
Education           Language, social skills              Grades

Aspirations                                          College, career
Activities        Gross and fine motor skills   Exercise, hobbies, friends

Dreams                     Sleep                         Sleep
Drugs                Second hand smoke           Tob, EtOH, illicit drugs
Depression                                            Disposition

                                                 Interests, relationships,
Sex
                                                    activity, protection
History



HPI: 15y girl with 5d of fever to 40.5C; 4d history
of severe, intermittent headache; 3d history of
malaise, generalized body ache; 1d of
nonpruritic rash.

ROS: Positive for abdominal pain and nausea;
no cough, sore throat, vomiting, or diarrhea.
History

Past: none

Meds: Tylenol PRN

Allergies: Penicillin

Family: brother with fever

Social: LAHW MD 8yB, visited Iguazu Falls, Argentina last
week; well balanced diet, honor roll; plays volleyball and
soccer, plans to go to college; no sleep problems, tried
alcohol once, happy; interested in boys, has a boyfriend, no
sexual activity
Physical exam

Vitals: T 38.5, H 119, R 18, P 130/68

Gen: fatigued adolescent

HEENT: MMM, normal conjunctivae; + anterior cervical LAD

CV: RRR, NL S1/2, no murmur, NL cap refill

Pulm: CTA B, no wheezing

GI: +BS, S/ND, +epigastric tendernesss; no rebound, guarding, or HSM

Neuro: A&O, nonfocal, negative Kernig and Brudzinski

Derm: non-pruritic, non-blanching petechiae over thighs, and on right arm
after sphygmometry
Tourniquet test




Test microvascular fragility and/or
thrombocytopenia


Postive test if 20 or more
petechiae per square inch after
cuff inflation for 5 minutes at MAP.
Summary




Adolescent with persistent fever, headache, myalgias, petechiae after travel to
Argentina.
Differential of fever, headache, rash, and myalgias


     Virus            Bacteria         Parasites   Other
     Influenza       Meningicoccemia     Malaria   Cancer
Arboviruses (RMSF,
Dengue, West Nile,
        etc.)
    Enterovirus
        EBV
        HIV
Labs

BMP: normal


LFT: Total protein 6.2, albumin 3.4, AST 587, ALT 412, Alk phos 157, Bilirubin 1
(0.2)


CBC: 3.5>13.4/39.6<56, N 59, L 33, M 6, E 1


ESR: 13


Urinalysis: normal


CSF: normal
Microbiology

Blood smear: negative for Malaria


IRP: negative


Monospot: negative


Blood culture: negative


CSF culture: negative


Dengue IgM: 4.93 (negative, <1.11)


Dengue IgG: 9.69 (negative, <1.11)
Goals




Become familiar with Dengue fever, an uncommon but emerging disease
Objectives

List the parts of a HEADS assesment.

Recall the significance of a positive tourniquette test.

Describe how Dengue fever is transmitted.

Recognize who is at risk for infection.

Describe how it presents.

Compare and contrast Dengue fever with other infections that present
similarly

Know the treatment of Dengue fever

Understand why it is worse the second time around
Dengue fever




               Arbovirus (Arthropod borne virus)
Endemic
Symptomatic cases of Dengue fever
Dengue fever




    50 million infections per year; 0.5 to 1 million symptomatic cases
Dengue fever

               Asymptomatic


               Dengue fever


          Dengue hemorrhagic fever


           Dengue shock syndrome
Dengue fever, aka “Break-bone fever”



Fever lasting 2-7 days
Dengue hemorrhagic fever



Fever lasting 2-7 days


Hemorrhagic manifestations


Thrombocytopenia less than 100k


Increased vascular permeability
Dengue shock syndrome



Fever lasting 2-7 days


Hemorrhagic manifestations


Thrombocytopenia less than 100k


Increased vascular permeability


Shock
Dengue vs. Influenza
Dengue vs. Influenza

          Similar              Influenza


          Fever          Respiratory symptoms


         Headache               Dengue


         Myalgia          Thrombocytopenia*


         Malaise             Transaminitis*


                       Hemorrhagic manifestations


                             Travel history
Dengue vs. Meningicoccemia
Dengue vs. Meningicoccemia

            Similar              Meningicoccemia


             Fever                      Sick


            Malaise             Altered mental status


             Rash                     Dengue


   Hemorrhagic manifestations      Travel history
            (DIC)
Dengue vs. Malaria
Dengue vs. Malaria

           Similar          Malaria


            Fever         Cyclic fevers


         Headache           Dengue


          Malaise        Biphasic fevers


            Rash


      Thrombocytopenia


        Travel history
Dengue vs. Infectious mononucleosis
Dengue vs. Infectious mononucleosis

          Similar           Infectious mononucleosis


           Fever                Lymphadenopathy


         Headache                  Sore throat


          Malaise                Splenomegaly


           Rash                 Prolonged course


        Transaminitis               Dengue


                                      Travel
Dengue vs. Rocky Mountain spotted fever
Dengue vs. Rocky Mountain spotted fever

         Similar               Rocky Mountain


          Fever                 Country music


        Headache                  Dengue


         Malaise                   Salsa


          Rash
Diagnosis

Clinical


Labs


   Leukopenia


   Thrombocytopenia


   Transaminitis


   Serologic evidence (IgM and IgG most common)
Treatment




Supportive
                        One of the few infections that is
Cocktail party trivia   worse the second time around.
Prognosis

Most do well and some become pediatric residents...
Bibliography

• www.who.int/csr/disease/dengue/impact/en/


• www.cdc.gov/dengue


• Clinical presentation and diagnosis of dengue virus infections, Uptodate.com
  18.2, Nov 2010.


• Kaushik et al. Diagnosis and Management of Dengue Fever in Children.
  Pediatrics in Review (2010) vol. 31 (4) pp. e28-e35

								
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