Juan, Dengue Fever.docx

Patient Presentation A 19-year-old women presents with a 3-days history of a continuous high fever. She reports generalised aches and pains that originate in the lower back, a headache that is more severe in the front of the head, and retro-orbital pain that gets worse with eye movement. She has a reduced appetite and abdominal pain. She lives in Nueva Ecija, where many cases of dengue fever have been reported recently. Past Medical History Patient had dengue when she was 9 years old and had been admitted at Infant Jesus Hospital for 9 days. As far as the grandmother recalled. Birth History Her birth weight was 3.0 kg. There were no complications at delivery. Both mother and baby were discharged after a two-day hospital stay. Social History Patient is the one who live with her grandparents. She is in her school. According to her grandmother their residence contains dirty drainage. Vaccination -

Bacille Calmette-Guérin vaccine (BCG); after birth

-

Hepatitis B vaccine (HBV); first dose after birth

-

Polio vaccine

-

Pneumococcal conjugate vaccine (PCV)

-

Measles-Mumps-Rubella vaccine (MMR)

-

Tetanus-Diptheria vaccine (Td)

-

Human Papillomavirus vaccine (HPV)

-

No Vaccination up to date

Medication Before Hospitalization: -

For fever, she usually gave Paracetamol

During Hospitalization: -

Tramadol Hydrochloride Paracetamol 325mg

-

Omeprazole 40mg

-

Cetirizine Dihydrochloride 10mg

After Hospitalization: -

Vitamin B Complex 1 Capsule once a day every morning for 5days

-

Sodium Ascorbate 1 tablet once a day for 5days

Allergies Patient doesn’t have any allergies to any food, dust, drugs, or anything according to her grandmother. Differential Diagnosis -

Chikungunya virus It causes fever and severe joint pain. Other symptoms include muscle pain, headache,

nausea, fatigue and rash. Joint pain is often debilitating and can vary in duration.

Zika virus infection

-

Can cause microcephaly in babies born to women who were infected while pregnant. -

Japanese Encephalitis

Encephalitis is an inflammation of the brain that can cause fever, headache confusion, seizures, and, in some cases, death. Hemorrhagic fever viruses

-

They affect many organs, they damage the blood vessels, and they affect the body's ability to regulate itself. Differential Diagnosis Examinations: Vital Signs: -

Temperature 38.3°C

-

Blood pressure 110/80 mmHg,

-

Radial pulse rate 92.

-

Respiratory rate 19

Anthropometry: -

Height: 5’2,

-

Weight: 50kilos

After hospitalization: -

Weight decrease 3kls.

Morphology It is noted that she has a generalised skin flush over her body that is more noticeable on her legs. General Patient looking unwell, lying in bed, trembling but alert. Skin, Hair, Nails Skin: -

No lesion.

-

Skin pallor present.

-

Rash present in right foot.

Hair: -

Hair is black in color.

Head/Scalp: -

No Evidence of alopecia.

-

Evenly distributed hair.

-

No dandruff.

-

No Lumps/masses.

-

No lesions.

-

Smooth skull contour.

-

Normal finding.

Eyes: -

Eye brows and eye lashes are evenly distributed.

-

Sclera is white in color.

-

Light accommodation.

-

Pupils are black in color.

-

Equal size.

-

Redness of eyes.

-

Normal findings.

Ears: -

Symmetrical auricle alignment with outer cantus of eyes.

-

Has no Earwax.

-

Normal findings.

Nose: -

No tenderness and lesions.

Chest: -

No retractions when breathing.

-

No use of accessory muscle used when breathing.

-

Symmetrical chest movement.

-

Normal findings.

-

The dengue rash is characteristically bright red petechial and usually appears first on the lower limbs and the chest.

Abdomen: -

Acute abdominal pain.

Neurological: Neurological complications have been classified into dengue virus encephalopathy, Dengue

virus

encephalitis,

immune-mediated

syndromes,

acute

disseminated

encephalomyelitis, myelitis, Guillain–Barré syndrome, neuritis brachialis, acute cerebellitis,, neuromuscular complications hypokalemic paralysis, transient benign muscle dysfunction and myositis, and dengue-associated stroke.

Investigation: Hematology: PROTHROMBIN TIME (PT) SYSMEX CA - 500 PATIENT’S VALUE REFERENCE RANGE 10.3 – 13.1 seconds

11.3 seconds INR

CONTROL

REFERENCE RANGE

0.97

11.9

10.7 – 13.7

ACTIVATED PARTIAL THROMBOPLASTIN TIME (APTT) SYSMEX CA - 500 PATIENT’S VALUE REFERENCE RANGE 38.2

28.3 – 36.1

CONTROL

REFERENCE RANGE

35.4

29.5 – 37.5

Serology: DENGUE DUO NS1 Antigen

NEGATIVE

IgM Antibody

NEGATIVE

IgG Antibody

POSITIVE

Method

Immunochromatography

Urinalysis: Result

Reference

Yellow Slightly Turbid Acidic 6.50 1.015 Neg (-) Neg (-) Pos (+1) Neg (-) Pos (+3) Neg (-) 11.8 12.3 28.2 431.1

Color Transparency Reaction pH Specific Gravity Sugar Nitrite Protein Urobilinogen Ketone Bilirubin Pus Cells Red Cells Epithelial Cells Bacteria

0 – 17 / uL 0 – 11 / uL 0 – 17 / uL 0 – 278 / uL

Daily Blood Testing Parameters

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

43.4

34.0

34.6

36.6

34.9

35.9

116.0

117.0

125.0

119.0

124.0

Hematocrit

37

54

Hemoglobin

120

170 144.0 440

172

135

97

94

89

116

4

10

3.0

6.2

2.5

3.0

4.6

6.3

NEUT%

37

72

65.7

69.1

39.7

19.6

14.4

16.2

LYMP&

20

50

19.0

22.3

44.9

64.3

68.3

68.4

MONO%

0

14

10.2

8.6

15.4

14.1

14.5

12.3

EO%

0

6

5.1

0.0

0.0

1.7

2.4

2.8

BASO%

0

1

0.0

0.0

0.0

0.3

0.4

0.3

RBC

3.5

5.5

5.3

4.1

4.2

4.5

4.3

4.4

MVC

80

96

82.4

83.5

83.2

82.2

82.1

81.8

MCH

27.5

33.5

27.3

28.5

28.1

28.1

28.0

28.2

MCHC

32

36

33.2

34.1

33.8

34.2

34.1

34.5

Platelet WBC

140

Discussion

Dengue fever is spread through the bite of mosquitoes that carry the virus. These mosquitos bite during the day. The biggest risk is at cooler times of the day like sunrise or late in the afternoon. The mosquitos breed in standing water, usually in cities or towns. The virus cannot spread from person to person through casual contact. People who have dengue fever should be protected from mosquito bites. If a mosquito bites an infected person, the mosquito becomes infected with the virus and can pass it to other people. 

The virus

The dengue virus (DEN) comprises four distinct serotypes (Dengue virus-1, 2, 3, 4) which belong to the genus Flavivirus, family Flaviviridae. Distinct genotypes have been identified within each serotype, highlighting the extensive genetic variability of the dengue serotypes. Among them, “Asian” genotypes of Dengue virus-2 and 3 are frequently associated with severe disease accompanying secondary dengue infections. 

The mosquito

The Aedes aegypti mosquito is the main vector that transmits the viruses that cause dengue. The viruses are passed on to humans through the bites of an infective female Aedes mosquito, which mainly acquires the virus while feeding on the blood of an infected person.



The human

Once infected, humans become the main carriers and multipliers of the virus, serving as a source of the virus for uninfected mosquitoes. The virus circulates in the blood of an infected person for 2-7 days, at approximately the same time that the person develops a fever. Patients who are already infected with the dengue virus can transmit the infection via Aedes mosquitoes after the first symptoms appear (during 4-5 days; maximum 12). In humans recovery from infection by one dengue virus provides lifelong immunity against that particular virus serotype. However, this immunity confers only partial and transient protection against subsequent infection by the other three serotypes of the virus. Evidence points to the fact that sequential infection increases the risk of developing severe dengue. The time interval between infections and the particular viral sequence of infections may also be of importance. 

Symptoms

A person infected by the dengue virus develops severe flu-like symptoms. The disease, also called 'break-bone' fever affects infants, children and adults alike and could be fatal. The clinical features of dengue fever vary according to the age of the patient. Individuals should suspect dengue when a high fever (40°C/ 104°F) is accompanied by two of the following symptoms: -

Severe headache

-

Pain behind the eyes

-

Nausea, Vomiting

-

Swollen glands

-

Muscle and joint pains

-

Rash

Symptoms usually last for 2-7 days, after an incubation period of 4-10 days after the bite from an infected mosquito. 

Who spreads dengue fever?

Dengue is spread through the bite of the female mosquito (Aedes aegypti). The mosquito becomes infected when it takes the blood of a person infected with the virus. After about one week, the mosquito can then transmit the virus while biting a healthy person. The mosquito can fly up to 400 meters looking for water-filled containers to lay their eggs but usually remains close to the human habitation.

Aedes aegypti is a daytime feeder: The peak biting periods are early in the morning and in the evening before dusk.

Dengue cannot be spread directly from person to person. However, a person infected and suffering from dengue fever can infect other mosquitoes. Humans are known to carry the infection from one country to another or from one area to another during the stage when the virus circulates and reproduces in the blood system.

Aedes aegypti has evolved into an intermittent biter and prefers to bite more than one person during the feeding period. This mechanism has made Aedes aegypti a very highly efficient epidemic vector mosquito

Treatment There is no specific treatment for dengue fever. Patients should seek medical advice, rest and drink plenty of fluids. Paracetamol can be taken to bring down fever and reduce joint pains. However, aspirin or ibuprofen should not be taken since they can increase the risk of bleeding. For severe dengue, medical care by physicians and nurses experienced with the effects and progression of the disease can frequently save lives. Maintenance of the patient's circulating fluid volume is the central feature of such care. Management and Prevention

There is no vaccine to prevent dengue fever. The best way to prevent the disease is to prevent bites by infected mosquitoes, particularly if you are living in or traveling to a tropical area. This involves protecting yourself and making efforts to keep the mosquito population down.

To protect yourself: 

Stay away from heavily populated residential areas, if possible.



Use mosquito repellents, even indoors.



When outdoors, wear long-sleeved shirts and long pants tucked into socks.



When indoors, use air conditioning if available.



Make sure window and door screens are secure and free of holes. If sleeping areas are not screened or air conditioned, use mosquito nets.



If you have symptoms of dengue, speak to your doctor.

To reduce the mosquito population, get rid of places where mosquitoes can breed. These include old tires, cans, or flower pots that collect rain. Regularly change the water in outdoor bird baths and pets' water dishes.

If someone in your home gets dengue fever, be especially vigilant about efforts to protect yourself and other family members from mosquitoes. Mosquitoes that bite the infected family member could spread the infection to others in your home. Remember the 4’s:

-

Self and destroy

-

Self-protection measures

-

Seek early consultation

-

Say no to indiscriminate fogging

References: World Health Organization. Weekly epidemiological record. Dengue and severe dengue. http://www.who.int/mediacentre/factsheets/fs117/en/. Accessed 29 Jul 2016. Wasay M, Channa R, Jumani M, Shabbir G, Azeemuddin M, Zafar A. Encephalitis and myelitis associated with dengue viral infection clinical and neuroimaging features. Clin Neurol Neurosurg. 2018;110(6):635–40. doi: 10.1016/j.clineuro.2018.03.011 Araújo F, Nogueira R, Araújo M de S, Perdigão A, Cavalcanti L, Brilhante R, et al. Dengue in patients with central nervous system manifestations, Brazil. Emerg Infect Dis. 2015;18(4):677–9. doi: 10.3201/eid1804.111522. Zaitseva, E. et al. Dengue virus ensures its fusion in late endosomes using compartmentspecific lipids. PLoS Pathogens 6, e1001131 (2010). doi:10.1371/journal.ppat.1001131