Dengue

CASE
PRESENTATION
Group 8 Clerk
UV Gullas College of Medicine | Mandaue City Health Center
General data
• 13-old boy
• BOD: Feb 14,2010
• Filipino
• Roman catholic
• Consolacion ,Mandaue city ,Cebu
• Came to consultant with the mother
• Schooling in Canduman national high school
Chief complaint
• fever, and headache for 5 days
• nausea, vomiting, and abdominal discomfort for 2 days
HPI
• He traveled to the Palawan from May 20, 2023 to May 25, 2023.
• He presented with a vomiting and high grade fever after 5 days of his
return.
• He diagnosed with an acute pharyngitis at a primary care clinic and
was treated with antipyretics.
• But the symptoms lasted for 5 days and other symptoms such as
nausea, vomiting and epigastric pain pain behind the eyes were
persistent.
• He was referred to our hospital for evaluation.
Past Medical History

• Born maturely at 40weeks of gestation via normal spontaneous vaginal

delivery(NSVD) to 28 years old; weight at birth was 3.6kgs

• mother G1P1 whose first prenatal visit was in the second trimester. His mother’s
prenatal screen revealed a negative Hepatitis B antigen, negative HIV screen,
nonreactive RPR, Rubella immune, and GBS negative according to the OB
discharge papers from the hospital,There were no complications at delivery.
Past Medical History
Past Surgical History: Circumcision, no complications
Immunizations: Hepatitis B vaccine was given in the nursery.
Allergies: No known allergies
Family History
Paternal side - Unknown
Maternal side - No diabetes, seizures, cancer, heart disease, hypertension or sickle
cell on the maternal side.
Social History
• Patient lives with father mother and grandmother in a apartment.
• Mother is a housewife. She is not currently working outside of the home.
• Father is a engineering.
• Their residence contains no pets.
• No one in the home smokes.
Diet
• Patient was breast-fed exclusively until 1 year old and given formula milk until 2
years old .
• Normal diet with vegetables included with 3 meals a day.
Developmental history
● moving strong ,coordinated manner
● using complex sentences
● becoming more aware of body,possibly developing secondary sex characteristics
● focusing attention for longer period of time
● reading and writing skills are learned
Physical examination
• temperature 39.7°C
• pulse rate of 120 beats/min
• blood pressure 110/70
• respiration rate 24 per minute
• body malaise,retro-orbital pain, myalgia, arthralgia, anorexia, nausea,
vomiting, diarrhea, itching skin, maculopapular rash on both extremities
• No hepatomegaly or splenomegaly on abdominal examination.
Laboratory
• hemoglobin (Hb) 14.9 g/dL ,(male 12-18yeas old : 12-16 mg/dl)
• hematocrit (Hct) 42.8 %, (male 36%-40%)
• white blood cell count (WBC) 2,400/mm3,(range 4500 to 13,500/mm3)
• absolute neutrophil count (ANC) 1,452/mm3, (range 1800 to 8000/mm3)
• platelets 90,000/ mm3, (range 150,000-450,000/mm3)
• total bilirubin 0.16 mg/dL, (range 0 to 1.5mg/dL)
• aspartate aminotransferase (AST) 38 IU/L, (range <46 IU/L)
• alanine aminotransferase (ALT) 27 IU/L, (range <35IU/L)
• total protein 7.6 g/dL, (range 6.6 to 8.2g/dL)
• albumin 4.1 g/dL, (range 3.5 to 5.5g/dL)
• blood urea nitrogen (BUN) 11.0 mg/dL, (range 7 to 18mg/dL)
• creatinine (Cr) 0.8 mg/dL, (range 0 to 1.5)
Laboratory
• sodium (Na) 110mmol/L, (range 136 to 145)
• potassium (K) 4.8 mmol/L, (range 3.5 to 5.0)
• chloride 102 mmol/L, (range 95 to 105)
• serum amylase 37 U/L, (range 30 to 110)
• serum lipase 24 U/ L, (range 20 to 140)
• C-reactive protein (CRP) <0.50 mg/dL
• erythrocyte sedimentation rate (ESR) 48 mm/hr
Laboratory
• Urine microscopy, chest X-ray and abdomen X-ray were normal.
• Viral hepatitis (A, B and C) and Epstein- Barr virus were excluded.
• Abdominal ultrasonography revealed mild hepatosplenomegaly.
• Blood and stool examinations were negative for bacteria, parasites
and malarial plasmodia.
• (+) Tourniquet test
• (+) Hermann’s sign
PRIMARY
IMPRESSIO
N
DENGUE FEVER
WITH WARNING SIGNS
 DIFFERENTIA
L
DIAGNOSES
Rule In Rule Out

Viral Gastroenteritis Nausea, vomiting, abdominal discomfort. (-) stool Examination for bacteria, parasites. Normal
abdominal ultrasonography that shows no
abnormalities with gastrointestinal tract

Acute Pharyngitis Previous diagnosis, but symptoms persist. Treated with antipyretics, Thrombocytopenia

Malaria Fever, vomiting, headaches (-) Malaria parasite upon blood microscopy.
 DIAG
NOSI
S
DENGUE FEVER
WITH WARNING SIGNS
CASE
DISCUSSION
 DENGUE
Dengue is a vector-borne viral infection and a globally important public health problem. The dengue
viruses (serotypes 1, 2, 3 and 4) are enveloped, single-stranded RNA viruses of the Flaviviridae
family. Transmission from human to human is predominantly by the mosquito Aedes aegypti, which
bites in the daytime, is adapted to human habitats and has a preference for human blood meals.

Reference : Infectious Disease (Third Edition),2010

 Any of the four serotypes of dengue virus can result in dengue, which is a systemic febrile
illness lasting 3–7 days and characterized by viremia, fever, rash, headache, muscle and joint ache.
Occasionally, dengue manifests as dengue hemorrhagic fever (DHF), a potentially life-threatening
illness associated with capillary leakage, hemorrhagic manifestations and, in severe cases,
hypovolemic shock

Reference : Infectious Disease (Third Edition),2010

EPIDEMIOLOGY
- Dengue is endemic throughout the tropical
and subtropical zones, where environmental
conditions are optimal for dengue virus
transmission by Aedes mosquitoes. Dengue
transmission occurs throughout the year in
endemic tropical areas; however, in most
countries there is a distinct seasonal pattern,
with increased transmission usually
associated with the rainy season (Dengue
incidence increased sharply from June, and
reached its peak in August).

Reference : Mansion’s Tropical Infectious Disease (Twenty-Third Edition), 2014, Pages 162-170
 In endemic areas dengue occurs most frequently in children aged between 2 and 15 years.
Severe dengue is usually associated with secondary dengue infection and during primary infection in
infants less than 1 year, born to dengue-immune mothers.

Reference : Mansion’s Tropical Infectious Disease (Twenty-Third Edition), 2014, Pages 162-170
- According to WHO, dengue fever and
dengue hemorrhagic fever are prevalent in all
regions of the Philippines, with epidemics
occurring every 3-4 years. Urban centers
such as Metro Manila, Cebu and Davao are
the areas with the highest morbidity and
mortality rates.
- The main vector responsible for dengue
transmission in the Philippines is Aedes
aegypti, which is predominant in urban areas,
but Aedes albopictus may be a secondary
rural vector.
- All four dengue virus serotypes are present in
the Philippines, although DENV 1, DENV 2
and DEVN 3 are predominant.

Reference : Asian Pacific Journal of Tropical Medicine, 2014

CLINICAL PRESENTATION
COURSE OF ILLNESS
Recovery phase
Last 2-3 days

Febrile phase Covalescent phase

Incubation period Critical phase

3-14 days
COURSE OF ILLNESS
Febrile Phase
-
Recovery phase
Nonspecific
Last 2-3 dayssymptoms : high fever,
chills, facial flushing, malaise, retro-
orbital eye pain, generalized body pain,
Febrile phase Covalescent phaseMaculopapular rash, sore
and arthralgia.
throat, and conjunctival injection.
- Mild hemorrhagic manifestations can
be seen.
Incubation period
3-14 days
Critical phase
- Most of the patients will recover, and
fever is usually cleared by day 8.
COURSE OF ILLNESS
-
Critical Phase
- The presence of plasma leakage, hemorrhage, or
organ involvement.
Hematocrit increase may be the earliest sign and
an indicator of the severity of plasma leakage.
-Recovery phase
Pleural effusion and ascites can develop.
-Last 2-3 days
Increasing liver size, persistent vomiting, and
severe abdominal pain are indications of plasma
leakage.
Febrile phase -
Covalescent phase
Signs of hemorrhage such as ecchymoses, GI
bleeding, and epistaxis appear.
- Severe organ involvement may develop, such as
hepatitis, encephalitis, and myocarditis.

Incubation period Critical phase - Shock develops in patients when a critical volume of
plasma is lost through leakage.
3-14 days - Decrease in the level of consciousness,
hypothermia, hypoperfusion resulting in metabolic
acidosis, progressive organ impairment, and DIC
leading to severe hemorrhage should raise concern
for shock.
- AKI in dengue largely occurs with shock
syndrome and shows a high mortality.
COURSE OF ILLNESS
Recovery phase
Last 2-3 days

Febrile phase Covalescent phase

Incubation period Critical phase

3-14 days
CLINICAL PRESENTATION
- Most infected patients are asymptomatic.
- Only 20% develop symptoms ranging from mild disease (dengue fever) to severe
hemorrhagic fever to fatal shock (dengue shock syndrome).
- <5% develop severe dengue.
- 1997, WHO classified symptomatic dengue: dengue fever (DF), dengue hemorrhagic fever
(DHF), and dengue shock syndrome (DSS).
- 2009 WHO classification: dengue without warning signs; dengue with warning signs; and
severe dengue.
1997 CLASSIFICATION
2009 CLASSIFICATION
TRANSMISSION
TRANSMISSION
INVESTIGATION
PROBABLE DENGUE
FEVER
- Live in / Travel to Dengue endemic area
- Acute high-graded fever for 2-7 days
- 2 or more of the following
- Pain : Headache, Retroorbital pain, Arthralgia, Bone pain, Myalgia
- Bleeding :Tourniguet test positive, Petechiae, GI bleeding, Epitaxis, Heavy/ Prolonged
menstrual bleeding
- Maculopapapular rach
- WBC< or = 5,000 cell/mm 3

- Platelet < or = 150,000 cell/mm 3

- Increase Hct 5-10%

CONFIRM DENGUE FEVER
- Probable Dengue Fever
- Lab Confirmation :
- NS1 Ag
- Dengue IgM , IgG
- Rising convalescent HAI IgG > or = 4Times
POSITIVE

DAY 1-4 NS1 Antigen

DAY 3+ Dengue IgG/IgM

DENGUE HEMORRHAGIC
FEVER
- Acute high-graded fever for 2-7 days
- Platelet < 100,000 cell/mm3
- Increase Hct > or = 20% From baseline or Sign of plasma leakage
- Pleural effusion
- Ascites
- Hypoalbuminemia
- Bleeding
bleeding
: Tourniguet test positive, Petechiae, GI bleeding, Epitaxis, Heavy/ Prolonged menstrual
GRADING OF DHF
- I : No shock, No(Only
spontaneous bleeding.
Tourniquet test positive , Easy bruising)
- II : No shock , Spontaneous bleeding.
(Ex: Petechiae, Epitaxis, GI bleeding)
- III : Compensated shock
Weak and rapid pulse + one of…..
- CRT > or = 2 sec.
- Pulse pressure < or = 20mmHg
- SBP < 80 mmHg ( Age < 5 yrs )
- SBP < 90 mmHg ( Age >or = 5 yrs)
- IV : Profound / Hypotensive shock.
(Undetectable BP and Pulse)
TREATMENT
COMPLICATIONS
COMPLICATION
- Dengue can range from asymptomatic infection or mild illness to severe disease.
- Anmostestimated 1 in 4 dengue virus infections are symptomatic. Symptomatic dengue virus infection
commonly presents as a mild to moderate, nonspecific, acute febrile illness.
- Infection
virus.
with one of the four dengue viruses will induce long-lived immunity for that specific

- Because
life.
there are four dengue viruses, people can be infected with DENV multiple times in their
COMPLICATION
- Approximately 1 in 20 patients with dengue virus disease progress to develop severe, life-
threatening disease called severe dengue.
- The second infection with DENV is a risk factor for severe dengue.
- Early clinical findings are nonspecific but require a high index of suspicion because recognizing
early signs of shock and promptly initiating intensive supportive therapy can reduce risk of death
among patients with severe dengue to <0.5%.
PROGNOSIS
PROGNOSIS
- Most cases of dengue fever don’t have symptoms, or the symptoms are mild, but sometimes you
can have a more serious case that requires immediate medical attention.
- Initial symptoms of dengue last (3-7) three to seven days. Most people begin to feel better after
this, but some have life-threatening severe dengue that requires treatment in a medical facility.
SURVIVAL RATE
- Most people recover from dengue fever without any lasting complications.
- Ifdengue.
you have symptoms of dengue fever, you have about a 1 in 20 chance of it worsening to severe

- Ifgreater
you have severe dengue and are treated immediately at a hospital or medical facility, you have a
than 99% chance of recovering.
COMPLICATIONS OF
DENGUE
- FEVER IN
If you’re pregnant and have dengue fever, it can cause miscarriage, low birth weight or premature

PREGNANCY
birth. It’s important to take steps to prevent getting dengue during pregnancy to protect yourself
and your unborn child.
CAN DENGUE OCCUR
MULTIPLE
- TIMES?
Yes. Because there are at least four versions (strains) of the dengue virus, you can get dengue more
than once.
- You’ll usually become immune to the first strain you get sick with and can’t get it again. But you
can get sick with one of the other three strains after that. In fact, you’re more likely to get severely
sick if you get dengue more than once.
PREVENTION
- The best way to prevent dengue fever is to eliminate pockets of stagnant water that serve as
mosquito breeding sites at home, at schools, workplaces and their vicinity, and to avoid mosquito
bites.
PREVENTION
- Precautionary measures to prevent the breeding of mosquitoes and avoid mosquito bites:
1. Put all used cans and bottles into dustbins with cover.
2. Change water for plants at least once a week, leaving no water in the saucers underneath
flowerpots.
3. Cover tightly all water containers, wells and water storage tanks.
4. Keep all drains free from choke.
5. Top up all defective ground surfaces to prevent the accumulation of stagnant water.
6. Wear long-sleeved clothes and long trousers.
7. Use insect repellent over the exposed parts of the body.
8. Use mosquito screens or nets when the room is not air-conditioned.
THANK YOU