A CASE ON DENGUE SHOCK SYNDROME This is a case of an 8 yr old female born December 6, 2002, from Pililia, Rizal who

came in with a chief complaint of fever. Four days PTA, patient had fever Tmax 39C accompanied by cough dry and watery nasal discharge and headache. Consult was done at Tanay Hospital where impression was unknown and she was given Cefalexin 5 ml TID and Paracetamol. Three days PTA, patient still had fever, intermittent, now accompanied by abdominal pain. No other symptoms were noted and no consult was done. One day PTA, still with fever, intermittent, accompanied by abdominal pain and headache, consult at Tanay General Hospital was done where BP was noted to be 70/40. Patient was admitted and was given PNSS as fast drip for 3 doses. Hypotension persisted and Dopamine and Dobutamine were given until it was increased to 15cc/hr due to persistence of hypotension. CBC showed Hgb 135 Hct 0.40 WBC 5.0 neutrophils 0.55 lymphocytes 0.45 platelet 124. Chext Xray showed pleural effusion. Due to persistence of symptoms, patient was then transferred to our institution. This is the patients 1st hospitalization. She is the second of two children. There are reported cases of dengue in their community and school. They have a family history of asthma. Their family lives in a mountainous area. Water is boiled from the faucet and electricity is from meralco. At the ER, patient was drowsy, in respiratory distress with the ff vital signs: BP unappreciated, CR 123 RR 44 Temp 36.3 with puffy eyelids, petechiae at the upper extremities, symmetrical chest expansion, with retractions, decreased breath sounds at both lower lung fields, adynamic precordium, tachycardic, no murmurs, distended abdomen, liver edge at 3cm BRCM with poor pulses and CRT 3secs. Patient was admitted as a case of Dengue shock syndrome with bilateral pleural effusion. Patient was placed on NPO with O2 face mask at 5lpm. Dopamine and dobutamine were maintained at 15cc/hr and D5LRS at 55cc/hr (MR). Furosemide was started. The ff labs were done: CBC: Hgb 170 hct 0.51 wbc 6.5 neutro 0.66 lympho 0.34 platelet 61 PT 13.9 (12.5) PTT 87.3 (35.2) INR 1.15 Na137 Albumin 20 SGPT 31 SGOT 120 AlkPO4 61 At the ER, patient was then noted to have palpatory BP 70 with weak pulses hence epinephrine drip was started. On the 1st ICU day, patient was afebrile, CR 140-150 RR 40s BP 110-120/70-80. Patient still had tachypnea. Patient was conscious, coherent, in distress. Symmetrical chest expansion, with decreased breath sounds at both lower lungfields. Abdomen is distended, circumference of 59with flank fullness. FFP transfusion was given. Repeat CBC showed Hgb163 Hct 0.49 WBC 14.3 Neutro 0.60 Lymph 0.39 Platelet 40. LDH 689 CKMB 55. 12 L ECG was also done. Dopamine, Dobutamine, and epinephrine drip were continued. Furosemide drip was also continued. On the 2nd ICU day, day 2 afebrile, patient is still tachypneic with RR 40s, subcostal retractions, decreased breath sounds on both lower lung fields. BP was 100-120/60-80 CR 90-120s Abdomen is distended. Pulses were full and equal. Urine output was adequate at 2.4cc/kg/hr. Epinephrine drip was discontinued. Dopamine and dobutamine drip was decreased to 5cc/hr. Albumin transfusion was given. Repeat CBC showed Hgb 140 hct 0.42 WBC 16.4 Neutro 0.71 Lymph 0.29 Platelet 80.

On the 3rd ICU day, day 3 afebrile. Bp range 90-120/60-80 CR 100-120 RR20-30. Patient had no difficulty of breathing. Symmetrical chest expansion, no retractions, with decreased breath sounds at the left basal lungfields. Abdominal circumference was 57cm, nondistended, soft, non tender. Pulses were full and equal. Urine output was adequate at 3.2cc/kg/hr. Repeat CBC showed Hgb 110 Hct 0.33 WBC 15 Neutro 49 Lympho 51 Platelet 60 PT 12.1(14.1) PTT 51.1(34.1). Dopa-Dobu drip was decreased to 3cc/hr and Furosemide drip was discontinued. IV Furosemide was started q8. IVF was shifted to D5IMB at maintenance rate. On the 4th ICU day, day 4 afebrile. BP range 90-120/60-80 CR 90-110 RR 20s Patient had no subjective complaints. She had symmetrical chest expansion, no retractions with decreased breath sounds at left basal lung fields.Abdomen was flat with normoactive bowel sounds, soft, nontender, no organomegaly.Pulses were full and equal. Urine output was at 4cc/kg/hr. Repeat CBC showed Hgb 106 Hct 0.32 WBC 6.6 neutro 52 Lympho 48 platelet 85. Dopa-dobutamine drip and furosemide drip were discontinued. Patient was then transferred to ward. IV line was shifted to hepline. Patient then discharged home and was advised follow up at General OPD and Cardio OPD.