CASE REPORT

A Dengue Hemorrhagic Fever s

Patient with Bilateral Pleural
Effusion
Faried Irawanto
M. Vitanata Arfijanto

Department of Internal Medicine

Medical Faculty of Airlangga Univ. - Dr Soetomo Teaching Hospital
Surabaya
2010

INTRODUCTION
Dengue is mosquito-borne infection that causes
severe flu like illness self limited dissease
Dengue Aedes aegypty DF & DHF
Sometimes a potentially lethal complication
dengue haemorhagic fever (DHF) bleeding, syok
syndrome
Cases : 1997 15%
1999 33%
2002 36%

Map produced by the Agricultural Research Service of the US Department of Agriculture.

Source: Slide #8 of a presentation by Gary G. Clark, PhD, entitled "Dengue: An emerging
arboviral disease.

Incidence rate (IR)

Incidence Rate DHF

(per 100.000 people)
2003-2008

Source: Center For Data And Information Ministry Of Health Of Republic of Indonesia . 2009

 DHF with PE 25% small PE,

(Wang, 2007)
4,5% moderate PE
1,9% massive PE
Plasma leakage
Pleural effusion right side (serous fluid)
ascites
Severe plasma leakage bilateral pleural effusion
Pleural effusion resorption
Plasma leakage usually resolves after 48 hours
followed by convalescence periode

CASE REPORT

Patients Identity
Mrs. W/ 24 yo
Moslem
A Housewife
From Trowulan-Jombang,
East Java, Indonesia
Admitted at Dr. Soetomo
Teaching Hospital at April, 5 2010
Referred from Jombang Hospital
With DSS + ARDS

ANAMNESIS
April, 5 2010
Chief Complaint : Shortness of
breath
Shortness of breath since 1 days before admission, continous, no cough.
Fever since 5 days before admission
There are headache, muscle and bone pains, nausea, anoreksia, no loss of
body weight
History of Past Illness :
No history of lung dissease, HT, liver dissease

PHYSICAL EXAMINATION
April, 5 2010
General Condition : Body weakness
GCS 456

BP 110/80

HR 80 bpm

RR 32 x/mnt

T 37.5C

Tourniquet test (+)

Head and Neck : Normal

Chest : Symmetric, Chest Percussion dullness, decreased
breath sounds, friction-rub, Breathing Sound Vesicular
Rales on Lower Chest (Bilateral)
Heart Sound : Normal
Abdominal : Flat, Liver & spleen unpalpable,
Shifting dulness (no ascites)
Extremities : Warm, Dry, Red

LABORATORY & RADIOLOGY RESULT

Hb

11,9 g/dL

Leuco

11,3 x 103/ul

Thrombo

82 x 103/ul

PCV

35,0%

BUN

11 mg/dL

SC

0,8 mg/dL

AST

396 IU/L

ALT

353 IU/L

Alb

2,3 g/dL

Sodium

137,5 mmol/L

Potassium

3,5 mmol/L

April, 5 2010

Blood Gas Analysis

(Oxygen 2 lpm)
PH
: 7,48
PCO2 : 30 mmHg
PO2
: 70 mmHg
HCO3 : 22,3 mmol/L
BE
: -1,2 mmol/L
O2 Sat : 95%

HBsAg (-)
Widal (-)
Urinalisis : normal limit

AP position

April, 5 2010

Consultation to Lung Departemen

A patient with bilateral pleural effusion that it
can be caused by underlying disease (DHF)
Evacuation 200 cc (Hemithorax D)
Haemorrhagic fluid
Pleural fluid analysis :
Cel = 200 sel/uL, mono nuclear cel = 15%, poli nuclear cel = 85%,
glucosa = 99mg/dL, protein = 3.3 g/dL, LDH = 3627 U/L,
rivalta positip

INITIAL ASSESSMENT
April , 5 2010

DHF gr II (5 th day) + Bilateral

Pleural Effusion

INITIAL PLANNING
April, 5 2010
Diagnostic
IgM & IgG anti dengue
Serial CBC

Therapy
Nasal O2 3 lpm
IVFD 1000 mL/24h
High Calorie High Protein 2100 kcal
Paracetamol 500 mg, tid, po
Monitoring
Vital signs, serial CBC

DISCHARGE

Platelet

Haematocrit
37%
11
61
34

32

11,7
34,5%

13,3
Haemoglobin
82

47
38

38

4,0

3,5

3,9

106

14

7
Fever Day

Respiration Rate
40
Leucocyte
4,1

20

13

Evacuation 800 cc (D) + 200 cc (S)

Haemorrhagic fluid

April, 6 2010 (Fever d6)

April, 8 2010 (Fever d8)

BP=120/80 , HR=72x/m , t= 37,50C,

rr=34x/m, IgM dan IgG positip
PPT= 18,3 s (15,1), APPT= 35,2 s (32,6)
O2 nasal 3 lpm, HCHP 2100 cal, RA 21
tts/mnt, Albumin 20% (100 cc), paracetamol
3x500 mg

BP=110/70 , HR=88x/m, t= 36,80C,

rr=38x/m
O2 masker rebreathing 10 lpm,
HCHP 2100 cal, Asering 1000 cc/
24 hr, paracetamol 3x500 mg

PROGRESS

April, 7 2010 (Fever d7)

BP=100/60 , HR=88x/m, t= 36,70C, rr=38x/m
BUN= 11 mg/dL, Sc= 0,8 mg/dL
AST= 189 IU/L, ALT= 246 IU/L, Alb= 3,1 g/dL
O2 masker rebreathing 10 lpm, HCHP 2100 cal,
Asering 1000 cc/ 24 hr, paracetamol 3x500 mg

April, 9 2010 (Fever d9)

BP=110/60 , HR=80x/m ,
t= 37,20C, rr= 40x/m
O2 masker rebreathing 10 lpm, HCHP 2100
cal, Asering 1000 cc/ 24 hr

April, 13 2010
BP=110/60 , HR=80x/m ,
t= 36,80C, rr=20x/m
DISCHARGE

PROGRESS

April, 12 2010
BP=100/60 , HR=88x/m ,
t= 36,30C, rr=24x/m
HCHP 2100 cal

DISCUSSION

Dengue infection
Fever
Anoreksia
vomiting

Bleeding
manifestation

Hepatomegali

Vascular
permeability

Trombocytopenia

Plasma leakage
Hemoconsentration
Hypoproteinemia
Pleural effusion
Ascites

Dehydration

Suchitra, 1993

Hypovolemia

DIC

Syok

GI Bleeding

Anoksia
Death

Acidosis

Indications for hospitalization

Tachychardia
Increased capillary refill time (>2 s)
Cool, mottled or pale skin
Diminished peripheral pulses
Changes in mental status
Oliguria
Sudden rise in haematocrit or continuously elevated
haematocrit despite administration of fluid
Narrowing of pulse pressure ( < 20 mmHg (2,7 kPa)
Hypotension ( a late finding representing uncorrected shock )

The World Health Organization (WHO) case definitions of

dengue haemorrhagic fever
Dengue haemorrhagic fever (DHF)

Patient

Fever or history of fever, lasting 2-7 days, occasionally

biphasic

Haemorrhagic tendencies

Thrombocytopenia (100,000 cells per mm3 or less)

Evidence of plasma leakage manifested by at least one of

the following :
a rise in the haematocrit equal or greater than 20% above
average for age, sex and population
a drop in the haematocrit following volume replacement
treatment equal to or greater than 20% of baseline
signs of plasma leakage such as pleural effusion, ascites
and hipoproteinemia. Definition of dengue shock
syndrome (DSS) : DHF cases with documented narrow
pulse pressure (< 20 mmHg), hypotension or other signs of
shock

PLEURAL EFFUSION

Accumulation of fluid between

the layers of the membrane that
lines the lungs and the chest
cavity
Normal: 1 mL of pleural fluid
Balance between
hydrostatic/oncotic forces
and lymphatic drainage
Abnormal: Pleural effusion
Disruption of balance

Pathogenesis of pleural effusion

Elevated capillary hydrostatic
pressure (cardiac failure)
Reduced capillary oncotic
pressure (hypoalbuminemia)
Enhanced capillary permeability
(inflammation)
Obstructed lymphatics (tumor)
Movement of fluid from
extrathoracic site (pancreatitis)

Light , 2002

 363 (DHF) Chest photo thorax 25%

with pleural effusion, mostly on the right
side (Wang, 2007)
Pleural effusion is mostly on the right
side, as a constant finding, but in shock
bilateral pleural effusion is a common
finding (Srikiatkhachorn, 2009)

Pleural Effusion must be evacuated

Shortness of breath
Massive pleural effusion
No coagulation dissorder

Guideline Management DHF

1: Management (Probable ) DHF ( Adult Without Shock)
2: Fluid Treatment DHF patient in the Emergency Ward
3: Management DHF with increased Ht > 20 %
4: Management Spontan Bleeding for Adult
5: Management DSS

Management DHF (Adult)

Suspect DHF
Spontan Bleeding dan Masif (-)
Syok (-)

-Hb, Ht (n)
-Platelet < 100.000
-Kristaloid Fluid
-Hb, Ht, Platelet / 24 hr

-Hb, Ht 10-20%
-Platelet < 100.000
-Kristaloid Fluid
-Hb, Ht, Tromb /12 hr

-Hb, Ht > 20%

-Platelet < 100.000

- management fluid
treatment DHF with
Ht > 20%
(2)

Criteria for discharging inpatients

Absence of fever for at least 24 h without the use of antifever

Return of appetite
Visible clinical improvement
Good urine output
Stable haematocrit
Passing of at least 2 days after recovery from shock
No respiratory distress from pleural effusion or ascites
Platelet count of more than 50.000 per mm3

SUMMARY
Report a woman 24 yo with dengue haemorrhagic
fever grd II and bilateral pleural effusion
Dengue hemorrhagic fever (DHF) is acute febrile
disseases which occur in the tropics, can be lifethreatening, and are caused by four closely related
virus serotypes of the genus Flavivirus, family
Flaviviridae self limited disease
Around the time of defervescence, DHF patients
localised plasma leakage manifested as
accumulation of fluid in pleural and abdominal
cavities and haemoconcentration.

...Contd
The extent of plasma leakage varies between
individual patients and can lead to intravascular
volume depletion requiring fluid resuscitation.
Pleural effusion is mostly on the right side, as a
constant finding, but in shock bilateral pleural
effusion is a common finding.

THANK YOU

Suramadu Bridge

Srikiatkhachorn, 2009

Clinical aspects

Dengue Virus
DEN-1, 2, 3, 4
Undifferentiated
fever

Dengue Fever
(DF)
Without
Hemorrhage

With unusual
hemorrhage

Dengue Hemorrhagic Fever

(DHF/DSS)
No shock
(DHF)

Shock
(DSS)

World Health Organization. Dengue Haemorrhagic Fever: Diagnosis, treatment,

prevention and control. 2 ed. 1997

Light, R. W. N Engl J Med 2002;346:1971-1977

PROGRESSION
April, 5-2010

April, 6-2010

April, 7-2010

April, 8-2010

April, 9-2010

Hb

11,9 g/dL

11,7 g/dL

13,1 g/dL

14,0 g/dL

13,3 g/dL

Leuco

11,3 x 103/ul

3,9 x 103/ul

4,0 x 103/ul

3,5 x 103/ul

4,1 x 103/ul

Thrombo

82 x 103/ul

61x 103/ul

47 x 103/ul

82 x 103/ul

106 x 103/ul

PCV

35,0%

37,0%

34,5%

BUN

11 mg/dL

11 mg/dL

SC

0,8 mg/dL

0,8 mg/dL

AST

396 IU/L

189 IU/L

ALT

353 IU/L

246 IU/L

Alb

2,3 g/dL

3,1 g/dL

Sodium

137,5 mmol/L

Potassium

3,5 mmol/L

Map showing the distribution of dengue fever in the world, as of 2006.

Map produced by the Agricultural Research Service of the US Department of Agriculture.
Source: Slide #8 of a presentation by Gary G. Clark, PhD, entitled "Dengue: An emerging
arboviral disease". Cyan: Areas infested with Aedes aegypti. Red: Areas with Aedes aegypti
and recent epidemic dengue fever

PROGRESSION

April, 5 2010

April, 12 2010

Hemorrhagic fevers

Family
Filovirid
ae

Arenaviri
dae

Bunyaviri
dae

Flavivirid
ae

Genus
Filoviru
s

Arenavi
rus

Virus
Ebola
Marburg
Lassa
New World
Arenaviridae

Nairovi
rus

CrimeanCongo
hemorrhagic
Rift Valley
fever
fever
Agents of
HFRS and HPS

Dengue
Yellow fever
Omsk HF

Kyasanur
Forest
disease

Phlebo
virus
Hantavi
rus
Flavivir
us

Disease
Ebola HF
Marburg HF
Lassa fever
New World HF
(Argentinean HF,
Bolivian HF, etc.)
Crimean-Congo
HF

Incubati
on
2-21
2-14
5-16
7-14

Vecto
rUnkn
own
Unkn
own
Roden
tRoden
t

3-12

Tick

Rift Valley Fever

HF renal
syndrome/
Hantavirus
DF, DHF, DSS
pulmonary
syndrome
Yellow fever
Omsk HF

2-6
9-35

Mosqu
ito
Roden
t

5-8
3-6
2-9

Mosqu
ito
Mosqu
ito
Tick

Kyasanur Forest
disease

2-9

Tick

DENGUE VIRUS
Bone Marrow
Stem cell
Macrophag
e

Lymphocytes
Ag-Ab complex

RES

Platelets

Thrombocytopenia

Hepatic disfunctions in dengue

Hepatocellular injury manifested
by hepatomegaly, elevation of
ALT, and coagulopathy are
common in DHF and even in DF,
although hepatomegaly is
absent.

Co-infection in dengue patients

Co - infection can modify clinical

presentations of dengue
disease and result in missed or
delayed diagnosis and
treatment and possible
misinterpretation as unusual
manifestations.

Management
Successful treatment of DHF
depends on early recognition
and careful monitoring of the
development of shock.

J Med Assoc Thai 2002; 85: S298 J Med Assoc Thai 2002; 85: S298- 301. Pediatr Pediatr Infect Infect Dis Dis J 1998; 17: 81 J 1998; 17: 81- 2. Med J Med J Aust Aust 1994; 160: 22
1994; 160: 22-6. 6.

DENGUE-MONOCYTES
Complemen
t
C3a, C5a

PLA2

Protein Binding

Lymphocyte
s activation

Proinflammator
y cytokine

IL-1
IL -6

TNF

Arachidonat metab

Eicosanoid

Prostacyclin
Thromboxsan
e
Leucotrienes

Malfunctio
n endothel

dystruction
endothel

INCREASED VASCULAR
PERMEABILITY

CAPILLARY LEAKAGE

Nasronudin, 2005

Dengue shock syndrome

Antibody level

Immune Response to Dengue infection

Secondary infection:
Low levels of IgM (may not be produced or
at undetectable levels in 20% of patients).
IgG rise rapidly 1-2 days after onset of
symptoms at higher levels than primary
infection.

Primary infection:
High level of IgM that appears 4-6
days after symptoms and may persist
for up to 10 weeks.
IgG appears 2 weeks after onset and
persists for life.
Clinical Symptoms,
Fever

NS1 Ag

Clinical Symptoms,
Fever

IgG antibodies

NS1 Ag

Virus

Virus

Primary Infection

Secondary Infection

IgM antibodies

SUMMARY
Points of Events

Sept, 25

Sept, 27

Oct, 5

Oct, 9

Oct, 14

ICU Setting
Tamiflu (Oseltamivir)
Antibiotics
Ventilatory Support
H5N1 positive

H5N1 negative

50
45
40
35
30
25
20
15
10
5
0
Category 1

Category 1

PROGRESSION
BLOOD GAS ANALYSIS
O2 Saturation 99
pH
pO2
CO2
Saturation

7.559

7.48

109

7.46
34
59

26.4

34
54

<60
Sep, 25 2006

Sep, 26 2006

Intermediate Care

<60
Sep, 27 2006
Intensive Care

April, 6 2010 (Fever d6)

BP=120/80 , HR=72x/m ,
t= 37,50C, rr=34x/m

April, 8 2010 (Fever d8)

BP=110/70 , HR=88x/m,
t= 36,80C, rr=38x/m

Hb=11,7 g/dL, L= 3,9 x 103/ul

T= 61x 103/ul, HCT= 37,0%
IgM dan IgG positip

Hb= 14,0 g/dL, L= 3,5 x 103/ul

T= 82 x 103/ul

PROGRESS

April, 7 2010 (Fever d7)

BP=100/60 , HR=88x/m, t= 36,70C,
rr=38x/m
Hb=13,1 g/dL,L=4,0 x 103/ul, T= 47 x 103/ul
HCT= 34,5%, BUN= 11 mg/dL, Sc= 0,8 mg/dL
AST= 189 IU/L, ALT= 246 IU/L, Alb= 3,1 g/dL

April, 9 2010 (Fever d9)

BP=110/60 , HR=80x/m ,
t= 37,20C, rr= 40x/m
Hb=13,3 g/dL, L= 4,1 x 103/ul, T= 106 x 103/ul
Evacuation of pleural effusion > OK paru
800 cc (D) & 200 cc(S)

April, 13 2010
BP=110/60 , HR=80x/m ,
t= 36,80C, rr=20x/m
DISCHARGE

PROGRESS

April, 12 2010
BP=100/60 , HR=88x/m ,
t= 36,30C, rr=24x/m

April, 12 2010