Correction

Non pitting edema (p11)pitting edema

English Case
Report

A BOY WITH COMPENSATED DENGUE SHOCK

SYNDROME, WELL NOURHISED, NORMOWEIGHT,
NORMOHEIGHT
Presented by : Bayu Prabowo
Supervisor :
dr. H. Rustam Siregar, Sp.A
dr. Husnia Auliatul Umma, Sp.A, M.Kes

Dengue virus
1.
Flavivirus
genus and
flaviviridae
family.
2. RNA
virus.
3.
Stegomya
aegepty
and
stegomya
albopictus
as vector.
3

Introduction

Especially in tropic and subtropic areas.

More common in >5 y.o
Indonesia is A cateogory
8% DSS
2.5% died
4

IDENTITY
NAME
: TDS
AGE
: 7 YEARS AND 2 MONTHS OLD
GENDER
: BOY
WEIGHT / HEIGHT : 18 KG / 120 CM
MR NUMBER
: 01334773

Chief complaint
Fever

PRESENT ILLNESS HISTORY

Morning before admission

Looked weak taken to a private
clinic
laboratory examination :
Hb 12.7 g/dl, Hct 35.9%,
platelets 127,000/ul, WBC 4,200/
ul.
The gums started bleeding, which
could stop themselves.
Abdomen pain, headache, and
muscle pain.
decreased appetite.
decreased fever

At the ER Dr Moewardi
Weak
No fever
No Cough
Last Urination : 8 hours before
admission (cloudy)
Normal Defecation

Past medical
history

previous hospitalization (-)

common cold and cured when taking medication from
the clinic.
nose bleeding and gum bleeding (-)

history of
family illness

None of the family members complained of fever, cough,

and runny nose.

Environment
al history

school friends suffered from dengue fever

No neighbours who are sick with dengue fever
The patient live in a village with a lot of vacant land and
rice fields.
9

History of pregnancy and birth

Spontaneus delivery helped by midwife with a birth weight of

3800 grams, body length of 50 cm
9 months of gestational age
Crying vigorously, bluish & yellowish denied, clear
amniotic fluid .
Routine pregnancy control, Illness during pregnancy (-)
Conclusion : normal pregnancy and delivery

10

Immunization history
BCG immunization 1 m.o
Hepatitis B immunization 0 , 2 , 3 & 4 m.o
DPT immunization 2 , 3 & 4 m.o
Polio immunization 1 , 2 , 3 & 4 m.o
Measles immunization 9 m.o
Immunization history at school during the first grade, but the kind of
immunization is unknown
Conclusion : Complete basic immunization based on Health Ministry
recommendation
11

History of nutrition
patients received breast milk from birth to 2 years of age
accompanied by formula milk
Since 6 months old, patients also received supplementary food,
ages 8 months began to eat porridge and the age of 1 year eat
with family menu
Now eat three times a day with rice, side dishes and vegetables
varies
Conclusion : good nutrition in quantity & quality

12

Growth history
current weight 18 kg with height 120 cm
The patient grows normally as his age.

Developmental history
Leaning age of 4 months, 5 months old on his stomach, sat at the age of 7
months, standing at 12 months and walked at 13 months.
Currently the patient is in grade 1 primary school, easy to get along with
friends, average achievement in class.
The impression of age-appropriate growth and development

Conclusion : growth & development are in

concordance with his age
13

Socioeconomic history
Single child
The 37-year-old father, javanese, islam, senior high school
graduated, an entrepreneur
The 35-year-old mother, javanese, islam , junior high school
graduated, a housewife
Family income of about Rp.2.000.000,00/month
Neighborhood health : health centers

Conclusion : middle income

14

Family tree

15

Nutritional status
BW/A = 18/23 100% = 78%; P10 <BW/A < P25
Normal weight
BH/A = 120/123 x 100% = 97%; P25 < BH/A < P50
Normal height
BW/BH = 18/22 x 100% = 81%; P10 < BB/TB < P25
Well nourish
Conclusion : well nourished, normal weight, normal height (CDC
2000)
16

Physical examination
the general state : weak, fully awake, GCS
E4V5M6
Blood pressure 90/75 mmHg
Heart rate : 125 bpm, regularly,
inadequate filling
Respiratory rate 22 times/min, regular
temperature : 37.1C,
Oxygen saturation : 97 %
17

Head
normocephal curly difficult repealed

Eye
sunken eyes (-), anemic conjunctiva (-), bleeding sub conjunctiva (-), and icteric
sclera (-), isocoric pupils (2mm / 2mm), light reflex(+ / +) and periorbital edema (+)
Nose
nasal flare (-), secret (-), and blood clot(-).
Mouth
Wet oral mucosa , acyanosis and bleeding gums, found traces of blood in the mouth,
pharynx and tonsils T1 / T1 : no hyperemia
neck
no lymphnodes enlargement.

18

Thorax
retraction (-)
Cardiac
I
: invisible ictus cordis
P : ictus cordis palpable in ICS VI left mid clavicula line
P : upper right heart border in ICS II right parasternal line upper left in ICS III left
parasternal line, right bottom in ICS IV right parasternal line, the apex in ISC IV left mid
clavicula line
A : normal I-II heart sound, regular, no murmur or gallop
Pulmo

I
P
P
A

: symmetric , the motion of right lung lagging

: decreased fremitus in the right lung
: dimmed in the lower right lung
: decreased vesicular sound in the right lung, no additional sound
19

Abdomen

I : the abdominal wall parallel to the chest wall

A : peristaltic sound were normal
P : tympani
P : epigastric tenderness, liver palpable 2 cm below the right
costal arch, flat surface sharp edges. No spleen enlargement,
normal abdominal turgor. Abdominal circumference : 45 cm.

Extremity
cold , edema (-), capillary refill time of more than 2 seconds,
dorsalis pedis artery : weak palpable
Inguinal
No edema. No lymphonody enlargement
20

Laboratory test
Routine blood tests :
haemoglobin 14.7 g/d
haematocrit 45% (before 35.9%, increase 25%)
erythrocytes 5,390,000/uL
leukocytes 5,900/uL
platelet 98,000/uL
MCV 82.2/uL
MCH 28.3 pg
MCHC 33.2 g/dl
RDW 11.9%
Erytrocyte sedimentation rate 15 mm/hour

21

RLD X ray

PLEURAL
EFFUSION
INDEX : 38%

22

PROBLEM LIST : A boy 7 yo with weight 18 kg

High fever since 4 days

Epigastric tenderness

Weakness

Gum bleeding

Liver was palpable 2 cm below the

right costal arcg

cold

capillary refill time > 2 seconds

dorsalis pedis artery weak palpable

Hb 14.7 g/dl

Hct 45% (Hct before 35.9%)

trombosit 98 ribu/ul

Sedimen erytroicyte rate 15 mm/hour

RLD X ray effusi pleura (effusi pleura

index : 38%)
23

Headache
Abdominal pain
Heart rate 125 bpm
Blood pressure 90/70 mmHg
edema palpebra
traces of blood in the mouth
decreased vesicular breath sounds in
the right lung

Differential diagnosis
Compensated Dengue shock syndrome with
hypovolemic shock with septic shock

24

Working diagnosis

Compensated DSS
Well nourished, normal weight,
normal height
25

Therapy
Admission to HCUfullinfection ward
Diet 1800 kkal/day
Loading Asering 20c/kgBW in an hour evaluation after
loading
Paracetamol 20mg/kgBW loading 350mg, after that 15
mg/kgBW/x = 250mg if fever

26

After loading
S

No fever

Composmentis
HR : 96 bpm
RR 22 times/minute
BP : 100/70mmHg
warm, capillary refill time<2 seconds,
dorsalis pedis arteri : strong palpable

Same

Asering reduce 7 ml/kgBW = 126 mL/hour

27

Diagnostic & Monitoring plan

diagnostic :

routine urinalysis
stool examination
Routine blood examination per 8 hours
IgG-IgM dengue fever on day 5 (2nd April)
Peripheral blood morphology

Monitoring :
general condition, vital signs & blood pressure/4 hours
fluid balance and diuresis/8 hours
Routine blood examination/8 hours
28

date

April 1st 2016 (06.00)

Fever (-), weak (+), headache (+), abdominal pain (+), nose bleed(-), gum bleeding (-), still lose of
appetite, normal urinate. D :1.3 ml/kgBW/hour, fluid balance +130cc

the general state : weak, fully awake, GCS E4V5M6

BP 100/70 mmHg, HR: 108bpm, RR 22times/mnt, remperature : 37.1C,
Head : normocephal, sunken eyes (-), anemic conjunctiva (-), icteric sclera (-), palpabra edema (+)
nasal flare (-), secret (-), and blood clot(-). Wet oral mucosa , acyanosis and bleeding gums,.
Thorax : retraksi (-)
Pulmo ;I the motion of right lung lagging. P : decreased fremitus in the right lung. P : dimmed in the lower
right lung. A : decreased vesicular sound in the right lung, no additional sound
Abdomen : I : the abdominal wall parallel to the chest wall. A : peristaltic sound were normal. P : tympani. P
:
epigastric tenderness, liver palpable 2 cm below the right costal arch, No spleen enlargement,Abdominal
circumference : 45 cm.
Extremity : warms, edema (-), capillary refill time <2 seconds, dorsalis pedis artery : strong palpable
Inguinal : No edema. No lymphonody enlargement

Lab

Hb

13.7 g/d

Hct

42%

Leukosit

6.2 103/ul

Trombosit

1.24 mmol/L

Eritrosit

5.12 106/ul.

Peripheral blood smear

Suggested Viral infection

urinalisa

normal

faeces

normal

29

date

April 1st 2016 (06.00)

1. Compensated DSS
2. Well nourished, normal weight, normal height

Diet 1800 kkal/day

IVFD Asering reduce 5mL/kgBW in an hour 90 ml/hour
Paracetamol 15 mg/kgBW/x = 250mg if fever
Plan : Routine blood examination per 8 hours

IgG-IgM dengue fever on day 5 (2nd April)

Monitoring :
general condition, vital signs & blood pressure/4 hours
fluid balance and diuresis/8 hours
Routine blood examination/8 hours

30

date

april 1st 2016 (14.00 & 22.00)

Fever (-), weak (+), headache (+), abdominal pain (+), nose bleed(-), gum bleeding (-), still lose of
appetite, normal urinate.

the general state : weak, fully awake, GCS E4V5M6

BP 105/70 mmHg, HR: 100bpm, RR 22times/mnt, remperature : 37.2C,
Head : normocephal, palpabra edema (+), blood clot(-), bleeding gums, (-)
Thorax : cardio and pulmo :stationer
Abdomen : stationer
Extremity : warms, edema (-), capillary refill time <2 seconds, dorsalis pedis artery : strong palpable
Inguinal : No edema. No lymphonody enlargement
14.00

22.00

Hb

16 g/dl

16.2 g/dl

Hct

47%

45%

PLT

91.103/u
l

68.103/ul

Leu

12.8
103/ul

9.8 103/ul

lab

Rbc

1. Compensated DSS
2. Well nourished, normo weight, normo height

31

 Planing
Diet 1800 kkal/day
IVFD Asering increase 7mL/kgBW 126 ml/hour
Paracetamol 15 mg/kgBW/x = 250mg if fever
Increase oral intake
Plan : Routine blood examination per 8 hours
IgG-IgM dengue fever on day 5 (2nd April)
Monitoring :
general condition, vital signs & blood pressure/4 hours
fluid balance and diuresis/8 hours
Routine blood examination/8 hours
32

date

april 2nd 2016 ( 06.00,14.00 & 22.00)

Fever (-) 2 day, weak (+), headache (+) and abdominal pain (+) but decrease, nose bleed(-), gum
bleeding (-), lose of appetite decrease, normal urinate, genetalia edema + . Fluid balance +320ml.
D : 2.3 ml/kgBW/hour

the general state : weak, fully awake, GCS E4V5M6

BP 90/60 mmHg, HR: 94bpm, RR 20times/mnt, remperature : 36.6C,
Head : normocephal, palpabra edema (+) , blood clot(-), bleeding gums, (-)
Thorax : cardio and pulmo :stationer
Abdomen : stationer
Extremity : Felt warms, edema (-), capillary refill time <2 seconds, dorsalis pedis artery : strong palpable
Inguinal : pitting edema, transluminasi (+) palpable testis(+) No lymphonody enlargement

lab

07

14.00

22.00

Hb

15.9 g/dl

12.1g/dl

12.5g/dl

Hct

45%

36%

36%

Plt

91.103/ul

48.103/ul

58.103/ul

leu

12.8 103/ul

9.103/ul

5.6.103/ul

IgG/I
gM

+/+

1. Compensated DSS
2. Well nourished, normo weight, normo height

33

P :
Diet 1800 kkal/day
IVFD Asering 7mL/kgBW 126 ml/hourreduce
5mL/kgBW at 14.00reduce 3mL/hour at 22.00
Paracetamol 15 mg/kgBW/x = 250mg if fever
Increase oral intake
Plan : Routine blood examination per 24 hours
Monitoring :
general condition, vital signs & blood pressure/4 hours
fluid balance and diuresis/24 hours
Routine blood examination/8 hours

34

date

april 3rd 2016 ( 06.00)

Fever (-) 3 day, weak (+), headache (-) and abdominal pain (-), nose bleed(-), gum bleeding (-),
better appetite, normal urinate, genetalia edema + . Fluid balance +340ml. D : 2.3
ml/kgBW/hour

the general state : weak, fully awake, GCS E4V5M6

BP 90/60 mmHg, HR: 94bpm, RR 20times/mnt, remperature : 36.6C,
Head : normocephal, palpabra edema (-) , blood clot(-), bleeding gums, (-)
Thorax : cardio and pulmo :stationer
Abdomen : stationer
Extremity : Felt warms, edema (-), capillary refill time <2 seconds, dorsalis pedis artery : strong palpable
Inguinal : decrease pitting edema, transluminasi (+) palpable testis(+) No lymphonody
enlargement

lab

07

Hb

11.6 g/dl

Hct

34%

Plt

74.103/ul

leu

5.4 103/ul

IgG/I
gM

+/+

1. Compensated DSS

35

P :
Diet 1800 kkal/day
IVFD D5 NS maintenence
Increasing oral intake
Plan : discharge

36

Dengue infection manifestation

37

Phase

38

This patient

Patient arrived on
day 4

39

Clinical
manifestatio
ns

Fever: acute onset, high and continuous, lasting two

to seven days in most cases
haemorrhagic manifestations including a positive
tourniquet test, petechiae, purpura, ecchymosis,
epistaxis, gum bleeding, and haematemesis and/or
melena.
Hepatomegaly
Shock, (tachycardia, poor tissue perfusion with weak
pulse and narrowed pulse pressure (20 mmHg or less)
or hypotension with the presence of cold, clammy skin
and/or restlessness.

Laboratory findings

Thrombocytopenia (100.000 cells/mm3 or less)

Haemoconcentration; haematocrit increase of
20%i from the baseline of patient or population
40
of the same age

Diagnosis
Two clinical criteria + thrombocytopenia and
haemoconcentration or a rising haematocrita clinical
diagnosis of DHF.
The presence of liver enlargement in addition to the first
two clinical criteria is suggestive of DHF before the onset of
plasma leakage.

41

 Fever: acute onset, high and continuous, lasting

two to seven days in most cases

haemorrhagic manifestations including a positive
tourniquet test, petechiae, purpura, ecchymosis,
epistaxis, gum bleeding, and haematemesis
and/or melena.

Clinical
manifestatio
Hepatomegaly
ns

(tachycardia, poor tissue perfusion

with weak pulse and narrowed pulse
pressure (20 mmHg or less) or hypotension

Shock,

with the presence of cold, clammy skin

Laboratory findings

Thrombocytopenia (100.000 cells /mm3 or

less)

Haemoconcentration;

of 20%i

haematocrit increase42

from the baseline of patient or population of

Classification

43

This patient

44

Therapy

45

This patient

Patient got RL 20 mL/kgBB in an hour

Patient had improvement and reduced the fluid rate from 7, 5, 3

mL/kgBB/hour and stopped on day 3 of admission (fever day 6).
46

47

This Patient

48

Thank you
49

50

pathogenesis

51

Pathophysiology

52

Pathophysiology of dengue shock

syndrom
Still controversial
Two theories, which are not mutual exclusive :
1. Secondary infection or immune enhacement
hypothesis
2. Viral virulence theory

53

54

55

56

57

Vector Control Methods:

Biological and Environmental Control
Biological control
Largely experimental
Option: place fish in containers to eat larvae
Environmental control
Elimination of larval habitats
Most likely method to be effective in the long term
Chemical Control:
Larvicides may be used to kill immature aquatic stages
Ultra-low volume fumigation against adult mosquitoes
Mosquitoes may have resistance to commercial aerosol
sprays

58