PEDIA Case 4.1. Dengue Fever

Pamantasan ng Lungsod ng Maynila College of Medicine Department of Pediatrics

PEREZ, William 3A Date of Interview: January 8, 2015 Informant: Patient and Mother of the patient

Pediatrics 2 Time of Interview: 1:00pm Reliability: 90% GENERAL DATA

J.C.A. is a 15 year-old male, currently living in Sta Ana, Manila. He was admiited at Ospital ng Maynila Medical center last January 7, 2015 at around 8:00 pm CHIEF COMPLAINT Rashes HISTORY OF PRESENT ILLNESS 3 days PTA. Patient had chills and fever with undocumented temperature. He was given paracetamol (Aldol) 500 mg every 6 hours and tepid sponge bath was done with afforded relief. Patient also complained of dizziness, anorexia and backache. No reported symptoms like easy fatigability, headache, cough and colds, or irregular urine patterns. Patient did not seek consult. Symptoms persist until 1 day PTA 1 day PTA. Persistence of symptoms were noted accompanied by 1 episode of greenish to black colored stool. Patient had phenylephrine HCl+ chlorphenamine maleate+ paracetamol (Bioflu) 500 mg taken every 6 hours with relief of fever. Day of Admission. Fever, Admission.  Fever, dizziness, anorexia and backache persist accompanied by pulsatile headache located in the crown of the head with a pain scale of 5/10. No other medication was taken. Parents also noted presence of pinpoint rashes on the arms which prompted consult in a private clinic and referred them to OMMC. REVIEW OF SYSTEM Constitutional HEENT Head Eyes Ears Nose and sinuses Mouth and Throat Respiratory Cardiovascular Gastrointestinal Genitourinary Endocrine Musculoskeletal Nervous/behavioral

(-) weight gain (-) lightheadedness (-) syncope (-) trauma (-) use of eye glasses (-) eye pain (-) blurred vision (-) discharge (-) discharge (-) hearing problem (-) discharge (-) tenderness (-) epistaxis (-) dysphagia (-) bleeding gums (-) hemoptysis (-) dyspnea (-)orthopnea (-) PND (-) chest pain (-) palpitations (-) vomiting (-) diarrhea (-) constipation (-) abdominal pain (-) flank pain (-) swelling (-) excessive sweating (-) weakness (-) spasticity (-) paresthesia (-) numbrness (-) convulsions

PAST MEDICAL HISTORY Childhood immunizations include 1 dose of BCG, and measles vaccine, 2 doses MMR and 3 doses Hep B, DPT, and OPV. He doesn’t have any allergies to food or medications but patient had a skin asthma once in 2010. No previous hospitalizations and surgical procedure done. No history of recent travel to

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PERSONAL HISTORY FEEDING HISTORY

HOME

Patient had a good appetite. He eats 3 meals per day with snacks in between. His breakfast usually consists of bread or noodles and egg. His lunch or dinner usually consists of 1 cup of rice, 1 serving of meat/fish but he doesn’t like to eat vegetables.  His favorite food is sinigang and he regularly takes Cherifer capsules. Patient lives with his parents, 3 siblings and 2 nieces in a studio type apartment with one bedroom and one comfort room for 15 years. r 

EDUCATION

Patient is currently in 3  year high school. He goes to school regularly and doing fine in his study. His favorite subject is mathematics. He mingles well with his classmates and at par with age. No frequent school changes, repetition of grade or learning disability reported.

ABUSE AND DRUGS

No history of emotional or sexual abuse. Denies smoking, alcohol intake or use of prohibited drugs.

SAFETY

No suicidal attempts or hazardous behaviors

SEXUALITY

Patient is not sexually active. He has a girlfriend and goes out with her occasionally

FAMILY/ FRIENDS

Parents are married and he is the youngest among 3 siblings. He is closest to his mother.

IMAGE

Patient doesn’t see himself as fat and doesn’t want to get fat or gain weight.

RECREATIONAL

Patient usually sleeps for 8 hours. He loves playing basketball with friends as well as computer games, and surfing the net. He also goes to the mall from time to time with his friends or his girlfriend.

SPIRITUALITY AND CONNECTEDNESS

Patient is a Roman Catholic and he attends mass regularly with his parents.

THREATS AND VIOLENCE

No reported self-harm or harm inflicted by others.

FAMILY HISTORY Father of the patient is a 58 years old and a hypertensive. His mother, aged 50, apparently well. He has 3 siblings: aged 31, 25 and 22 years old. All of his siblings are apparently well and no known medical condition. No history of family members recently affected with dengue. No history of stroke, cardiac disease, cancer, asthma or tuberculosis in the family. SOCIOECONOMIC HISTORY Father of the patient is a house painter while her mother is a housewife. The source of income of the family is coming from his father and 2 elder siblings. ENVIRONMENTAL HISTORY Patient is exposed to smoke because both parents are smokers. Their source of drinking water is mineral water. Their garbage is being collected daily and their water source is NAWASA. No epidemic of any disease in their area and environment is peaceful. GENERAL SURVEY Patient was seen awake, alert and ambulatory. He was not ill-looking and appeared well-nourished. He was not in cardiopulmonary distress. Acute illness observational scale score of 8

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VITAL SIGNS The patient is at rest but awake when VS were taken. o Temperature: 37.9 C, axillary (febrile) Respiratory Rate: 20 breaths per min Cardiac Rate: 104 compressions per minute Blood Pressure 120/80 mmHg ANTHROPOMETRIC DATA

Weight Height BMI

48 kg 1.55 m (5 feet and 1 inch) 20 kg/m

Patient is 15 years old and has a height of 155 cm. Based on the graph, z-score is below -1. This suggests that the patient has a normal height for age.

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Patient is 12 years old and has a BMI of 20 kg/m2. Based on the graph, z-score is bin between 0 and 1. This suggests that the patient has a normal BMI for age.

PHYSICAL EXAMINATION Skin

Patient skin was pinkish and no jaundice or cyanosis were noted. Pox marks were noted on her abdomen. Skin was warm to touch and with good skin turgor .

Head and Scalp

Hair is black and evenly distributed on the scalp, coarse hair, neither lice nor nits were noted. Head is rounded and symmetrical without lumps, lesions or swelling.

Face

Face and facial expression is symmetrical. No facial deformities, lesions and lumps were noted.

Eyes

Eyes and eyebrows are symmetrical. Lids are symmetrical with no ptosis, ectropion and entropion. Anicteric sclera was noted. palpebral conjunctiva was pink and there was neither swelling nor discharges found. Red orange reflex was noted for both eyes and fundi were yellowish with discrete margins.

Ears

Ears are symmetrical. No discharge from the ear canal. No presence of lesions noted. No grimace on the face when the outer ear was touched. Ear canal revealed scanty dried cerumen but tympanic membrane was not observed because patient refused.

Nose and Sinuses

Patent nares on both sides. No alar flaring. No nasal discharge. Nasal septum is midline of two nares. No nasal obstruction. No sinus tenderness. Pinkish and moist turbinates were noted.

Mouth and Throat

Lips: Pink, moist without excoriations. No circumoral pallor or cyanosis. Gums: Pinkish, without lesions or bleeding.

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Tongue: Not enlarge, pinkish, moist, no ulcers, no abnormal movements and in midline. Oropharyngeal mucosa: Pinkish, no thrush, vesicles nor ulcers. Palate and uvula: Pinkish, no petechiae, ulcers, thrush, vesicles. Uvula is pinkish, midline, not enlarged. No excessive drooling. Tonsils: Pinkish. Tonsillar size grade 0. Neither exudates nor adherent membrane noted. Neck

No rigidity observed. Trachea present at the midline. No palpable masses nor lymph nodes noted. Thyroid gland not palpable.

Chest and Lungs

Inspection: Transverse diameter is greater than anteroposterior diameter. No presence of deformities or asymmetry noted. Presence of petechiae were noted both on the chest and at the back. Neither retractions of interspaces during inspiration nor use of accessory muscles when breathing were noted. Palpation: Chest expansion is symmetrical. No palpable masses and no tenderness noted. Percussion: Symmetrical, resonant breath sounds in both lung fields.  Auscultation: Vesicular breath sounds heard throughout both lung fields. No wheeze, stridor, crackles.

Precordium and Heart

Inspection: Adynamic precordium. No visible pulsation. Apex beat not visible. th Palpation: PMI is approximately 2 cm in diameter palpated at the left 5  intercostal space midclavicular line occupying only 1 ICS. No precordial heaves, thrills and substernal thrust.  Auscultation: S1 best heard at apex, S2 heard best at the base. S2 split inaudible during inspiration. No S3, S4, OS, systolic clicks and other extra heart sounds heard. No bruit. No murmur.

 Abdomen

Inspection: Flat abdomen. Umbilicus is inverted. Petechiae were present all over the abdomen. No visible dilated veins, striae or scars.  Auscultation: Bowel sounds rate of 3/minute heard at right lower quadrant. No bruit noted. Percussion: Dullness on RUQ and epigastrium but tympanitic in the rest of the abdomen. Liver span of 8 cm at right midclavicular line. Negative splenic percussion sign. Palpation: Direct tenderness and abdominal guarding in the epigastric area was noted. Liver edge and spleen are not palpable. No mass palpated. Kidneys not palpable.

Neurologic Exam

Neurologic Examination of the patient is essential normal.

MENTAL STATUS EXAMINATION Patient was conscious, awake and oriented into place but not time. His immediate, recent and remote memory was intact. He was able to follow the command given. Overall, patient was able to perform executive functions like memory, language, speech perception and object recognition significantly well. Mental State A. Orientation (Time and Place) B. Immediate Recall 1. Subtraction C. Recall 1. Naming 2. Repetition 3. Three-Stage Command 4. Reading 5. Writing

Parameter Was able to identify correctly the date (day, month, year, time of the day) and her location (hospital, city, country) Was able to recite immediately the ff: Mata, Bola, Papel 93, 86,79, 72, 65 Was able to recall the ff: Mata, Bola, Papel Was able to identify objects shown: watch and pen Was able to repeat “No ifs, ands, or buts.” Was able to follow three-stage command: Takes paper in right (dominant) hand, folds paper in half and puts paper on bed Was able to read (and follow) written instruction Was able to write a sentence

Patient’s

Response 10/10

3/3 5/5 3/3 2/2 1/1 3/3 1/1 1/1

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6. Copying

Was able to copy/draw pentagon Total:

CRANIAL NERVES: Olfactory (I) Optic (II)

1/1 30/30

Intact sense of smell Visual acuity: 20/20  on both eyes. Visual fields intact on all fields.

Optic (II) and Oculomotor (III)

Direct and consensual response showed both pupils are equally round reacting to light.

Oculomotor (III), Trochlear (IV),  Abducens (VI)

Conjugate extraocular movements of both eyes were noted for all six directions. Nystagmus was not observed and there was no difficulty converging his eyes.

Trigemina (V)

Contractions of temporal and masseter muscles were felt on both sides of the face. Patient was able to detect light touch on both sides of the face. Intact corneal reflex was noted.

Facial (VII)

Facial movements are symmetrical at rest and upon movement. Palpebral fissures, nasolabial folds and corners of the mouth were symmetrical.

Vestibulocochlear (VIII)

Patient was able to hear whispered voice at 2 ft . Weber and Rinne test not performed.

Glossopharyngeal (IX), Vagus and (X)

Gag reflex present; uvula is in the midline. No hoarseness.

Spinal Accessory (XI)

Upon inspection, no atrophy and fasciculation were noted in the trapezius muscle. Patient was able to shrug both shoulders against resistance. Patient was able to turn their head/face against resistance on both directions

Hypoglossal (XII)

The tongue does not exhibit signs of weakness or deviation as it was able to push against resistance equally on both sides.

MOTOR EXAMINATION Muscles in the extremities are symmetric in size and bulk without wasting, hypertrophy of fascicultions. No involuntary movements were observed. No rigidity, spasticity, flaccidity. Patient had a grade of 5/5 for all major muscle groups. SENSORY EXAMINATION Patient was able to accurately detect the pain sensation on all location and was able to differentiate sharp from dull sensation on all extremities. He was able to correctly identify the position of her big toe as well as the objects placed on her hand which signifies intact proprioception and stereognosis, respectively. REFLEXES The patient has grade 2+ (normal) for knee reflex and brachial reflex.

SALIENT FEATURES fever with 3 days duration tachycardia (104 compression/minute)   petechiae

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  chills   backache   anorexia   headache no abdominal pain, vomiting, liver enlargement

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APPROACH TO DIAGNOSIS The presenting manifestation of the patient is rashes. Approach to diagnosis will be based on the presenting manifestation that points to a GROUP OF DISEASE OR DISORDERS.

Petechiae

Infectious

Noninfectious

Bacterial Infection

Viral Infection

Dengue Virus Infection

Vasculitis

Strep Throat

DIFFERENTIAL DIAGNOSIS CRITERIA FOR RULING IN Strep Throat

  fever   tachycardia   headache muscle pain (backache)  petechial rash

CRITERIA FOR RULING OUT  no throat pain  no difficulty swallowing  tonsils grade 0  no lymphadenopathy

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RULED OUT Vasculitis

  fever   headache muscle pain (backache)  petechial rash

 no numbness or weakness  no ulcerations  no tingling sensation

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RULE OUT Dengue fever

  fever   tachycardia   headache muscle pain (backache)  petechial rash CANNOT TOTALLY RULE OUT

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WORKING DIAGNOSIS: DENGUE FEVER WITHOUT WARNING SIGNS Dengue is a disease with a wide spectrum of clinical presentation often with unpredictable clinical progression and outcome. It is considered to be endemic in the Philippines and continue to be significant causes of morbidity and mortality here in the country. Early recognition of patients who may rapidly develop more severe clinical disease is crucial in order to facilitate hospital admission or referral and institute urgent management. The incubation period is 1-7 days. The clinical manifestations are variable and are influenced by the age of the patient. For this case, the patient manifested with sudden onset of fever, severe back pain accompanied by anorexia and headache which are common manifestation to adolescent patients. Also appearance of petechial rash was noted on the day of admission. No presence of abdominal pain, persistent vomiting, bleeding tendencies, signs of fluid accumulation like edema, difficulty of breathing, ascites were noted. Based on the clinical manifestations of the patient, his case is considered under the classification of Dengue Fever Without Warning Signs.

DIAGNOSTIC WORK-UP Clinical diagnosis of dengue fever derives from high index of suspicion and a knowledge of geographic distribution and environmental cycles of causal viruses. . COMPLETE BLOOD COUNT CBC is use to monitor changes in blood parameters that may indicate progression of the disease. Leukopenia, often with lymphopenia, is observed near the end of the febrile phase of illness. Lymphocytosis with atypical lymphocytes, commonly develops before defervescence or shock. A hematocrit level increase greater than 20% is a sign of hemoconcentration and precedes shock Hematocrit level should be monitored at least every 24 hours to facilitate early recognition of dengue hemorrhagic fever and every 3-4 hours in severe cases of DHF. Thrombocytopenia less than 100,000 cells/μL are seen in DHF or DHS and occur before defervescence and the onset of shock. Platelet count should be monitored every 24 hours to facilitate early recognition of DHF.     

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SERUM STUDIES  Demonstration of a fourfold or greater change in reciprocal immunoglobulin G (igG) or immunoglobulin M (IgM) antibody titers to one or more dengue virus antigens in paired serum samples. 

COAGULATION STUDIES

Coagulation studies may help to guide therapy in pati ents with severe hemorrhagic manifestations. Findings are as follows:   

Prothrombin time is prolonged Activated partial thromboplastin time is prolonged Low fibrinogen and elevated fibrin degradation product levels are signs of disseminated intravascular coagulation

METABOLIC PANEL Watch out for hyponatremia and metabolic acidosis specially if patient progresses to DHF Elevated BUN may indicate decrease renal perfusion due to shock  

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MANAGEMENT A. FLUID RESUSCITATION Obtain reference hematocrit before intravenous therapy begins. Give only isotonic solutions such as 0.9% saline, Ringer’s lactate Since the patient can drink, encourage oral fluids. If not tolerated, start isotonic IV fluid therapy of 0.9% NaCl (saline) or Ringer’s Lactate with or without dextrose at maintenance rate. Isotonic solutions are appropriate for Dengue patients without warning signs who are admitted but without shock. 

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ORAL REHYDRATION Since patient can drink, oral rehydration solution should be given based on weight, using currently recommended ORS. For 30-60kg body weight, the recommended ORS to be given is 40-50 ml/kg/day. Sports drinks should not be given INTRAVENOUS REHYDRATION THERAPY REHYDRATION PHASE: 3-5 cc/kg/hr (weight: 48kg) to run for 4-8 hours 3 x 48 = 144 cc/hr; 5 x 48 = 240 144 – 240 cc/hr for 8 hours 

MAINTENANCE PHASE 2-3 cc/kg/hr (weight 48 kg) to run for 24 hours 2 x 48 = 96 cc/hr 3 x 48 = 144 cc/hr 96 – 122 cc/hr for 24 hours 

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Periodic assessment is needed so that fluid may be adjusted accordingly. Clinical parameters should be monitored closely and correlated with the hematocrit. this will ensure adequate hydration, avoiding under and over hydration. The IVF rate may be decreased anytime as necessary based on clinical assessment.

B. CONTINUOUS MONITORING Patient should be monitored until the period of risk is over. A detailed fluid balance should be maintained. Parameters that should be monitored include: vital signs, temperature pattern and peripheral perfusion (every 1-4 hours until the patient is out of critical phase) volume of fluid intake and losses urine output (every 4-6 hours) hematocrit (before and after fluid replacement, then every 6-12 hours) blood glucose and other organ functions (such as renal profile, liver profile and coagulation profile as indicated) warning signs o abdominal pain or tenderness o persistent vomiting o clinical fluid accumulation o mucosal bleed o lethargy; restlessness o liver enlargement >222cm o laboratory: increased in hct concurrent with rapid decrease in platelet count 

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C. PALLIATIVE MANAGEMENT Give antipyretics to control body temperature. However, aspirin is contraindicated. 

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Analgesics may be given to provide pain relief as needed.

D. DISCHARGE CRITERIA  All of the following conditions must be present: No fever for 48 hours Improvement in clinical status (general well-being, appetite, hemodynamic status, urine output, no respiratory distress) Increasing trend of platelet count Stable hematocrit without intravenous fluids  

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REFERENCES

Kliegman, Robert M., et al. Nelson Textbook of Pediatrics. Philadelphia: Saunders, An Imprint of Elsevier. 2007. 18th ed. Chai See Lum, Lucy, et al. Handbook for Clinical Management of Dengue. World Health Organization Publication. 2012. Gonzales, Lisa Antoinette, et al. 2010 PPS Interim Guidelines on Fluid Management of Dengue Fever and Dengue Hemorrhagic Fever. 2011.

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