Dengue case presentation
Prof (Dr) Yee-Sin LEO Clinical Director Communicable Disease Centre Director Institute of Infectious Disease and Epidemiology Tan Tock Seng Hospital
APAN-TEIN Manila Jan 2016
As at March 2014
TTSH Campuses (Total Staff Strength 6383)
TTSH No of Beds: 1819
Rehabilitation Centre @ Ang Mo Kio Hospital No of Beds: 99
Communicable Disease Centre 1 No of Beds: 211
Communicable Disease Centre 2 No of Beds: 94
Analysis of 6989 records, 295 (34.4%) were older adults aged >60 Less fulfill WHO 1997 clinical diagnostic criteria More DHF (29.3 vs 21.3%) and severe dengue (20.3% vs 14.6%) Non difference in frequency of warning signs Older adults hospitalised longer, higher frequency of pneumonia and urinary tract infections
Temp
TW 2.6 Hb 13.3 Hct 37.8 Plt 27K
TW 2.2 Hb 15.2 Hct 43.2
TW 2.8 Hb 16.2 Hct 45.2 Plt 5K
TW 4.2 Hb 16.2 Hct 46.2 Plt 5K
TW 5.8 Hb 14.8 Hct 41.4 Plt 19K
D5
Haemodynamic changes
Stop anti-hypertensive
Pain score
57, male, hypertension, DHF
Re-start anti-HTN
75 years old Chinese female, DM, HTN, HLD, dementia Premorbid ADL independent non toxic T 37.9, BP 147/76, HR 102, 98% RA H S1S2, Lung clear, Abd Soft, no hepatomegaly Calf supple, No pedal oedema TWC 14,900/ul, Poly 96% Hb 10.6g/dl, Hct 31.9% Platelet 129,ooo/ul Fever x 3/7, a/w jaundice x 2/7 with tea colour urine, a/w vomiting, chills and rigor and myalgia, No dysuria, No abdo pain, No Chest pain, No SOB No travel, No ill contacts
Cr 129 umol/L, S Bil 160u/l AST 52u/l ALT 69u/l ALP450u/l
Day 2 hospital day: Dilated common bile duct Stone successfully removed
Day 3 hospital day TWC 8500/ul, poly 91%
Blood culture
Hb 9.5 g/ul
E.Coli
Platelet 92,000/ul
TWC
19.5K
3.9K
6.4K
5.7K
5.5K
7.8K
Hct
31.1
28.2
31.5
30.9
30.2
30.5
92K
53K
28K
61K
106K
Platelet 121K
Fever and hypotension 39, Female designer, history of Thalassemia, Prolapsed intervertebral disc, No recent travel for the past 2 weeks before illness onset Consulted GP twice (D1 and D3 illness-> referred to ED) 1st ED presentation at D3 Illness 14:00: T 39.6 C, lowest BP recorded 86/50, HR 91/min 1.5 L NS given, advised admission but patient requested AMA (personal commitment) BP 94/58, HR 90/min upon ED discharge 2nd ED presentation D3 illness 21:26: returned for admission, BP 78/58, HR 99/min, total 2 L IV NS given, IV dopamine 5 10 mcg/kg/min
History on admission Present (describe) / Absent
Duration (days)
Fever
Yes
3 days
Headache
No
Vomiting
No
Abdominal pain
No
Bleeding manifestations
Yes- menses
Rash
No
Myalgia
Yes
Lethargy
No
Diarrhea
Yes
Shortness of breath
No
Altered mental state
No
Others
Nausea
2 days
3 days 3 days
Examination findings on admission Assessment
Assessment
Mental state
Alert
Hydration
Oral mucosa dry
Vital signs (Temp/HR/BP/RR/ SpO2)
T 37.7 C, HR 63/min, BP 89/55 (on dopamine 15 mcg/kg/min), RR 18.min SpO2 99% RA
Circulation
BP low
Cardiovascular Respiratory Gastrointestinal Central nervous system Skin Bleeding manifestations
S1 S2 no murmurs, JVP not elevated Lungs: clear Abdomen: soft, non tender, no hepatosplenomegaly, DRE no bleeding (done in ED) Alert, GCS 15 Petechiae on shins Menses
Investigations on Admission Full Blood Count
Value
Haemoglobin (g/L)
10.8
Sodium (mmol/L)
136
Haematocrit (%)
32.8
Potassium (mmol/L)
3.6
Platelet (x109/L)
39
Urea (umol/L)
0.8
White Blood Cell (x109/L)
1.8 (P 79%,L 13%, M 6.7%)
Creatinine (mmol/L)
51
Liver function tests
Biochemistry
Value
Other tests
Alanine transferase (ALT) (IU/L)
28
ECG
low voltage Relative bradycardia
Aspartate transferase (AST) (IU/L)
51
CXR
Clear
Bilirubin (umol/L)
10
Others
Albumin (g/L)
31
Trop I normal, lactate normal
ECG: D3 4:20 PM
Fever and hypotension
Differential diagnosis
Dengue confirmation test Dengue NS1+, IgM/IgG negative PCR: serotype 2
Any warning sign Severe dengue DHF / DSS ?
Serial Blood Results Day Of Illness Time
D3 16:05
D3 22:12
D4 02:24
D4 15:36
D4 20:44
D5 07:00
D5 15:59
HCT (%)
35.1
32.8
38.3
39.7
37.6
41.8
39.5
Hb (g/L)
11.4
10.8
12.4
12.8
12.3
13.7
13.2
49
39
40
32
21
18
25
1.9
1.8
2.3
2.0
2.3
3.9
4.8
53
51
47
-
-
39
-
0.9
0.8
0.7
-
-
0.6
-
ALT (IU/L)
-
28
31
31
-
-
-
AST (IU/L)
-
51
61 47.1/14.3
-
-
-
-
42.1/1 3.1
0.22
0.39
-
0.39
PLT (x109/L) WBC (x109/L) Cr (mmol/L) Urea (mmol/L)
APTT/PT
-
-
59 47.5/15.9
Trop I
-
-
30, conscious and alert, not restless, 37.50C, heart rate 83bpm, irregularly irregular, blood pressure 67/40 mmHg, SpO2 room air 99% Macular-papular rash seen, chest was clear, abdoman soft with no palpable liver and spleen, no bleeding noted, unremarkable CNS findings
Investigations on Admission Full Blood Count
Value
Haemoglobin (g/L)
16.6
Biochemistry
Value
Sodium (mmol/L)
133
Haematocrit (%)
49
Potassium (mmol/L)
3.0
Platelet (x109/L)
174
Urea (umol/L)
8.0
White Blood Cell (x109/L)
3.2
Creatinine (mmol/L)
158
Liver function
Other tests
Alanine transferase (ALT) (IU/L)
Others
ECG
Atrial fibrillation
Aspartate transferase (AST) (IU/L)
Others
CXR
Normal
Bilirubin (umol/L)
Others
Others
Albumin (g/L)
38
Trop I normal, CRP 8, procal 0.40
ECG
Differential diagnosis
NS1 positive, IgM/IgG negative PCR genotype 2
Confirmed dengue, WHO 2009 - severe dengue, WHO 1997 – Dengue fever, SEARO 2011- Dengue with organ involvement
Serial Blood Results Day Of Illness Date / Time
D4 10:50
D4 21:07
D5 05:55
D5 12:37
D5 21:14
HCT (%)
49
43
44.8
44.8
41.6
Hb (g/L)
16.6
14.6
15.2
15
14.4
PLT (x109/L)
174
139
130
115
117
WBC (x109/L)
3.2
2.1
3.3
2.1
1.7
Cr (mmol/L)
158
96
67
-
65
Urea (mmol/L)
8.0
5.8
3.1
-
2.3
ALT (IU/L)
79
61
57
53
53
AST (IU/L)
82
58
56
52
54
Lactate (mmol/L)
1.3
-
-
-
-
pH
7.42
-
-
-
-
HCO3 (mmol/L)
23
-
-
-
-
APTT/PT
33.8/13.3
-
-
-
-
TFT
normal
-
-
-
-
Trop I
0.03
0.02
0.04
-
-
Serial Blood Results Day Of Illness Date / Time-
D6 06:00
D6 12:15
D7 09:09
D8 13:47
HCT (%)
40.9
41.7
45.5
45.3
Hb (g/L)
14.1
14.2
15.1
15.4
PLT (x109/L)
99
97
90
125
WBC (x109/L)
1.5
1.4
1.5
2.8
Cr (mmol/L)
68
66
72
-
Urea (mmol/L)
1.4
1.5
0.8
-
ALT (IU/L)
58
58
-
90
AST (IU/L)
61
62
-
77
Lactate (mmol/L)
-
-
-
-
pH
-
-
-
-
HCO3 (mmol/L)
-
-
-
-
APTT/PT
-
-
-
-
Others
-
-
-
-
Others
-
-
-
-
Day of Illness Date / Time
D4
D5
D6
Progress Note
Presented to ED with syncopal episode. No fever/ warning signs. Hypotensive on dopamine. AF on ECG
No nausea. Tmax 37.50C. Weaned off dopamine at 9pm the day before. AF persisted
No complaints. Converted to sinus rhythm on D5 evening
T/BP/HR/SpO2 (%)
37.50C, 83bpm, 67/40 mmHg, 17, 99% RA
37.20C, 93 bpm, 109/75 mmHg, 97% RA
37.60C, 79 bpm, 128/92 mmHg, 97% RA
Fluid volume (ml)/day
2500 (ED), 4438 (HD)
6799
3958(HD),1650(GW )
Blood product volume/day
-
-
-
Total fluid input (ml)/day
6938
6799
5608
Total fluid output (ml)/ day
3740
5756
5990