Dengue case presentation

Dengue case presentation Prof (Dr) Yee-Sin LEO Clinical Director Communicable Disease Centre Director Institute of Infectious Disease and Epidemiolog...
Author: Erick Skinner
5 downloads 0 Views 2MB Size
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