Thrombocytopenia, fever, rash, hypotension. Alexander D. Hristov MD University of Wisconsin Hospital and Clinic Internal Medicine PGY 2

Transcription

1 Thrombocytopenia, fever, rash, hypotension Alexander D. Hristov MD University of Wisconsin Hospital and Clinic Internal Medicine PGY 2

2 Case Chief Complaint: Fever, diarrhea, bloody nose, rash HPI: 38 y/o Indonesian Male Presented to urgent care w/ 5 days of fever, epistaxis, and melena. Recent 2 week trip to Indonesia w/ daughter for family wedding Returned 1 week ago Hypotensive, light-headed with scattered petechiae and thrombocytopenia (PLT 10). Social Hx: Born in Indonesia. Family Hx: Daughter w/ similar symptoms w/o bleeding.

3 Serang Jakarta

4 Physical Exam BP: 96/59, HR:114,Temp:102.6 GENERAL: diaphoretic HEENT: petechiae on palate, dry mucous membranes, dried blood on nares ABD: epigastric tenderness SKIN: petechiae on LUE and bilateral LE, +Tourniquet Sign

5 Differential Diagnosis US Patient DIC from Sepsis TTP/HUS Tick Borne Disease Babesiosis Ehrlichiosis Returning Traveler Vector Borne Illness Malaria Dengue Typhoid Tick Borne Disease Scrub Typhus Meningococcal Sepsis

6 Admission Labs >40% bands PTT: 67 INR: 1.1 LDH: 634 Fibrin Monomer: (-) Fibrinogen: 205 Blood Smear: AST: 138 ALT: 61 Alk Phos: 55 Tbili: 0.4 Blood Cultures: Pending Stool Cultures: Pending

7 Hospital Course Hypotension - fluid responsive. Developed edema Skin morbilliform rash developed across trunk, petechiae resolved Fever defervesced Epistaxis Resolved without recurrence Melena resolved with some residual loose stool Treated w/ Ceftriaxone for 5 days given concern for typhoid. Thrombocytopenia Improved without transfusion Plt 69 Blood cultures negative Dengue antibodies IgM and IgG positive after 5 days

8 Dengue Epidemiology WHO estimates million infections yearly. US reports ~100 cases per year Most due to returning travelers Sporadic outbreaks in Florida, Hawaii, and Texas Vector Borne Illness Incubation Period 4-10 days Four different strains DENV 1-4

9 WHO 2009 Classification Dengue w/o Warning Signs Nausea, Rash, Leukopenia, Dengue w/ Warning Signs Abdominal pain, Mucosal Bleeding, Plasma leak Thrombocytopenia, High HCT Severe Dengue Shock due to severe plasma leakage Severe Bleeding Organ Failure

10 Diagnosis Dengue Serology anti-denv IgM and IgG Real time PCR Non structural Enzyme ELSIA (NS1) During febrile phase (10 days) Serology w/ RT PCR or NS1 is highly specific and sensitive.

11 In Summary Returning traveler w/ fever, petechiae, bleeding diatheses Always rule out sepsis, DIC, TTP/HUS Must consider Dengue, Malaria, Typhoid, Rickettsial Diseases Travel history helps guide diagnosis Patients w/ prior exposure present w/ worse symptoms Why his daughter had lessened response Supportive therapy is key in Dengue

12 Thank you Dr. Bennett Vogelman Dr. Sean O Neill Dr. Kelly Lavin Dr. Jessica Tischendorf Dr. Brian Lewis Dr. Melissa MacDonald

13 Citations World Health Organization. Dengue: Guidelines for diagnosis, treatment, prevention and control, New edition. WHO: Geneva (Accessed on December 07, 2016). Dengue. (2014, June 09). Retrieved August 20, 2017, from Hunsperger, E. A., Muñoz-Jordán, J., Beltran, M., Colón, C., Carrión, J., Vazquez, J.,... & Margolis, H. S. (2016). Performance of dengue diagnostic tests in a single-specimen diagnostic algorithm. The Journal of infectious diseases, 214(6), World Health Organization, Special Programme for Research, Training in Tropical Diseases, World Health Organization. Department of Control of Neglected Tropical Diseases, World Health Organization. Epidemic, & Pandemic Alert. (2009). Dengue: guidelines for diagnosis, treatment, prevention and control. World Health Organization. Kalra, N. L., Joshi, A. B., Dash, A. P., Hilderbrand, A., Sawguanprasitt, B., & Prasittisuk, C. (2011). Comprehensive guidelines for prevention and control of dengue and dengue haemorrhagic fever. India: World Health Organization (WHO) Regional Office for South-East Asia,