Case Study 6C. [TQ, 7-months-old infant girl] Dengue Clinical Management. Acknowledgements

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Erick Oliver Murphy
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Case Study 6C [TQ, 7-months-old infant girl] Dengue Clinical Management Acknowledgements This curriculum was developed with technical assistance from the University of Malaya

1 Case Study 6C [TQ, 7-months-old infant girl] Dengue Clinical Management Acknowledgements This curriculum was developed with technical assistance from the University of Malaya Medical Centre. Materials were contributed by the Ministry of Health, Singapore, the United States Centers for Disease Control and Prevention, and the University of Malaya Medical Centre.

2 TQ, 7 month-old infant girl; Date of onset of fever 17 May Day 1: appetite was normal but less active; GP antipyretics and antibiotics Day 2: normal appetite, reduced activity; 2 nd GP antipyretics and antibiotics Day 3: Fever persisted with reduced oral intake; private hospital concerned about dengue, not able to get blood test done, given antibiotics and antipyretics Day 4: Still febrile, reduced oral intake, vomited 3 times and less active; 9 am at Gov t hospital: Temp 38.5 o C, HR 124/min At Gov t Hosp, parents were told that dengue was unlikely, sent home but to repeat CBC next day 12 hours later (9 pm): Parents worried about increasing lethargy and vomiting; brought child to private hospital: Temp 39 o C, HR 150/min, lethargic, cool extremities, feeble pulse, BP not measured, liver 2 cm palpable CBC: PCV: 39.2 WBC: 3.1 Platelet Count: 124 Does this look like dengue? History and CBC could go for dengue What would be your management? (Refer to slides 4-6 for more discussion) CBC taken and given one bolus of normal saline, 12 ml/kg over 1 hour Post-bolus (10 pm): Temp 36.8 o C, HR 128/min, warm extremities, good pulse CBC: (pre-bolus) PCV: 42 WBC: 3.2 Platelet Count: 52

3 TQ, 7 month-old infant girl, date of fever onset: 17 May, currently day 4 of illness Comment on clinical picture and the 2 CBC done 12 hours apart on Day 4 of illness? What would be the most likely diagnosis? Post bolus fluid resuscitation, baby was referred to a teaching hospital, Day 5 of illness. Four days of fever, infant had reduced oral intake and developed warning signs: persistent vomiting, increasing lethargy in the morning of D4; worsening warning signs and signs of shock by 9 pm D4. Note: 1. Rise in HCT and sudden decrease in platelet count from 9 am to 9 pm, within 12 hours 2. Sudden drop in body temp between 9 pm to 10 pm on D4. Most likely diagnosis: Dengue shock Day 5, 1 am: Warm, pink extremities, right pleural effusion, firm liver 5 cm, IVF at 7 ml/kg for 1 hour, then gradual step wise reduction. Appetite improved and IVF discontinued on Day 6 of illness NS1 Ag Positive, Dengue IgM weakly positive Mother had fever onset on the same day as infant, but was well, her CBC at Day 4: HCT 39.7, WBC 3.2, PLT 135 Note: Mother and infant had similar HCT, but do they mean the same?

4 TQ, 7 month-old infant girl, date of fever onset: 17 May, currently day 5 of illness D4 AM D4 PM 1 am 8 am 6 pm 11 pm D6 D7 D8 Right Hb pleural HCT effusion 33 WBC PLT AST ALT Describe the trend of HCT from D4 to IVF discontinuation on D6, and until D8 Increased HCT within 12 hours on D4, from 39.2 to 42 due to plasma leakage Fluid resuscitation at 9pm D4 leads to decreased HCT from 42 to 40 at 1 am Further plasma leakage leads to increased HCT 45, together with detection of right pleural effusion Step-wise reduction in IVF leads to gradual decrease in HCT until IVF discontinued on D6 Reabsorption of fluid leads to hemodilutionon D7 After diuresis, HCT rises again

5 TCQ, 7 month-old infant girl, date of fever onset: 17 May, currently day 5 of illness D4 AM D4 PM 1 am 8 am 6 pm 11 pm D6 D7 D8 Hb HCT WBC PLT AST ALT Which of the above HCT represents infant s baseline? HCT on D8 33, after diuresis Normal HCT of infant Calculate % increase in HCT from baseline on D4 AM, PM AM, HCT increase of ( ) 33 = 19% above baseline; PM 27% above baseline HCT increase above the baseline indicates degree of plasma leakage What would have happened had mother taken AM doctor s advise to come back on? Infant would have presented in severe shock state by 8 am on Day 5!

6 TQ, 7 month-old infant girl, date of fever onset: 17 May; Summary 1 st doctor Normal appetite Less active AntiB, antipyretic 2 nd doctor Normal appetite Less active AntiB, antipyretic 3 rd doctor Poor appetite Lethargy AntiB, antipyretic 4 th doctor Poor appetite Lethargy Vomiting HCT 39.2, Plt124 5 th doctor Defervescence, Poor appetite Lethargy Vomiting Shock, HCT 42, Plt52 17 May 18 May 19 May 20 May, AM 20 May, PM Lessons Learnt: 1. Between D1 to D4, parents visited 5 different doctors! Suspected something on D4! 2. Infants are high risk group for severe dengue because of leaky capillaries and should be admitted early if dengue is suspected. 3. Baseline HCT of infant < After Day 3, clinical deterioration with warning signs on D4: Decreased appetite, vomiting and increasing lethargy indicate beginning of plasma leakage. 5. HCT increase and leucopenia precede shock which coincide with defervescence 6. Platelet count drops rapidly during the critical phase of dengue. 7. Good outcome depends on prompt fluid resuscitation and stopping IVF when patient improves.

MODULE 8B: Management of Group B Dengue with Warning Signs or Dengue with Co-existing Conditions

MODULE 8B: Management of Group B Dengue with Warning Signs or Dengue with Co-existing Conditions Dengue Clinical Management Acknowledgements This curriculum was developed with technical assistance from