1

Dengue
Hemoragic
Fever
 1

ACKNOWLEDGMENTS

We are greatly indebt to the Almighty One for giving us blessing to finish this case report,
Dengue Hemoragic Fevers. This case report is requirement to complete the clinical assistance
program in Department of Child Health in Haji Adam Malik General Hospital, Medical Faculty
of North Sumatera University.
We are also indebt to our supervisor and adviser, dr. Rizky Ardiansyah, M. Ked (Ped), Sp.
A (K) for much spent time to give us guidance, comments, and suggestions. We are grateful
because without Him, this case report wouldnt have taken its present shape.
This case report has gone through series of developments and corrections. There were
critical but constructive and relevants suggestions from the reviewers. Hopefully the content will
be useful for everyone the future.

Medan, Mei 2016

Writers
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CONTENTS

ACKNOWLEDGMENTS.....................................................................................................i
CONTENTS...........................................................................................................................ii
CHAPTER 1 INTRODUCTION...........................................................................................1
CHAPTER 2 LITERATURE REVIEW.................................................................................3
CHAPTER 3 CASE REPORT...............................................................................................15
CHAPTER 4 DISCUSSION..................................................................................................25
CHAPTER 5 SUMMARY.....................................................................................................27
REFERENCES ......................................................................................................................30
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CHAPTER 1
INTRODUCTION
1.1 Background
Dengue is the most rapidly spreading mosquito-borne viral disease of man kind, with a
30- fold increase in global incidence over the last five decades. It is a major public health concern
throughout the tropical and subtropical regions of the world. Almost half the world's population
lives in countries where dengue is endemic. According to World Health Organization (WHO),
about 50100 million new dengue infections are estimated to occur annually in more than 100
endemic countries, with a steady increase in the number of countries reporting the disease. (1) An
estimated 500 000 people with DHF require hospitalization each year. A very large proportion
(approximately 90%) of them are children aged less than five years, and about 2.5% of those
affected die. Epidemics of dengue are increasing in frequency. During epidemics, infection rates
among those who have not been previously exposed to the virus are often 40% to 50% but can
also reach 80% to 90%.(3)
Approximately 1.8 billion (more than 70%) of the population at risk for dengue
worldwide live in Member States of the WHO South-East Asia Region (SEAR) and Western
Pacific Region, which bear nearly 75% of the current global disease burden due to dengue. Of the
11 countries of SEAR, 10 countries including Indonesia are endemic for dengue. The only
exception is the Democratic People's Republic of Korea. In 2012, SEAR countries reported
approximately 0.29 million cases, of which Thailand contributed almost 30%, Indonesia 29% and
India 20%. (2)
Since 2000, epidemic dengue has spread to new areas and has increased in the already
affected areas of the region. In 2003, eight countries -- Bangladesh, India, Indonesia, Maldives,
Myanmar, Sri Lanka, Thailand and Timor - Leste reported dengue cases. Epidemic dengue is a
major public health problem in Indonesia, Myanmar, Sri Lanka, Thailand and Timor-Leste which
are in the tropical monsoon and equatorial zone where Aedes aegypti is widespread in both urban
and rural areas, where multiple virus serotypes are circulating, and where dengue is aleading
cause of hospitalization and death in children.(1)
The number of dengue cases has increased over the last three to five years, with recurring
epidemics. Moreover, there has been an increase in the proportion of dengue cases with their
severity, particularly in Thailand, Indonesia and Myanmar. Reported case fatality rates for the
 2

region are approximately 1%, but in India, Indonesia and Myanmar, focal outbreaks away from
the urban areas have reported case-fatality rates of 3--5%.(3)
In Indonesia, where more than 35% of the countrys population lives in urban areas, 150
000 cases were reported in 2007 (the highest on record) with over 25 000 cases reported from
both Jakarta and West Java. The case-fatality rate was approximately 1%.(1)
 3

CHAPTER 2
LITERATURE REVIEW
2.1 Epidemiology
Dengue is one of the most important emerging viral disease of humans in the world
afflicting humanity in terms of morbidity and mortality. Currently the disease is endemic in all
continents except Europe. The Epidemiology of dengue is a complex phenomenon that mainly
depends upon an intricate relationship between the 3 epidemiological factors: the host (man and
mosquito), the agent (virus) and the environment. The complexity of relationship among these
factors eventually determines the level of endemicity in an area.(4)

2.1.1. Dengue Virus

The agent of dengue, i.e. dengue viruses, are categorized under the genus Flavivirus.
These viruses contain single stranded RNA and are small in size (50 nm). There are four dengue
virus serotypes which are designated as DENV-1, DENV-2, DENV-3 and DENV- 4. These
serotypes may be in circulation either singly, or more than one can be in circulation in any area at
the same time. Although all four serotypes are antigenically similar, they are different enough to
elicit crossprotection only for a few months after infection by any one of them. Infection with any
one serotype confers lifelong immunity to the virus serotype. (1)
The genome is cleaved by host and viral proteases in three structural proteins (capsid, C,
prM, the precursor of membrane, M, protein and envelope, E) and seven nonstructural proteins
(NS).(2)

2.1.2 Vector
Dengue viruses are transmitted by the bite of female Aedes (Ae) mosquitoes. Ae.aegypti is
the most potential vector but other species such as Ae albopictus, Ae. polynesiensis and Ae.
niveus have also been incriminated as secondary vectors. Dengue is transmitted by the bite of
female Aedes mosquito. Female Aedes mosquito deposits eggs singly on damp surfaces just
above the water line. Under optimal conditions the life cycle of aquatic stage of Ae. aegypti can
be as short as seven days. It is a day time feeder and can fly up to a limited distance of 400
meters. To get one full blood mea the mosquito has to feed on several persons, infecting all of
them.(4)
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2.1.3. Host
Dengue viruses, having evolved from mosquitoes, adapted to non-human primates and
later to humans in an evolutionary process. The viraemia among humans builds up high titres two
days before the onset of the fever (non-febrile) and lasts 57 days after the onset of the fever
(febrile). It is only during these two periods that the vector species gets infected. Thereafter, the
humans become dead-ends for transmission. The spread of infection occurs through the
movement of the host (man) as the vectors movements are very restricted. The susceptibility of
the human depends upon the immune status and genetic predisposition. (3)

2.1.4. Environmental Factors

The population of Ae. aegypti fluctuates with rainfall and water storage. Its life span is
influenced by temperature and humidity, survives best between 16-30 C and a relative humidity
of 60-80%. Ae. aegypti breeds in the containers, in and around the houses. Altitude is an
important factor in limiting the distribution of Ae. aegypti, it is distributed between sea level and
1000 ft above sea level. Ae. aegypti is highly anthropophilic and rests in cool shady places. The
rural spread of Ae. aegypti is a relatively recent occurrence associated with the development of
rural water supply schemes, improved transport systems, scarcity of water and like style changes.
Ae. aegypti breeds almost entirely in domestic man-made water receptacles found in and around
households, construction sites and factories; natural larval habitats are tree holes, leaf axils and
coconut shells. In hot and dry regions, overhead tanks and ground water storage tanks become
primary habitats. Unused tyres, flower pots and desert coolers are among the most common
domestic breeding sites of Ae. Aegypti. (4)

2.1.5. Transmission cycle

The female usually becomes infected with the dengue virus when it takes a blood meal
from a person during the acute febrile (viremia) phase of dengue illness. After an extrinsic
incubation period of 8 to 10 days, the mosquito becomes infected. The virus is transmitted when
the infected female mosquito bites and injects its saliva into the wound of the person bitten. The
cycle of dengue continues by this process. Dengue begins abruptly after an intrinsic incubation
period of 4 to 7 days (range 314 days). There is also evidence of vertical transmission of dengue
virus from infected female mosquitoes to the next generation. Though transmission primarily
occurs through the bite of a vector, there are reports of dengue transmission through blood
 5

transfusion and organ transplantation. There are also reports of congenital dengue infections
occurring in neonates born to mothers infected very late in pregnancy.(1)

2.2 Pathogenesis
Primary or first infection in non immune persons usually causes Dengue fever.
Subsequent dengue infection by different serotype causes more severe illness like DHF/DSS. The
key manifestations of the DHF/DSS are sudden onset of shock, capillary leakage, haemorrhagic
diathesis/ thrombocytopenia occurring at the time of defervescence of fever. Pathogenesis is not
well defined but it is suggested that it ismediated through soluble mediators, compliment
activation and cytokines that are responsible for various manifestations. (4)

2.3. Clinical Manifestation

Dengue virus infection may be asymptomatic or may cause undifferentiated febrile illness
(viral syndrome), dengue fever (DF), or dengue haemorrhagic fever (DHF) including dengue
shock syndrome (DSS). Infection with one dengue serotype gives lifelong immunity to that
particular serotype, but there is only short-term cross-protection for the other serotypes. The
clinical manifestation depends on the virus strain and host factors such as age, immune status,
etc. (3)
 6

Differentiation between dengue fever and dengue hemorrhagic fever is difficult early in
the course of illness. A relatively mild 1st phase with abrupt onset of fever, malaise, vomiting,
headache, anorexia, and cough may be followed after 2-5 days by rapid clinical deterioration and
collapse. In this 2nd phase, the patient usually has cold, clammy extremities, a warm trunk,
flushed face, diaphoresis, restlessness, irritability, mid epigastric pain, and decreased urinary
output. Frequently, there are scattered petechiae on the forehead and extremities; spontaneous
ecchymoses may appear, and easy bruising and bleeding at sites of venipuncture are common. A
macular or maculopapular rash may appear, and there may be circumoral and peripheral cyanosis.
Respirations are rapid and often labored. The pulse is weak, rapid, and thready, and the heart
sounds are faint. The liver may enlarge to 4-6 cm below the costal margin and is usually firm and
somewhat tender. Approximately 20-30% of cases of dengue hemorrhagic fever are complicated
by shock (dengue shock syndrome). Dengue shock can be subtle, arising in patients who are fully
alert, and is accompanied by increased peripheral vascular resistance and raised diastolic blood
pressure. Shock is not from congestive heart failure but from venous pooling. With increasing
cardiovascular compromise, diastolic pressure rises toward the systolic level and the pulse
pressure narrows. Fewer than 10% of patients have gross ecchymosis or gastrointestinal bleeding,
usually after a period of uncorrected shock. After a 24-36 hr period of crisis, convalescence is
fairly rapid in the children who recover. The temperature may return to normal before or during
the stage of shock. Bradycardia and ventricular extrasystoles are common during convalescence.
(5)
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2.4 Laboratory Diagnosis

Unequivocal diagnosis of dengue infection requires laboratory confirmation, either by
isolating the virus or detecting dengue-specific antibodies. For virus isolation or detection of
DENV RNA in serum specimens by serotype-specific, real-time reverse transcriptase polymerase
chain reaction (RT-PCR), an acute-phase serum specimen should be collected within 5 days of
symptom onset. If the virus cannot be isolated or detected from this sample, a convalescent-phase
serum specimen is needed at least 6 days after the onset of symptoms to make a serologic
diagnosis by testing for IgM antibodies to dengue with an IgM antibody-capture enzyme-linked
immunosorbent assay (MAC-ELISA).(5)
Acute-phase and convalescent-phase serum samples should be sent to the state health
department or tothe Centers for Disease Control and Prevention (CDC) for testing. Acute-phase
samples for virus diagnosis may be stored on dry ice (-70C) or, if delivery can be made within 1
week, stored unfrozen in a refrigerator (4C). Convalescent-phase samples should be sent in a
rigid container without ice, if next-day delivery is assured. Otherwise, they should be shipped on
ice in aninsulated container to avoid heat exposure during transit.
Most tests for anti-dengue antibodies yield nonspecificresults for flaviviruses, including West
Nile and St. Louis encephalitis viruses. Because commercial kits may vary in sensitivity and
specificity, test results may need to be confirmed by a reference laboratory.(6)
 8

2.5 Criteria for clinical diagnosis of DHF/DSS

Clinical manifestations
Fever: acute onset, high and continuous, lasting two to seven days in most cases.
Any of the following haemorrhagic manifestations including a positive tourniquet test (the most
common), petechiae, purpura (at venepuncture sites), ecchymosis, epistaxis, gum bleeding, and
haematemesis and/or melena.
Enlargement of the liver (hepatomegaly) is observed at some stage of the illness in 90%98% of
children. The frequency varies with time and/or the observer.
Shock, manifested by tachycardia, poor tissue perfusion with weak pulse and narrowed pulse
pressure (20 mmHg or less) or hypotension with the presence of cold, clammy skin and/or
restlessness.

Laboratory findings
Thrombocytopenia (100 000 cells per mm3 or less).
Haemoconcentration; haematocrit increase of 20%i from the baseline of patient or population
of the same age.
The first two clinical criteria, plus thrombocytopenia and haemoconcentration or a rising
haematocrit, are sufficient to establish a clinical diagnosis of DHF. The presence of liver
enlargement in addition to the first two clinical criteria is suggestive of DHF before the onset of
plasma leakage.
The presence of pleural effusion (chest X-ray or ultrasound) is the most objective
evidence of plasma leakage while hypoalbuminaemia provides supporting evidence. This is
particularly useful for diagnosis of DHF in the following patients:
anaemia.
severe haemorrhage.
where there is no baseline haematocrit.
rise in haematocrit to <20% because of early intravenous therapy.

In cases with shock, a high haematocrit and marked thrombocytopenia support the
diagnosis of DSS. A low ESR (<10 mm/first hour) during shock differentiates DSS from
septic shock.(3)
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2.6. Management
Approach to clinical management of dengue Fever may vary depending on severity of
illness. The patients who have simple fever without any danger signs or complications may be
managed with symptomatic approach. Those who have warning signs and symptoms should be
closely monitored for progression of disease. The patients of DHF without shock, significant
bleeding or involvement of various organs require aggressive management to reduce morbidity
and mortality. Patient may develop complications during later stage of fever (defervescence) or a
febrile phase, where clinician should be careful to look for danger signs and signs of fluid
overload.

2.6.1. Management of dengue fever

Management of dengue fever is symptomatic and supportive
i. Bed rest is advisable during the acute phase.
ii. Use cold/tepid sponging to keep temperature below 38.5 C.
iii. Antipyretics may be used to lower the body temperature. Aspirin/NSAIDS like
Ibuprofen, etc should be avoided since it may cause gastritis, vomiting, acidosis, platelet
dysfunction and severe bleeding. Paracetamol is preferable in the doses given below:
1-2 years: 60 -120 mg/dose
3-6 years: 120 mg/dose
7-12 years: 240 mg/dose
Adult : 500 mg/dose
Note: In children the dose of paracetamol is calculated as per 10 mg/Kg body weight per
dose. Paracetamol dose can be repeated at the intervals of 6 hrs depending upon fever and
body ache.
iv. Oral fluid and electrolyte therapy is recommended for patients with excessive sweating
or vomiting.
v. Patients should be monitored for 24 to 48 hours after they become afebrile for
development of complications.
Management during febrile phase
Paracetamol is recommended to keep the temperature below 39 C. Adequate fluid should
be advised orally to the extent the patient tolerates. Oral rehydration solution (ORS), such as
those used for the treatment of diarrhoeal diseases and / or fruit juices are preferable to plain
 10

water. Intravenous fluid should be administered if the patient is vomiting persistently or refusing
to feed.
Patients should be closely monitored for the initial signs of shock. The critical period is
during the transition from the febrile to the afebrile stage and usually occurs after the third day of
illness. Sometimes serial haematocrit determinations are essential to guide treatment plan, since
they reflect the degree of plasma leakage and need for intravenous administration of fluids.
Haematocrit should be determined daily specially from the third day until the temperature
remains normal for one or two days.

2.6.2 Management of DHF without Shock

Any person who has dengue fever with thrombocytopenia, high haemoconcentration and
presents with abdominal pain, black tarry stools, epistaxis, bleeding from the gums etc. needs to
be hospitalized. All these patients should be observed for signs of shock. The critical period for
development of shock is during transition from febrile to abferile phase of illness, which usually
occurs after third day of illness. Rise of haemoconcentration indicates plasma leakage and loss of
volume for which proper fluid management plays an important role.
Despite the treatment, if the patient develops fall in BP, decrease in urine output or other
features of shock, the management for Grade III/IV DHF/DSS should be instituted. Oral
rehydration should be given along with antipyretics like Paracetamol.

Notes:
*Improvement: Hct falls, pulse rate and blood pressure stable, urine output rises
 11

**No Improvement: Hct or pulse rate rises, pulse pressure falls below 20 mmHg, urine output
falls

2.6.3 Management of Shock

Immediately after hospitalization, the haematocrit, platelet count and vital signs should be
examined to assess the patient's condition and intravenous fluid therapy should be started. The
patient requires regular and continuous monitoring. If the patient has already received about 1000
ml of intravenous fluid, it should be changed to colloidal solution preferably Dextran 40 or if
haematocrit further decreases fresh whole blood transfusion 10-
20ml/kg/dose should be given.
However, in case of persistent shock even after initial fluid replacement and resuscitation
with plasma or plasma expanders, the haematocrit continues to decline, internal bleeding should
be suspected. It may be difficult to recognize and estimate the degree of internal blood loss in the
presence of haemoconcentration. It is thus recommended to give whole blood in small volumes of
10ml/kg/hour for all patients in shock as a routine precaution. Oxygen should be given to all
patients in shock. Treatment algorithm for patients with DHF with shock:

Crystalloid: Normal Saline, ringer lactate

Colloid: Dextran 40/degraded gelatine polymer (polygeline)
 12

#ABCS= Acidosis, Bleeding, Calcium (Na++ &K+), Sugar

Notes:
*Improvement: Hct falls, pulse rate and blood pressure stable, urine output rises
**No improvement: Hct or pulse rate rises, pulse pressure falls below 20 mmHg, urine
output falls
Unstable vital signs: urine output falls, signs of shock

-Crystalloid: Normal Saline, ringer lactate

-Colloid: Dextran 40/degraded gelatine polymer (polygeline)
- ABCS= Acidosis, Bleeding, Calcium (Na++ &K+), Sugar
Notes:
*Improvement: Hct falls, pulse rate and blood pressure stable, urine output rises
**No Improvement: Hct or pulse rate rises, pulse pressure falls below 20 mmHg, urine output
falls
Unstable vital signs: Urine output falls, signs of shock
In cases of acidosis, hyperosmolar or Ringer's lactate solution should not be used
 13

Serial platelet and Hct determinations: drop in platelets and rise in Hct are essential for
early diagnosis of DHF
Cases of DHF should be observed every hour for vital signs and urine output

2.6.4. Management of severe bleeding

In case of severe bleeding, patient should be admitted in the hospital and investigated to
look for the cause and site of bleeding and immediately attempt should be made to stop the
bleeding. Internal bleeding like GI bleeding may be sometime severe and difficult to locate.
Patients may also have severe epistaxis and haemoptysis and may present with profound shock.
Urgent blood transfusion is life saving in this condition. However, if blood is not available shock
may be managed with proper IV fluid or plasma expander.. If the patient has thrombocytopenia
with active bleeding, it should be treated with blood transfusion and then if required platelet
transfusion. In case of massive haemorrhage blood should be tested to rule out coagulopathy by
testing for prothrombin time (PT) and aPTT. Patients of severe bleeding may have liver
dysfunction and in such case, liver function test should also be performed. In rare circumstances,
intracranial bleed may also occur in some patients who have severe thrombocytopenia and
abnormality in coagulation profile.

2.7. Criteria for admission of a patient

If a DF patient presents with significant bleeding from any site, signs of hypotension,
persistent high grade fever, rapid fall of platelet count, sudden drop in temperature should
be admitted in hospital. However, those patients who have evidence of organ involvement
should also be admitted for proper monitoring and management. Dengue patients with warning
signs and symptoms should be admitted and closely monitored.

2.8. Criteria for discharge of patients

The admitted patients who have recovered from acute dengue infection having no fever
for atleast 24 hours, normal blood pressure, adequate urine output, no respiratory distress,
persistent platelet count >50,000/cu.mm should be discharged from hospital.
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2.9. Indication of Platelet transfusion

1. Platelet count less than 10000/cu.mm in absence of bleeding manifestations
(Prophylactic platelet transfusion).
2. Haemorrhage with or without thrombocytopenia.
Packed cell transfusion/FFP along with platelets may be required in cases of severe
bleeding with coagulopathy. Whole fresh blood transfusion doesn't have any role in managing
thrombocytopenia.
Platelets can be classified as random donor platelets (prepared by buffy coat removal
method or by platelet rich plasma method), BCPP (buffy coat pooled platelet) and single donor
platelets (SDP) or aphaeretic platelets (AP).

2.10. Vaccine for dengue infection

Till now there is no licensed vaccine available against dengue viral infection. Several
rials are ongoing in the world for the development of tetravalent dengue vaccine. So far phase III
trials of a recombinant, live attenuated tetravalent dengue vaccine (CYD-TDV) has completed in
Five Asian countries in children which may be promising in preventing dengue infection in near
future.
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CHAPTER 3
CASE REPORT
3.1. Case
KA, a five years 7 months old boy with 15 kg of body weight nd 109 cm of body height
came to Unit Gawat Darurat RS Haji Adam Malik on 6th mei 2016 at 20.10 p.m. His chief
complaint was a fever since 3 days ago.
3.2. History Of Disease
KA, a five year 7 months years old boy with 15 kg of body weight and 109 cm of body
height. KA is the eldest child in the family (from2 siblings) came to Unit Gawat Darurat RS with
a fever as a main complaint , and the fever is reduce with antipyretic drugs. The highest
temperature measure was 39 . It was taken by his mother. No history of shivering.
Diarhhea was experienced within these 6 days before being admitted to the hospital. The
frequency of diarrhea experienced more than 3 times a day. The consistensy of stool was more
liquid than a waste. The patient also felt nauseated since 6 days before came to the hospital.
Patient vomited once before coming to the hospital. The vomit contents is the food and the drinks
he consumed.
Patient also experienced headache and joint pain since 3 days ago. Abdominal pain also
found during history taking. There is no history of epixtasis, hematemesis and melena. There was
no problem found with his urinary system. Defecation frequency is more then 3 times a day. His
mother also complaint there was a reddish skin (rash) at the upper and lower extrimities. There
was no history of seizure.

3.3. History of Medication

Patient previously treated by a general practitioner prior to referral to RS Haji Adam
Malik, Medan.he was givem Chloramphenicol, Parasetamol, pseudoefedrin HCL,
metoclopramide and diazepam.

3.4. History of Familys Disease

Patients family does not have the same history of disease as patient but the symptoms
showed by patients friend is the same with patient.
Mother Father
Name : Vivin Sofyana Name : Ilhamsyah
 16

Age : 29 tahun Age : 36 tahun

Religion : Islam Religion : Islam
Race : Jawa Race : Jawa
Occupation : Ibu Rumah Tangga Occupation : Staf pengajar / Dosen
Education : SMA Education : S2
Revenue :- Revenue : Rp. 3 juta/ bulan
First son : Khairul Azman Second daughter : Khanza Alia Fitri
Age : 5 years 7 months Usia : 1 years 9 monts
Gender : Boy Gender : Girl
Occupation : siswa TK Occupation :-

3.5. Family Medical History

No history of disease in patients family

3.6. History of Birth

The patient was born spontaneously pervaginam, assisted by a midwife. Gestation weeks
were approximately 36 months. Body weight at birth was 2800 gram. Cyanosis and Jaudice were
not found at bitrh. Patients mother was 22 years old when she gave birth and there was no
history of disease. Medication consumed during pregnancy (-) Herbal medication (+)

3.7. History of feeding

0 - 3 month : Breast feeding
3 6 month : Breast feeding and Formula feeding
> 6 month : Formula feeding and porridge

3.8. History of Immunization

Patient had a complete immunization.
Hepatitis B : 3x
BCG : 1x at 2 month
Polio : 4x at 0,2,4,6 months
DTP : 3x at 2,4,6 months
Measles : 1x at 9 month

3.9. History of Growth and Development

 17

According to patients mother growth and development went normal. Patient lifted up his
head at 3 month, patient could stand up and walk at 1 year 2 months.

3.10. Physical Examination :

Present Status:
Sensorium : Compos mentis, GCS : 15
Temperatur : 36,4
Body Weight: 15 kg Body Height: 109 cm.
dyspnea (-), cyanosis (-), edema (-)
Localized Status :
Head
Face : edema (-)
Eye : light reflex (+/+), isochoric pupil, pale inferior palpebral conjunctiva(-/-)
Ears : both ear lobe in normal morphologic
Hidung : septum deviation (-), nasal flares (-), normal morphologic
Mouth : Normal morphologic
Neck
Lymph node enlargement (-)
Thorax
Simetris fusiformis, retraction (-/-), RR: 25 bpm, regular, ronchi (-/-) Respiratory
sound : vesiculer, additional sound (-), HR: 90 bpm, regular, murmur (-).
Abdomen: Soepel, peristaltik sound (+) normal, epigastric pain (+). Hepar and
Lien: unpalpable.
Extremity:
TD : 90/70 mmHg, HR: 90 kali/min, regular, warm exterimity, CRT < 3,
pretibial oedem (-), ptechie (+) at upper and lower extrimity.

Laboratory Finding: 07 may 2016 07:02:46

Complete Blood Analysis:

Test Result Unit References

Hemoglobin 13.2 g% 10.8 15.6
Erythrocyte 4.97 106/mm3 4.50 6.50
Leucocyte 3.03 103/mm3 4.5 - 13.5
Thrombocyte 84 103/mm3 150-450
 18

Hematocrite 39 % 33 45
Eosinophil 0 % 1-5
Basophil 0.3 % 0-1

Neutrophil 56.50 % 25 60
Lymphocyte 35.30 % 25 50
Monocyte 7.90 % 16
3
Neutrophil Absolute 1.71 10 /L 2.4-7.3
Lymphocyte Absolute 1.07 103/L 1.7-5.1

Monocyte absolute 0.24 103/L 0.2-0.6

Basophil absolute 0.01 103/L 0-0.1

Eusinophil absolute 0 103/L 0.1 0.3

MCV 79 fL 69 93

MCH 26.6 Pg 22 34

MCHC 33.5 g% 32 36

RDW 12.4 % 11 15

PCT 0.110 % 0.1 0.5

ELECTROLYTE

Calsium 7.9 Mg/dl 8.4 10.2

Sodium 131 Mg/dl 135 155

Pottasium 3.6 Mg/dl 3.6 5.5

Chloride 96 Mg/dl 96 106

Laboratorium findings: 07 may 2016 21:17:18

Complete Blood Analysis:

Test Result Unit References

Hemoglobin 14.2 g% 10.8 15.6
Erithrocyte 5.28 106/mm3 4.50 6.50
Leukocyte 2.94 103/mm3 4.5 - 13.5
 19

Trombocyte 32 103/mm3 150-450

Hematocrite 42 % 33 45
Eosinophil 0 % 1-5
Basophil 1 % 0-1

Neutrophill 38.8 % 25 60
Lymphocyte 53.70 % 25 50
Monocyte 6.50 % 16
3
Neutrophil Absolute 1.14 10 /L 2.4-7.3
Lymphocyte Absolute 1.58 103/L 1.7-5.1

Monocyte absolute 0.19 103/L 0.2-0.6

Basophil absolute 0.03 103/L 0-0.1

Eusinophil absolute 0 103/L 0.1 0.3

MCV 80 fL 69 93

MCH 26.9 Pg 22 34

MCHC 33.5 g% 32 36

PCT 0.04 Mg/dl 0.1 0.5

Laboratorium Findings: 08 may 2016 09:41:42

Complete Blood Analysis:

Tes Hasil Unit Rujukan

Hemoglobin 14.3 g% 10.8 15.6
Eritrocyte 5.37 106/mm3 4.50 6.50
Leukocyte 4.1 103/mm3 4.5 - 13.5
Trombocyte 18 103/mm3 150-450
Hematocrite 43 % 33 45
Eosinophil 0.2 % 1-5
Basophil 1 % 0-1

Neutrophil 29 % 25 60
 20

Lymphocyte 59.8 % 25 50
Monocyte 10 % 16
3
Neutrophil Absolute 1.19 10 /L 2.4-7.3
Lymphocyte Absolute 2.45 103/L 1.7-5.1

Monocyte absolute 0.41 103/L 0.2-0.6

Basophil absolute 0.03 103/L 0-0.1

Eosinophil absolute 0.01 103/L 0.1 0.3

MCV 79 fL 69 93

MCH 26.6 Pg 22 34

MCHC 33.6 g% 32 36

PCT 0.02 % 0.1 0.5

RDW 12.3 % 11- 15

Laboratorium Findings: 08 may 2016 21:45:43

Complete Blood Analysis:

Tes Hasil Unit Rujukan

Hemoglobin 12.8 g% 10.8 15.6
Eritrocyte 4.77 106/mm3 4.50 6.50
Leukocyte 4.9 103/mm3 4.5 - 13.5
Trombocyte 26 103/mm3 150-450
Hematocrite 38 % 33 45
Eosinophil 0.4 % 1-5
Basophil 0.4 % 0-1

Neutrophil 29 % 25 60
Lymphocyte 62.7 % 25 50
 21

Monocyte 7.5 % 16
103/L
Neutrophil Absolute 1.44 2.4-7.3
103/L
Lymphocyte Absolute 3.11 1.7-5.1
103/L
Monocyte absolute 0.37 0.2-0.6
103/L
Basophil absolute 0.02 0-0.1
103/L
Eosinophil absolute 0.02 0.1 0.3

MCV 79 fL 69 93

MCH 26.8 Pg 22 34
MCHC 34 g% 32 36

PCT 0.03 % 0.1 0.5

RDW 12.3 % 11- 15

Laboratory findings: 09 may 2016 01:40:30

Complete Blood Analysis:

Test Result Unit References

Hemoglobin 12.7 g% 10.8 15.6
Eritrhocyte 4.78 106/mm3 4.50 6.50
Leucoyte 6.34 103/mm3 4.5 - 13.5
Trombocyte 36 103/mm3 150-450
Hematocrite 38 % 33 45
Eosinophill 0.3 % 1-5
Basophil 0.5 % 0-1

Neutrophil 36.9 % 25 60
Limphocyte 56.6 % 25 50
 22

Monocyte 5.7 % 16
103/L
Neutrophil Absolute 2.34 2.4-7.3
103/L
Lymphocyte Absolute 3.59 1.7-5.1
103/L
Monocyte absolute 0.36 0.2-0.6
103/L
Basophil absolute 0.03 0-0.1
103/L
Eosinophil absolute 0.02 0.1 0.3

MCV 79 fL 69 93

MCH 26.6 Pg 22 34
MCHC 33.8 g% 32 36

PCT 0.04 % 0.1 0.5

RDW 12.2 % 11- 15

3.11. Differential diagnose

1. Dengue hemorrhagic fever without shock
2. Typhoid fever
3. Leptospirosis

3.12. Confirm Diagnosis

Dengue Hemorrhagic fever without shock
3.13. Therapy
- IVFD RL 3cc / KgBB , 45 cc/ hour
- Zinc 1x 20 mg
- Paracetamol 3 x 150 mg

3.14. Planning
- Complete blood analysis / 6 jam, IgG dan IgM anti dengue, Foto Thorax

3.15. Prognosis
Dubia ad Bonam
 23

FOLLOW UP
Date : 7 may 2016
S Fever (+), Spontaneous bleeding (-), diarrhea (+)
Sens: CM T: 37,9 oC BW: 15 kg BH: 109 cm
Head : Eye : LR (+/+),isochoric pupil , pale inferior palpebral conjunctiva
(-/-), E/N/M: normal morphologic
Thorax: Simetris fusiformis, retraction,
HR: 100 x/min, regular, murmur (-)
O
RR: 22 x/min, regular, ronchi (-/-)
Abdomen: soepel, peristaltik (+) N, H/L : unpalpable
Upper extrimity: HR 94 x/min, regular, P/V adequate, warm extrimity, CRT
<3, BP: 110/70 mmHg, ptechie (+)
Lower extrimity : pretibial oedem (-)
A 1. DHF without shock
P IVFD RL 3 cc / kgBB / jam
Zinc 1x20 mg
Paracetamol 150 mg / day
Planning :complete blood analysis, IgG dan IgM anti dengue, chest
 24

radiography

Date : 8 may 2016

S Fever (+), Spontaneous bleeding (-), mencret (+)
Sensorium: CM T: 38,1 oC BW: 15 kg BH: 109 cm
Head: Mata RC (+/+), Isochoric pupil,pale konj. palpebral inferior (-/-),
E/N/M: normal morphologic
Thorax: Simetris fusiformis, retraction (-).
O HR: 100 x/min, regular, murmur (-)
RR: 20 x/min, regular, ronchi (-/-)
Abdomen: soepel, peristaltik (+) N, H/L : unpalpable, shifting dullness (+)
Upper extrimity: HR 95 x/min, regular, P/V adequate, warm extrimity, CRT
<3, BP: 100/70 mmHg, ptechie (+) at upper and lower extrimity
A 1. DHF without shock
IVFD RL 3 cc / kgBB / jam
Zinc 1x20 mg
P
Paracetamol 150 mg / day
Planning : complete blood analysis every 6 hour

Date : 9 may 2016

S Fever (+), Spontaneous bleeding (-),

Sens: CM T: 37,9 oC BW: 15 kg BH: 109 cm
Head : Eye LR(+/+),Isochor pupil, pale inferior palpebra conjunctiva (-/-),
E/N/M: normal morphologic
Thorax: Simetris fusiformis, Retraction (-),
O HR: 104 x/min, regular, murmur (-)
RR: 22 x/min, regular, Respiratory sound : weaker at right lungs, ronchi (-/-)
Abdomen: soepel, peristaltik (+) N,shifting dullness (+) H/L : unpalpable
Upper extrimity: HR 94 x/min, regular, P/V cukup, warm extrimity, CRT <3,
BP: 110/70 mmHg, ptekie (+) pada ekstrimitas atas dan bawah
A 1. DHF without shock
IVFD RL 3 cc / kgBB
Zinc 1x20 mg
P
Paracetamol 150 mg / day
Planning : Complete blood analysis , IgG dan IgM anti dengue,
 25

Date : 10 may 2016

S Fever (-), Spontaneous bleeding (-),
Sens: CM T: 36,9 oC BW: 15 kg BH: 109 cm
Head : Eye LR(+/+),Isochor pupil, pale inferior palpebra conjunctiva (-/-),
E/N/M: normal morphologic
Thorax: Simetris fusiformis, Retraction (-),
O HR: 120 x/min, regular, murmur (-)
RR: 18 x/min, regular, Respiratory sound : weaker at right lungs, ronchi (-/-)
Abdomen : soepel, peristaltik (+) N,shifting dullness (-) H/L : unpalpable
Upper extrimity: HR 94 x/min, regular, P/V cukup, warm extrimity, CRT <3,
BP: 100/70 mmHg
A 1. DHF without shock
IVFD RL 3 cc / kgBB
P Zinc 1x20 mg
Planning : Complete blood analysis , IgG dan IgM anti dengue,

Date : 11 may 2016

S Fever (-), Spontaneous bleeding (-),

Sens: CM T: 36,9 oC BW: 15 kg BH: 109 cm
Head : Eye LR(+/+),Isochor pupil, pale inferior palpebra conjunctiva (-/-),
E/N/M: normal morphologic
Thorax: Simetris fusiformis, Retraction (-),
O HR: 120 x/min, regular, murmur (-)
RR: 18 x/min, regular, Respiratory sound : weaker at right lungs, ronchi (-/-)
Abdomen: soepel, peristaltik (+) N,shifting dullness (-) H/L : unpalpable
Upper extrimity: HR 94 x/min, regular, P/V cukup, warm extrimity, CRT <3,
BP: 100/70 mmHg
A 1. DHF without shock
Patient discharge after fever was diminished but the respiratory sound still
weaker at right lungs with improvement.
Patients education:
P
Patient needs a rest
Drink enough water
Parasetamol is given if fever is found
 26

CHAPTER 4
DISCUSSION
Dengue viral infected person may be asymptomatic or symptomatic and clinical
manifestations vary from undifferentiated fever to florid haemorrhage and shock. Clinical
Features of DF: An acute febrile illness of 2-7 days duration with two or more of the following
manifestations: Headache, retro-orbital pain, myalgia, arthralgia, rash, haemorrhagic
manifestations. In this case was found fever as a main complaint. The fever was reduce with
antipyretic drugs. The highest temperature measure was 39 . It was taken by his mother. No
history of shivering. Patient experienced headache and joint pain since 3 days ago. His mother
also complaint there was a reddish skin (rash) at the upper and lower extrimities. The patient also
felt nauseated since 6 days before came to the hospital. Patient vomited once before coming to
the hospital. The vomit contents is the food and the drinks he consumed.
Diagnosis of Dengue Hemoragic Fever is a case of clinical criteria of dengue Fever, plus
Haemorrhagic tendencies evidenced by one or more of the following: Positive tourniquet test,
petechiae, ecchymoses or purpura, bleeding from mucosa, gastrointestinal tract, injection sites or
other sites, plus thrombocytopenia (<100 000 cells per cumm), plus evidence of plasma leakage
 27

due to increased vascular permeability, manifested by one or more of the following: Arise in
average haematocrit for age and sex > 20%, a more than 20% drop in haematocrit following
volume replacement treatment compared to baseline, and Signs of plasma leakage (pleural
effusion, ascites, hypoproteinemia). In this case there was petechiae, Abdominal pain also found
during history taking. Based on the laboratorium result show that there was thrombocytopenia
(84.000/mm3). There was shifting dullness and when auskultasi in the respiratory sound found
weaker at right lungs. This auskultation was supported by chest radiography that found pleural
effusion in the right lung. In this case there was no rapid and weak pulse and narrow pulse
pressure ( mmHg) or hypotension for age, cold and clammy skin and restlessness.
Any person who has dengue fever with thrombocytopenia, high haemoconcentration and
presents with abdominal pain, black tarry stools, epistaxis, bleeding from the gums etc. needs to
be hospitalized. All these patients should be observed for signs of shock. The critical period for
development of shock is during transition from febrile to abferile phase of illness, which usually
occurs after third day of illness. Rise of haemoconcentration indicates plasma leakage and loss of
volume for which proper fluid management plays an important role. Despite the treatment, if the
patient develops fall in BP, decrease in urine output or other features of shock, the management
for DHF without shock should be instituted. Oral rehydration should be given along with
antipyretics like Paracetamol, sponging, etc. So, for this patient was given IVFD RL 3 cc / kgBB
for rehydration, Zinc 1x20 mg, and Paracetamol 3x 150 mg if the patient got fever.
Criteria for discharge of patients, the admitted patients who have recovered from acute
dengue infection having no fever for atleast 24 hours, normal blood pressure, adequate urine
output, no respiratory distress, persistent platelet count >50,000/cu.mm should be discharged
from hospital. (3)
Vaccine for dengue infection till now there is no licensed vaccine available against dengue
viral infection. Several trials are ongoing in the world for the development of tetravalent dengue
vaccine. So far phase III trials of a recombinant, live attenuated tetravalent dengue vaccine
(CYD-TDV) has completed in Five Asian countries in children which may be promising in
preventing dengue infection in near future.(3)
 28

CHAPTER 5
SUMMARY
KA, a boy, a five years 7 months old boy with 15 kg of body weight nd 109 cm of
body height came to Unit Gawat Darurat RS Haji Adam Malik on 6th mei 2016 at 20.10 PM with
fever asa a chief complaint. Diarrhea, joint pain, headache, stomach pain were found during
history taking. Ptekie was also found during physical examination. Patient diagnosed with
Dengue Hemorrhagic Fever and treated with supportive and symptomatic therapy. Patient treated
with Fluid therapy, Zinc and Paracetamol for the symptomatic complaint. Therapy were given
onward for 4 days with an improvement in clinical manifestation on day 4. On 11th may 2016,
patient returned home after clinical improvement found during examination.
 29

REFERENCE
1. World Health Organization. National Guidelines for Clinical Management of Dengeu Fever;
2015.
2. World Health Organization and Tropical Diseases Research. Handbook for clinical
management of dengue. Geneva: World Health Organization; 2012.
3. World Health Organization Guidelines for Clinical Management of Dengue Fever, Dengue
Hemorragic Fever, and Dengue Shock Sindrome;CDC.
4. World Health Organization Dengue Guidelines for Diagnosis, Treatment, Prevention, and
Controls; 2009.
5. World Health Organization. Comprehensive guidelines for prevention and control of dengue
and dengue hemorrhagic fever. New Delhi:WHO,SEARO; Revised and expanded
edition.2008.
6. Elsevier. Nelson Textbook of Pediatrics. 2015
7. World Health Organization. Dengue and Dengue Hemoragic Fever; 2008