DHF Case Presentation Dyta

Dengue Hemorrhagic Fever grade I
with
Right Pleural Effusion and Ascites
Supervised by: dr. Ulinar Marpaung, Sp.A
Created by: Amiradyta Mahartiza (07120100076)
Departemen of Pediatrics
Clerkship of Clinical Pediatrics Hospital Bhayangkara Tk. I Raden Said
Sukanto
Faculty of Medicine University of Pelita Harapan
IDENTITY OF THE PATIENT

Name
MRA
Age
4 years 5 months
Gender
Male
Address
Jl. Alsafiah Gg. H. Muktar RT

08/03 No. 1, Cilangkap
Nationalit
y
Indonesian
Religion
Moslem
Education
IDENTITY OF THE PATIENTS

PARENTS
Father
Mother
Mr. B
Mrs. E
42 years old
36 years old
Jl. Alsafiah Gg. H.

Muktar RT 08/03 No. 1,
Cilangkap
Jl. Alsafiah Gg. H.

Muktar RT 08/03 No. 1,
Cilangkap
Indonesian
Indonesian
Moslem
Moslem
Education
Senior High School
Junior High School
Occupati
on
Private Employee
Housewife
Name
Age
Address
Nationalit
y
Religion
HISTORY TAKING
Anamnesis was done with alloanamnesis
method with the patients mother on the
date of admission, June 25th 2014.
Chief complaint: Fever since 4 days before
admission to the hospital
Additional complaint: body feels sore, pain in
the stomach
HISTORY OF PRESENT ILLNESS

The patient had fever since 4 days before admission.
The fever was sudden and instantly went to the high
temperature, but it was never measured. The fever was
continuous throughout the day. The patient was also
often shivering. History of seizure was denied.
Since the onset of illness, the patient also complained
about sore all over his body, and also he felt pain in the
upper-middle area of the abdomen. The pain was sharp,
continuous, and not migrating to the other part of the
body. He felt nausea but there isnt any vomiting. The
patients appetite had decreased since the onset of
illness
The patient had no complain about urination. The

patient hadnt defecated since the onset of the illness.
History of nosebleeds, gum bleeding, red spots on the
skins was denied.
3 days before admission the patient went to the
physician in the clinic. The patient had been given
paracetamol and some antibiotics, but there was no
significant improvement regard the patients symptoms.
The fever only relieved for several hours when the
patient took paracetamol, and the body temperature
would rise again.
2 days before admission the mother gave ibuprofen to

the patient and the body temperature was declined. The
patient had gained his appetite, and the patient was
able to do his activities again. At night the fever
returned suddenly and the patient took some ibuprofen.
Several hours before admission the body temperature
was declined in the morning and the patient went to the
nearest Puskesmas to get his blood tested.
HISTORY OF PAST ILNESSES

Pharingitis/ Tonsilitis
Enteritis
Bronchiolitis
Bacilarry Dysentery
Pneumonia
Dysentery Amoeba
Morbili/Measles
Typhoid
Pertusis
Worm
Varicella
Surgery
Diphtheria
Brain Concussion
Malaria
Fracture
Polio
Drug Reaction
Dengue Fever/Dengue
Hemorrhagic Fever
Hospitalized
MOTHERS PREGNANCY HISTORY

Antenatal Care: Mother checkups her pregnancy
to the health center (midwife/obstetrician) every
month. No problem during pregnancy and the
fetus in the womb was healthy.
Disease during pregnancy: no history of problems
and diseases during pregnancy.
Drugs taken: Mothers get vitamins every
antenatal care.
BIRTH HISTORY
Labor : Pasar Rebo Hospital

Birth attendants : Obstetrician
Mode of delivery : Caesarean delivery
Gestation : 37 weeks
Fetal membrane: Clear
Infant state : Healthy
Birth weight : 4 kg
Body length : 48 cm
According to the mother, the baby started to cry and
the baby's skin is red. No congenital defects.
POST NATAL HISTORY

The baby and the mother was examined
by the midwife
The health state of the infant: Healthy
HISTORY OF DEVELOPMENT
First dentition: 7 months
Psychomotor development
Smile : 2 months
Slant: 4 months
Prone : 4 months
Sitting : 7 months
Crawling : 8 months
Standing : 9 months
Walking : 10 months
Conclusion: good motor developmental status
HISTORY OF EATING
Breast milk: from birth until 2 years old.
Formula milk: from 2 years old until now,
but rarely; only 1 glass each time, 2-3
times a week.
Fruits and vegetables: apple, banana,
spinach
Solid food: rice, chicken, fish, meat, and
some other vegetables
IMMUNIZATION HISTORY
Immunization
BCG
Hepatitis B
DPT
Polio
MMR
Frequency
1 times
3 times
4 times
4 times
1 times
Time
1 month
0, 1, 6 month
2, 4, 6, 18 month
2, 4, 6, 18 month
15 months
FAMILY HISTORY
Family data
Information
Father
Mother
Number of marriage
Age at marriage
33 years old
27 years old
State of health
Healthy
Healthy
Mode of reproduction
The patient is the second child of two
siblings
Number of children Age
Gender
1
8 years old
Female
4 years 5 months
Male
Father: The patients father is 42 years old. The patients

father is healthy and has no history of the disease. No
history of drug or food allergies.
Mother: The patients mother is 36 years old. The
patients mother is healthy and has no history of the
disease. No history of drug or food allergies.
HISTORY OF DISEASE IN OTHER FAMILY

MEMBERS/AROUND THE HOUSE
Family members: The patients older sibling has
just recovered from fever illness 1 week before
the patient admitted to the hospital.
Around the house: for the past 1 month there
were 2 children whose admitted to the hospital
because of dengue hemorrhagic fever.
PHYSICAL EXAMINATION
Generalized status
General appearance
: moderately
ill
Awareness
: compos mentis
Vital signs
GCS
:E4/M6/V5
Heart rate : 111x/min
Respiratory rate
:
37x/min
Blood pressure : 100/70
mmHg
Temperature
: 38,2 0C
(axilla)
Anthropometric
Data
Weight : 14 kg
Height : 100 cm
(June 25th, 2014)
Nutritional
Status
Nutritional Status based

NCHS (National Center for
Health Statistics) year 2000:
Interpretation based on
Lokarya Antropometri
Depkes 1974 dan Puslitbang
Gizi 1978
WFA (Weight for Age): 14/17
x 100% = 82,3%
HFA (Height for Age):
100/105 x 100% = 95,23%
WFH (Weight for Height):
14/16 x 100% = 87,5%
Conclusion: nutrition
status of the patient is
good.
SYSTEMIC PHYSICAL
EXAMINATION Ears :
Skin :
Color: Tones, not pale, no
cyanosis, no petechiae
Turgor: normal
Head :
Shape and size: Normocephali,
no deformity
Large fontanel: Closed
Hair: black, not easy to repeal,
equitable distribution
Eyes :
Pupil
: Isokor
Pupil reflex : +/+
Eyes movement
: no
deformity
Conjungtiva
: Anemis -/Sklera
: Icterus -/Sunken eyelids : -/-
Cerumen : Tympanic membrane :

Intact +/+
Nose :
Shape : Normal
Septum : Deviation (-)
Secrete
: No secrete
Mucosa : Hyperemia -/Mouth and throat
Lips: pale (-), cyanosis (-),
dry (-)
Teeth : caries (-)
Tongue : clear, tremor (-)
Pharynx
: hyperemia (-)
Tonsils : T2/T2
Neck
Tyroid
(-)
Trachea
: enlargement
: In the middle
Lymph nodes :
Neck lymph nodes : no
enlargement
Axilla lymph nodes: no
enlargement
Thorax
Lungs :
Inspection
: Symmetric in a static state and dynamic,
suprasternal
retractions (-), intercostal retractions (-), ictus cordis is not
visible
Palpation
: ictus cordis palpable in the fourth intercostals
space of the
left linea midclavicularis, tactile fremitus are symmetrical
Percusion
: sonor in both lung fields
Top border of heart
: ICS II linea left parasternalis
Left border of heart
: ICS IV linea left midclavicula
Right border of heart : ICS IV linea right parasternalis
Auscultation :
Breath sound:Vesicular breath sounds, no rhonki, no wheezing
Heart sound : First and second heart sounds regular, murmur (-),
gallop(-)
Abdomen
Inspection : Convex, epigastric retraction (-), there is no a
widening of the veins, no spider nevi.
Palpation
: Supple, tenderness in right upper
quadrant and
epigastrium, liver is palpable +- 2cm below
costal margin,
abdominal mass (-), kidney ballotenment (-)
Percussion : The entire field of tympanic abdomen, shifting
dullness (-)
Auscultation
: Bowel sound (+) 5 times / minutes
Vertebrae : Theres no scoliosis, kyphosis, and lordosis, do

not
look any mass along the line of the vertebral
Genitalia
: Covering the labia majora labia minora
Anus
: Hole intact, does not seem that out of the
mass of
the anus
Extremities : Warm, capillary refill time <2 seconds,
infusion sets
mounted on the left hand
NEUROLOGICAL
EXAMINATION
Meningeal signs:
Neck stiffness : (-)
Brudzinski I maneuver : (-)
Brudzinski II maneuver: (-)
Kernig maneuver : (-)
Physiological Reflex
Biceps Reflex : normoreflex/normoreflex
Triceps Reflex : normoreflex/normoreflex
Patellar Reflex : normoreflex/normoreflex
Achilles Reflex : normoreflex/normoreflex
Pathological Reflec
Hoffmann-TrommerReflex : -/ Babinski Reflex: -/ Oppenheim Reflex : -/ Schaefer Reflex : -/ Chaddock Reflex : -/ Gordon Reflex : -/-
INVESTIGATION
(June 25th, 2014)
From Puskesmas Ciracas

Hematology
Results
(morning)
Normal Value
Hemoglobin
15,9 g/dL
13-16 g/dL
Hematocrit
47%
40-48%
Leukocytes
7.700/uL
5-10.000/uL
Thrombocytes
95.000/uL
150.000-40.000/uL
Erythrocytes
5,8 millions/uL
4,5-5,5 millions/uL
From Puskesmas Ciracas

Widal Serology
Salmonella Typhi O
Salmonella Paratyphi AO
Salmonella Paratyphi BO
Salmonella Paratyphi CO
Salmonella Typhi H
Salmonella Paratyphi AH
Salmonella Paratyphi BH
Salmonella Paratyphi CH
Results
From Polri Hospital

Hematology
Results
Normal Value
Hemoglobin
15,2 g/dL
13-16 g/dL
Hematocrit
44%
40-48%
Leukocytes
9.600/uL
5-10.000/uL
Thrombocytes
27.000/uL
150.000-40.000/uL
Erythrocytes
5,86 millions/uL
4,5-5,5 millions/uL
INVESTIGATIONS
(June 26th, 2014)
Urinalysis
Results
Normal Value
Colour
Yellow
Clearness
Clear
Reaction / pH
5 8.5
Specific gravity
1,025
1000 1,030
Protein
Negative
Bilirubin
Negative
Glucose
Negative
Ketones
Negative
Blood / Hb
Negative
Nitrite
Negative
Urobilinogen
0.1
0.1 1,0 IU
Leukocytes
Negative
Sediment
Leukocytes
0-1 / field of view
Erythrocytes
0-1 / field of view
Epithelial cells
+ / field of view
Cylinder
Crystal
etc.
FECES
Macroscopic
o
Color
Yellow
Consistency
Soft
Mucus
Blood
Microscopic
o
Leukocytes
1-3/field of view
Eritrocytes
0-2/field of view
Worm egg
o
Ascaris Sp
Anchilostoma Sp
Trichiuris Sp
Oxyuris Sp
WORKING DIAGNOSIS
Dengue Hemorrhagic Fever grade
I
MANAGEMENT
Parenteral infusion Ringer Lactate
Maintenance (Holiday-Segaar):
1200 ml
+10% because of DHF: 120 ml
Total parenteral fluid/24 hours:
1320 ml 18 dpm
Injection of Vitamin K 3x1 ampul
Paracetamol 3x500mg (if fever
presents)
Isprinol 3x5ml
PROGNOSIS
Quo ad vitam
: dubia ad
bonam
Quo ad functionam : bonam
Quo ad sanationam : bonam
Follow Up
The first day of hospitalization, 5 th

day of sickness June 25th 2014
S
Fever, Body feels sore, Nausea, but no vomit, Pain above the umbilical
General condition: moderately ill

Awareness: Compos mentis
Vital Signs
Blood pressure: 100/70 mmHg
Heart rate: 111 times/minute, strong, full, regular
Respiratory Rate: 37 times/minute
Temperature: 38,2 C
Abdominal Examination
Inspection : Flat, epigastric retraction (-)
Palpation : Supple, tenderness (+) in right upper quadran and epigastrium, liver is
palpable 2 cm below costal margin, abdominal mass (-)
Percusion : Tympanic, shifting dullness (-)
Auscultation : Bowel sounds 8 times / minutes
Investigation
From Puskesmas Ciracas (morning)
Hematology
Results
Normal Value
Hemoglobin
15,9 g/dL
13-16 g/dL
Hematocrit
47%
40-48%
Leukocytes
7.700/uL
5-10.000/uL
Thrombocytes
95.000/uL
150.000-40.000/uL
Erythrocytes
5,8 millions/uL
4,5-5,5 millions/uL
Widal Serology
Results
Salmonella Typhi O
Salmonella Typhi H
From Polri Hospital:

Hematology
Results
Normal Value
Hemoglobin
14,5 g/dL
13-16 g/dL
Hematocrit
42%
40-48%
Leukocytes
5.300/uL
5-10.000/uL
Thrombocytes
44.000/uL
150.000-40.000/uL
Erythrocytes
5,65 millions/uL
4,5-5,5 millions/uL
Parenteral infusion Ringer Lactate 18 dpm

Paracetamol 3x500mg (if fever presents)
Isprinol 3x5ml
The 2nd day of hospitalization, 6th day of sickness,

June 26th 2014
S
Body feels sore, Pain above the umbilical

Vital Signs
Temperature: 37,5 C
Inspection : Flat, epigastric retraction (-)
Palpation : Supple, tenderness (+) in right upper quadran and epigastrium, liver is
palpable 2 cm below costal margin, abdominal mass (-)
06.42
Hematology
Results
Normal Value
Hemoglobin
15,2 g/dL
13-16 g/dL
Hematocrit
44%
40-48%
Leukocytes
9.600/uL
5-10.000/uL
Thrombocytes
27.000/uL
150.000-40.000/uL
Erythrocytes
5,86 millions/uL
4,5-5,5 millions/uL
Hematology
Results
Normal Value
Hemoglobin
13,3 g/dL
13-16 g/dL
Hematocrit
38%
40-48%
Leukocytes
10.800/uL
5-10.000/uL
Thrombocytes
32.000/uL
150.000-40.000/uL
Erythrocytes
4,93 millions/uL
4,5-5,5 millions/uL
18.20
Urinalysis
Results
Normal Value
Colour
Yellow
Clearness
Clear
Reaction / pH
5 8.5
Specifc gravity
1,025
1000 1,030
Protein
Negative
Bilirubin
Negative
Glucose
Negative
Ketones
Negative
Blood / Hb
Negative
Nitrite
Negative
Urobilinogen
0.1
0.1 1,0 IU
Leukocytes
Negative
Leukocytes
0-1 / field of view
Erythrocytes
0-1 / field of view
Epithelial cells
+ / field of view
Cylinder
Crystal
etc.
Sediment
STOOL
Macroscopic
o
Color
Yellow
Consistency
Soft
Mucus
Blood
Microscopic
o
Leukocytes
1-3/field of view
Eritrocytes
0-2/field of view
Worm egg
o
Ascaris Sp
Anchilostoma Sp
Trichiuris Sp
Oxyuris Sp

Isprinol 3x5ml
The 3rd day of hospitalization, 7th

day of illness, June 27th 2014
S
Pain above the umbilical, Body feels sore

Vital Signs
Temperature: 36,5 C
Thorax Examination
Inspection :Symmetric in a static state and dynamic, suprasternal retractions (-), intercostal
retractions (-), ictus cordis is not visible.

Palpation : ictus cordis palpable in the fourth intercostal space of the left linea
midklavikularis
Percusion : Sonor on both lung fields
Auscultaion : Decrease vesicular breath sound on lower right lung felds, no

wheezing, no rhonchi, first and second heart sounds regular, murmur (-), gallop (-)
Inspection : looks distended, epigastric retraction
Palpation : Supple, tenderness (+) in right upper quadran and epigastrium,
liver is palpable 2 cm below costal margin, abdominal mass (-)
Percusion : Tympanic, shifting dullness (+)
Skin: mild rash in the trunk

Investigation:
Morning
Hematology
Results
Normal Value
Hemoglobin
13,2 g/dL
13-16 g/dL
Hematocrit
38%
40-48%
Leukocytes
12.800/uL
5-10.000/uL
Thrombocytes
34.000/uL
150.000-40.000/uL
Erythrocytes
4,90 millions/uL
4,5-5,5 millions/uL
Afternoon
Hematology
Results
Normal Value
Hemoglobin
12,7 g/dL
13-16 g/dL
Hematocrit
37%
40-48%
Leukocytes
11.400/uL
5-10.000/uL
Thrombocytes
34.000/uL
150.000-40.000/uL
Erythrocytes
4,68 millions/uL
4,5-5,5 millions/uL
3,1 g/dL
3,5-5,2 g/dL
Clinical chemistry
Albumin
Viral Immunoserology
Anti Dengue IgG /
Results
Normal Value
Anti DengueIgM
Negative
Negative
Anti DengueIgG
Positive
Negative
IgM
Thorax X-ray RLD:

Interpretation:
Sinus/diaphragm is normal
Mediastinum isnt widened
Heart is hard to assessed
Pulmonary: right pleura is widened,
no active lesion is seen
No abnormalities in the bone
Conclusion: right pleural effusion

A
Dengue Hemorrhagic Fever grade I with right pleural effusion and ascites

Injection of Vitamin K 3x1ampul
Isprinol 3x5ml
The 4th day of hospitalization, 8th

S
Pain in the upper abdomen

Vital Signs
Temperature: 36 C
Thorax Examination
Palpation : ictus cordis palpable in the fourth intercostal space of the left linea midklavikularis
Auscultaion : Decrease vesicular breath sound on lower right lung fields, no wheezing, no
rhonchi, first and second heart sounds regular, murmur (-), gallop (-)
Inspection : epigastric retraction (-) , looks distended
Palpation : Supple, tenderness (+) in right upper quadrant and epigastrium,
liver is palpable 2 cm below costal margin, abdominal mass (-)
Percusion : Tympanic, shifting dullness (+)
Investigation
Morning
Hematology
Results
Normal Value
Hemoglobin
12,5 g/dL
13-16 g/dL
Hematocrit
36%
40-48%
Leukocytes
11.900/uL
5-10.000/uL
Thrombocytes
56.000/uL
150.000-40.000/uL
Erythrocytes
4,64 millions/uL
4,5-5,5 millions/uL
Afternoon
Hematology
Results
Normal Value
Hemoglobin
12,4 g/dL
13-16 g/dL
Hematocrit
35%
40-48%
Leukocytes
15.500/uL
5-10.000/uL
Thrombocytes
66.000/uL
150.000-40.000/uL
Widal Serology
Results
Salmonella Typhi O
Salmonella Typhi H
+1/80

Isprinol 3x5ml

day of illnes, June 29th 2014
S
General condition: mildly ill

Vital Signs
Temperature: 36,5 C
Thorax Examination

Palpation : ictus cordis palpable in the fourth intercostal space of the left linea
midklavikularis
Auscultaion : Vesicular breath sounds in both lung fields, no wheezing, no rhonchi, first and
second heart sounds regular, murmur (-), gallop (-)
Inspection : epigastric retraction (-) , looks flat
Palpation : Supple, tenderness (-), , liver is palpable 2 cm
below costal margin, abdominal mass (-)
Investigation
Hematology
Results
Normal Value
Hemoglobin
12,9 g/dL
13-16 g/dL
Hematocrit
36%
40-48%
Leukocytes
13.400/uL
5-10.000/uL
Thrombocytes
110.000/uL
150.000-40.000/uL
Erythrocytes
4,62 millions/uL
4,5-5,5 millions/uL
Dengue Hemorrhagic Fever grade I with right pleural effusion and ascites refinement

Isprinol 3x5ml

S
General condition: well

Vital Signs
Temperature: 37,3 C
Investigation
Hematology
Hemoglobin
Results
Normal Value
11,9 g/dL
13-16 g/dL
Hematocrit
35%
40-48%
Leukocytes
9.800/uL
5-10.000/uL
Thrombocytes
211.000/uL
150.000-40.000/uL
Erythrocytes
4,39 millions/uL
4,5-5,5 millions/uL
Observation
Hematology
J une25th
J une25th
J une26th
J une26th
J une27th
(morning)
(afternoon)
(morning)
(afternoon)
(morning)
Hemoglobin
15,9
14,5
15,2
13,3
13,2
Hematocrit
47
42
44
38
38
Leukocytes
7.700
5.300
9.600
10.800
12.800
Thrombocytes
95.000
44.000
27.000
32.000
34.000
Erythrocytes
5,8
5,65
5,86
4,93
4,90
Hematology
J une27th
J une28th
J une28th
J une
J une
(afternoon)
(morning)
Hemoglobin
12,7
Hematocrit
Normal Value
(afternoon)
29th
30th
12,5
12,4
12,9
11,9
13-16 g/dL
37
36
35
36
35
40-48%
Leukocytes
11.400
11.900
15.500
13.400
9.800
5-10.000/uL
Thrombocytes
34.000
56.000
66.000
110.000
211.000
150.00040.000/uL
Erythrocytes
4,68
4,64
4,64
4,62
4,39
4,5-5,5
millions/uL
SPECIAL CONTROL LIST

Date
June 26th,
2014
June 27th,
2014
June 28th,
2014
Input
Output
IVFD (ml)
Eat, Drink
(ml)
Urine
Output
(ml)
8pm (June
25th)-6am
540
350
400
6am-10am
216
100
325
10am-4pm
324
200
675
4pm-11pm
378
400
950
11pm-6am
378
500
600
6am-10am
216
800
600
Time
10am-4pm
324
550
800
4pm-8pm
216
400
300
8pm-7am
594
1000
1000
7am-11am
216
500
750
11am-6pm
270
300
420
6pm-11pm
90
Balance
(ml)
Diuresis
311
2508
2350 =
+158
6,2/kg/hour
311
2664
2300 =
+364
5,98/kg/ho
ur
311
2970
2170 =
+800
5,74/kg/ho
ur
IWL (ml)
Input
Date
June 29th,
2014
Output
IVFD (ml)
Eat, Drink
(ml)
Urine
Output
(ml)
11pm-6am
126
200
500
6am-12pm
108
12pm-6pm
108
250
200
Time
Balance
(ml)
Diuresis
311
792 - 700
= +92
0,63/kg/ho
ur
311
1570
1200 =
+370
5,7
ml/kg/hour
IWL (ml)
June 30th,
2014
6pm-9am
270
1300
1200
Literature Review
Dengue Hemorrhagic Fever
DEFINITION
Dengue fever is a benign syndrome caused by several
arthropod-borne viruses and characterized by biphasic
fever, myalgia or arthralgia, rash, leukopenia and
lymphadenopathy.
Dengue hemorrhagic
fever (DHF) is a severe, often fatal,
febrile disease caused by dengue viruses characterized
by abnormalities of hemostasis and capillary permeability
that leads, in severe cases, to a protein-losing shock
syndrome (dengue shock syndrome, DSS).
Dengue and dengue hemorrhagic fever (DHF) are caused
by one of four closely related, but antigenically distinct,
virus serotypes (DEN-1, DEN-2, DEN- 3, and DEN-4), of the
genus Flavivirus.
EPIDEMIOLOGY
Estimation: 50 million infections per year
in 100 countries
First time appeared in Asia: Thailand, 1950
and first time appeared in Indonesia:
1969.
In 2007the number of dengue incidence
in ESA was increased about 18% and the
morbidity was 15% higher than in 2007.
ETIOLOGY
Dengue and DHF are caused by one of four virus serotypes
dengue virus (DEN).
In Indonesiaall serotypes are found and DEN 3 is the most
common one
Flavivirus has spherical shape with a lipid envelope; the particles are
approximately 50 nm in diameter. The dengue virus genome is

11,644 nucleotides in length.
The flavivirus structural protein genes encoding the nucleocaprid or
core protein (C), a membrane-associated protein (M), an envelope
protein (E), and seven non-structural protein (NS) genes. Among
non-structural proteins, envelope glycoprotein, NS1, is of diagnostic
and pathological importance.
Infection with one dengue serotype provides lifelong

immunity to that virus, but there is no cross-protective
immunity to the other serotypes. Thus, persons living in
an area of endemic dengue can be infected with three,
and probably four, dengue serotypes during their lifetime.
Aedes aegypti and Aedes albopictus are the two most
important vectors of dengue. A. aegypti, the principal
vector, is a small, black-and-white, highly domesticated
tropical mosquito that prefers to lay its eggs in artificial
containers commonly found in and around homes, for
example, flower vases, old automobile tires, buckets that
collect rainwater, and trash in general.
Aedes aegypti originates from Africa, but now is spreading worldwide
and become the most common dengue virus transmitter in the world.
Aedes albopictus originates from South East Asia, Western Pacific,
and Indian Ocean.
PATHOPHYSIOLOGY
Several theories; the most common one:
Secondary-infection or immune
enhancement hypothesis.
patients experiencing a second infection

with a heterologous dengue virus serotype
have a significantly higher risk for
developing DHF and DSS.
Preexisting
heterologous dengue
antibody recognizes
the infecting virus and
forms an antigenantibody complex
increased
vascular
permeability
Hypovolemia
and shock
AAC bound to and

internalized by
immunoglobulin Fc
receptors on the cell
membrane of
leukocytes,
especially
macrophages
produce and secrete

vasoactive
mediators
(cytokines,
complements) in
response to dengue
infection
the virus is not

neutralized and
is free to
replicate once
inside the
macrophage
Prior infection
(Antibodydependent
enhancement
(ADE)) enhances
the infection and
replication of
dengue virus in
cells of the
mononuclear cell
lineage
Endothelial cells dysfunction disruption in the function of endothelial

glycocalyx.
Glycocalyx functions as a molecular sieve
Proteinuria and
hypoalbuminemi
a
Glycocalyx has
heparan sulfate
Selectively restricting molecules

within plasma according to their
size, charge, and shape
Albumin and protein loss
Dengue virus and

NS1 bind to
heparan sulfate
Glycocalyx loss its

function
Increase heparan sulfate in urine has been

detected in severe dengue cases
Thrombocytopen
ia
Early bone marrow suppression
Increased peripheral destruction of

platelets during the febrile and early
convalescent phase
1. Dengue produces transient suppression of hematopoiesis via direct
infection or macrophage inflammatory protein 1-alpha
2. Dengue virus binds to platelets in the presence of virus-specific antibody
Mechanism of coagulopathy unknown
Mechanisms of liver injury in dengue may be due to:

direct effects of the virus or host immune
response on liver cells
circulatory compromise
metabolic acidosis and/or hypoxia caused by
hypotension
localized vascular leakage inside the liver.
The predominant findings in these studies were
microvesicular steatosis and small foci of
hepatocellular necrosis in addition to the presence
of councilman bodies, Kupffer cell hyperplasia and
mononuclear cell infiltrates at the portal tract.
CLINICAL MANIFESTATION
Undifferentiated fever
The people who got infected by dengue virus may develop a simple fever
that cant be distinguished from other viral infections (atypical symptoms).
Maculopapular rashes may accompany the fever or may appear during
defervescence. Upper respiratory and gastrointestinal symptoms are
common.
Dengue Fever
Dengue fever (DF) is most common in older children, adolescents and adults.
It is generally an acute febrile illness, and sometimes biphasic fever with
severe headache, myalgias, arthralgias, rashes, leucopenia and
thrombocytopenia may also be observed. Severe headache, muscle and joint
and bone pains (break-bone fever), particularly in adults. Occasionally
unusual haemorrhage such as gastrointestinal bleeding, hypermenorrhea and
massive epistaxis occur.
Dengue Hemorrhagic Fever
DHF is characterized by the acute onset of high fever. There are

common haemorrhagic diatheses such as positive tourniquet test
(TT), petechiae, easy bruising and/or GI haemorrhage in severe
cases. By the end of the febrile phase, there is a tendency to develop
hypovolemic shock (dengue shock syndrome) due to plasma leakage.
The presence of preceding warning signs such as persistent
vomiting, abdominal pain, lethargy or restlessness, or
irritability and oliguria are important for intervention to prevent
shock. Abnormal haemostasis and plasma leakage are the main
pathophysiological hallmarks of DHF. Thrombocytopenia and
rising haematocrit/haemoconcentration are constant findings
before the subsidence of fever/ onset of shock.
Febrile Phase
High temperature (38.5C) accompanied by
headache, vomiting, myalgia, and joint pain,
sometimes with a transient macular rash.
Anorexia, nausea and vomiting
Petechiae, mucosal membrane bleeding and bruising,
palpable liver are commonly noted
Laboratory findings mild-to-moderate
thrombocytopenia and leukopenia
Lasts 3-7 days
Critical Phase
Defervescence (day 3-7 illness)
Increase in capillary permeability
hemoconcentration, hypoproteinemia, pleural
effusions, and ascites
Clinically significant plasma leakage 24-48
hours
Hemorrhagic manifestation in children isnt
clinically significant, associates with profound
and prolonged shock
Moderate-to-severe thrombocytopenia
Looking for warning signs
Recovery/Convalescent Phase
Vascular permeability is back to normal
after 48-72 hours after critical phase
Rapid improvement of patients
symptoms; stabilization of vital signs
Second rash may appear, might be
generalized pruritus
Caution of administration of intravenous
fluids
Investigations
The following laboratory tests are available to diagnose
dengue fever and DHF:
Virus isolation: serotypic/genotypic characterization
Viral nucleic acid detection: RT-PCR
Viral antigen detection: NS1
Immunological response based tests: IgM and IgG
antibody assays; MAC-ELISA, IgG/IgM ratio, MAC ELISA,
haemaglutination inhibition test, complement fixation
test, neutralization test
Analysis for hematological parameters
Primary antibody response individual

who are not immune to dengue
Secondary immune response
previous dengue infection
Primary infection: slow and low-titre
antibody response
Immunoglobulin (Ig)M antibodies are the
first isotype to appear, by day 35 of
illness in 50% of hospitalized patients
and by day 610 of illness in 9399% of
cases. The IgM levels peak ~2 weeks
after the onset of fever and then
generally decline to undetectable levels
over the next 23 months
Dengue-specific IgG is detectable at low
titre at the end of the first week of illness
and slowly increases
Secondary infection:
high levels of IgG
antibodies that are
detectable even in the
acute phase and rise
dramatically over the
following 2 weeks.
as IgM levels are
significantly lower in
secondary dengue
infections, falsenegative test results for
dengue-specific IgM
have been reported
during secondary
infections.
Following a dengue
infection, IgG can be
lifelong, which
complicates the
MANAGEMENT AND TREATMENT

No specific therapy is available at the
present time for symptomatic dengue
infections. Effective treatment relies on
good supportive care, with particular
emphasis on fluid therapy and
management of bleeding complications
Indications for IV fluid in critical period of DHF:

inadequate oral fluid intake or vomiting in patient
hematocrit continues to rise 10%-20% despite oral
rehydration
impending shock/warning signs.
The following parameters should be monitored:
General condition, appetite, vomiting, bleeding and
other signs and symptoms.
Peripheral perfusion
Vital signs must be checked every 24 hours in nonshock patients and 12 hours in shock patients.
Serial haematocrit must be checked every four to six
hours in stable cases.
Urine output (amount of urine) should be recorded. During
this period the amount of urine output should be about 0.5
ml/kg/h (this should be based on the ideal body weight).
General principles of fluid therapy in DHF:

Isotonic crystalloid solutions should be used throughout
the critical period
Hyper-oncotic colloid solutions (osmolarity of >300
mOsm/l) such as dextran 40 or starch solutions may be used in
patients with massive plasma leakage, and those not responding
to the minimum volume of crystalloid.
A volume of about maintenance +5% dehydration should
be given to maintain a intravascular volume and circulation.
The duration of IV fluid therapy not exceed 24-48 hours for
shock patients
the duration of intravenous fluid therapy not more than 60 to
72 hours for nonshock
In obese patients, the ideal body weight should be used as a
guide to calculate the fluid volume
Managing DHF Grade I and II

without Shock
the fluid allowance (oral + IV) is about
maintenance (for one day) + 5% deficit
(oral and IV fluid together), to be
administered over 48 hours.
The rate of IV replacement should be
adjusted according to the rate of plasma
loss, guided by the clinical condition, vital
signs, urine output and haematocrit levels.
Antipyretic such as paracetamol can be
given
Managing DHF Grade III

Most cases of DSS will respond to 10 ml/kg in
children over one hour or by bolus, if
necessary.
before reducing the rate of IV replacement:
the clinical condition, vital signs, urine output
and haematocrit levels should be checked to
ensure clinical improvement. It must be
continued for a minimum duration of 24 hours
and discontinued by 36 to 48 hours
Managing DHF Grade IV

10 ml/kg of bolus fluid be given as soon as possible, within 10-15
minutes
Not reversible
restored
Continuing IV fluid
as in Grade 3
Repeat 10 ml/kg bolus and obtain lab

results to be corrected
Urgent blood transfusion should be
considered as the next step (after
reviewing the pre- resuscitation HCT)
and followed up by closer monitoring,
e.g. continuous bladder
catheterization, central venous
catheterization or arterial lines.
Management of Convalescence
Convalescence can be recognized by the improvement in
clinical parameters, appetite and general well-being.
Haemodynamic state such as good peripheral perfusion and
stable vital signs should be observed.
Decrease of HCT to baseline or below and dieresis are usually
observed.
Intravenous fluid should be discontinued.
In those patients with massive effusion and ascites,
hypervolemia may occur and diuretic therapy may be
necessary to prevent pulmonary oedema.
Bradycardia is commonly found and requires intense
monitoring for possible rare complications such as heart block
or ventricular premature contraction (VPC).
Convalescence rash is found in 20%30% of patients.
Signs of Recovery
Stable pulse, blood pressure and breathing
rate.
Normal temperature.
No evidence of external or internal bleeding.
Return of appetite.
No vomiting, no abdominal pain.
Good urinary output.
Stable haematocrit at baseline level.
Convalescent confluent petechiae rash or
itching, especially on the extremities.
Criteria for Discharging Patients

Absence of fever for at least 24 hours without the use of
anti-fever therapy.
Return of appetite.
Visible clinical improvement.
Satisfactory urine output.
A minimum of 23 days have elapsed after recovery from
shock.
No respiratory distress from pleural effusion and no ascites.
Platelet count of more than 50 000/mm3. If not, patients
can be recommended to avoid traumatic activities for at
least 12 weeks for platelet count to become normal. In
most uncomplicated cases, platelet rises to normal within 3
5 days.
REFERENCES
Gubler DJ, Clark GG. Dengue/dengue hemorrhagic fever: the emergence of a global health problem. Emerg Infect
Dis. 1995 Apr-Jun; 1(2): 5557.
Jagadishkumar K, Jain P, et al. Hepatic Involvement in Dengue Fever in Children. Iran J Pediatr. Jun 2012; 22(2): 231
236
Smith DR, Khakpoor A. Involvement of the liver in dengue infections. Molecular Pathology Laboratory, Institute of
Molecular Biosciences, Mahidol University, Thailand Dengue Bulletin Volume 33, 2009, p. 75-86
Guzman MG, Halstead SB, Artsob H, et al. Dengue: a continuing global threat. Nature Reviews Microbiology,S7S16|doi:10.1038/nrmicro2460
WHO SEARO. Comprehensive Guidelines for Prevention and Control of Dengue and Dengue Haemorrhagic Fever
(Revised and Expanded Edition). 2011. Pub WHO : http://apps.searo.who.int/pds_docs/B4751.pdf
Simmons, Cameron P., et.al. Dengue. New England Journal Medicine. NEJM 366;15: Massachussets Medical
Society:2012
Hadinegoro S.R.H, Satari H.I. Demam Berdarah Dengue, Naskah Lengkap, Pelatihan bagi Pelatih Dokter Spesialis
Anak & Dokter Spesialis Penyakit Dalam dalam Tatalaksana Kasus DBD. Jakarta : Balai Penerbit Fakultas Kedokteran
Universitas Indonesia. 2005.
Halstead, Scott B. Dengue. Tropical Medicine Science and Practice Vol.5. Imperial Collage Press: London
Standar Pelayanan Medis Demam Berdarah Dengue, Buku Ajar Ikatan Dokter Anak Indonesia. Jakarta. 2009.
WHO. Dengue: Guidelines for Diagnosis, Treatment, Prevention, and Control. 2009.
Karyana IPG, et al. The value of IgG to IgM ratio in predicting secondary dengue infection. Paediatrica Indonesiana
vol 46, no. 5-6;2006;p 113-117
WHO. Handbook for Clinical Management of Dengue. 2012.
Karyanti MR, Hadinegoro SR. Perubahan Epidemiologi Demam Berdarah Dengue di Indonesia. Sari Pediatri, Vol.
10;6;2009;p.424-432
Lei, HY et al. Immunopathogenesis of Dengue Virus Infection. J Biomed Sci 2001;8:377388

DHF Case Presentation Dyta

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Dengue Hemorrhagic Fever grade I

Created by: Amiradyta Mahartiza (07120100076)

IDENTITY OF THE PATIENT

Jl. Alsafiah Gg. H. Muktar RT

IDENTITY OF THE PATIENTS

Jl. Alsafiah Gg. H.

Jl. Alsafiah Gg. H.

Senior High School

Junior High School

HISTORY OF PRESENT ILLNESS

The patient had no complain about urination. The

2 days before admission the mother gave ibuprofen to

HISTORY OF PAST ILNESSES

MOTHERS PREGNANCY HISTORY

Labor : Pasar Rebo Hospital

POST NATAL HISTORY

Father: The patients father is 42 years old. The patients

HISTORY OF DISEASE IN OTHER FAMILY

(June 25th, 2014)

Nutritional Status based

Cerumen : Tympanic membrane :

Vertebrae : Theres no scoliosis, kyphosis, and lordosis, do

(June 25th, 2014)

From Puskesmas Ciracas

From Puskesmas Ciracas

From Polri Hospital

(June 26th, 2014)

0-1 / field of view

0-1 / field of view

The first day of hospitalization, 5 th

General condition: moderately ill

Inspection : Flat, epigastric retraction (-)

Auscultation : Bowel sounds 8 times / minutes

From Polri Hospital:

Dengue Hemorrhagic Fever grade I

Parenteral infusion Ringer Lactate 18 dpm

The 2nd day of hospitalization, 6th day of sickness,

Body feels sore, Pain above the umbilical

General condition: moderately ill

Inspection : Flat, epigastric retraction (-)

Auscultation : Bowel sounds 12 times / minutes

0-1 / field of view

0-1 / field of view

Dengue Hemorrhagic Fever grade I

Parenteral infusion Ringer Lactate 18 dpm

The 3rd day of hospitalization, 7th

Pain above the umbilical, Body feels sore

General condition: moderately ill

retractions (-), ictus cordis is not visible.

Percusion : Sonor on both lung fields

Auscultaion : Decrease vesicular breath sound on lower right lung felds, no

Skin: mild rash in the trunk

Thorax X-ray RLD:

Conclusion: right pleural effusion

Parenteral infusion Ringer Lactate 6 dpm

The 4th day of hospitalization, 8th

Pain in the upper abdomen

General condition: moderately ill

retractions (-), ictus cordis is not visible.

Percusion : Sonor on both lung fields

Parenteral infusion Ringer Lactate 6 dpm

The 5th day of hospitalization, 9th

General condition: mildly ill