CASE REPORT

A Dengue Hemorrhagic Fever s Patient

with Bilateral Pleural Effusion

Division of Tropical and Infectious Disease

Department of Internal Medicine
Medical Faculty of Airlangga Univ. - Dr Soetomo Teaching Hospital
Surabaya
CASE REPORT

Patients Identity

Mrs. W/ 24 yo
Islam
A Housewife
From Trowulan-Jombang,
East Java, Indonesia
 ANAMNESIS
April, 5 2010

Chief Complaint : Dypsneu

Dypnsneu since 1 days before admission, continous, no cough.

Fever since 5 days before admission

There are headhace, muscle and bone pains, nausea, anoreksia

Dispepsia
No history of lung dissease, HT or the other dissease
 PHYSICAL EXAMINATION
April, 5 2010
General Condition : Body weakness

GCS 456 BP 110/80 P 80 bpm RR 32 x/min T 37.5C

Tourniquet test (+)

Head and Neck : Normal

Chest : Symmetric, Chest Percussion dullness, decreased

breath sounds, friction-rub, Breathing Sound Vesicular
Rales on Lower Chest (Bilateral)
Heart Sound : Normal

Abdominal : Flat, Liver & spleen unpalpable

Extremities : Warm, Dry, Red
 LABORATORY & RADIOLOGY RESULT
April, 5 2010

Hb 11,9 g/dL
Leuco 11,3 x 103/ul
Thrombo 82 x 103/ul Blood Gas Analysis
(Oxygen 2 lpm)
PCV 35,0%
PH : 7,48
BUN 11 mg/dL PCO2 : 30 mmHg
SC 0,8 mg/dL PO2 : 70 mmHg
AST 396 IU/L HCO3 : 22,3 mmol/L
ALT 353 IU/L BE : -1,2 mmol/L
O2 Sat : 95%
Alb 2,3 g/dL
Sodium 137,5 mmol/L
Potassium 3,5 mmol/L
AP position
 INITIAL ASSESSMENT
Sep, 5 2006

DHF gr II + Bilateral Pleural Effusion

 INITIAL PLANNING
April, 5 2010

Diagnostic

IgM & IgG anti dengue

Pleural fluid analysis
Serial CBC

Therapy

Nasal O2 3 lpm
IVFD 1000 mL/24h
High Calorie High Protein 2100 kcal
Paracetamol 500 mg, tid, po

Monitoring

Vital signs, serial CBC

 PROGRESSION
April, 5-2010 April, 6-2010 April, 7-2010 April, 8-2010 April, 9-2010
Hb 11,9 g/dL 11,7 g/dL 13,1 g/dL 14,0 g/dL 13,3 g/dL
Leuco 11,3 x 103/ul 3,9 x 103/ul 4,0 x 103/ul 3,5 x 103/ul 4,1 x 103/ul

Thrombo 82 x 103/ul 61x 103/ul 47 x 103/ul 82 x 103/ul 106 x 103/ul

PCV 35,0% 37,0% 34,5% - -

BUN 11 mg/dL - 11 mg/dL - -
SC 0,8 mg/dL - 0,8 mg/dL - -
AST 396 IU/L - 189 IU/L - -
ALT 353 IU/L - 246 IU/L - -
Alb 2,3 g/dL - 3,1 g/dL - -
Sodium 137,5 mmol/L - - - -

Potassium 3,5 mmol/L - - - -

April, 5 2010
Consulted to Lung departemen
A patient with pleural effusion can be caused by
underliying dissease (DHF) pleural fluid analysis April, 7 2010
sel = 200 sel/uL, sel mono nuclear = 15%, sel
poli nuclear = 85%, glukosa cairan pleura = T=100/60 , N=88x/m ,
99mg/dL, protein cairan pleura = 3.3 g/dL, t= 36,70C, rr=38x/m
LDH cairan pleura = 3627 U/L, rivalta positip

April, 6 2010
T=120/80 , N=72x/m ,
t= 37,50C, rr=34x/m
April, 8 2010 April, 12 2010
T=110/70 , N=88x/m , T=100/60 , N=88x/m ,
t= 36,80C, rr=38x/m t= 36,30C, rr=24x/m

April, 13 2010
April, 9 2010 T=110/60 , N=80x/m ,
T=110/60 , N=80x/m , t= 36,80C, rr=20x/m
t= 37,20C, rr=40x/m
Evakuation of pleural effusion
> OK paru
800 cc (D) & 200 cc(S)
 PROGRESSION

April, 5 2010 April, 12 2010

DISCUSSION
Map showing the distribution of dengue fever in the world, as of 2006.
Map produced by the Agricultural Research Service of the US Department of Agriculture.
Source: Slide #8 of a presentation by Gary G. Clark, PhD, entitled "Dengue: An emerging
arboviral disease". Cyan: Areas infested with Aedes aegypti. Red: Areas with Aedes aegypti
and recent epidemic dengue fever
 80
70
Incidence rate (IR)

60
50
40
30
20
10
0
2003 2004 2005 2006 2007 2008

IR = Angka kejadian Penyakit per 100.000 penduduk

Source: Center For Data And Information Ministry Of Health Of Republic of Indonesia . 2009
 Clinical aspects

Dengue Virus
DEN-1, 2, 3, 4

Undifferentiated Dengue Fever Dengue Hemorrhagic Fever

fever (DF) (DHF/DSS)

Without With unusual No shock Shock

Hemorrhage hemorrhage (DHF) (DSS)

World Health Organization. Dengue Haemorrhagic Fever: Diagnosis, treatment,

prevention and control. 2 ed. 1997
 The World Health Organization (WHO) case definitions of
dengue haemorrhagic fever
Dengue haemorrhagic fever (DHF) Patient
Fever or history of fever, lasting 2-7 days, occasionally +
biphasic
Haemorrhagic tendencies +
Thrombocytopenia (100,000 cells per mm3 or less) +
Evidence of plasma leakage manifested by at least one of
the following :
a rise in the haematocrit equal or greater than 20% above
average for age, sex and population
a drop in the haematocrit following volume replacement
+
treatment equal to or greater than 20% of baseline
signs of plasma leakage such as pleural effusion, ascites
and hipoproteinemia. Definition of dengue shock syndrome
(DSS) : DHF cases with documented narrow pulse pressure
(< 20 mmHg), hypotension or other signs of shock
Figure 2: Immunopathogenesis of DHF. Srikiatkhachorn (2009)
Primary exposure to dengue virus induces both humoral (antibodies) and cellular (T cells) mediated immune responses.
During a secondary infection with a different dengue virus serotype, cross-reactive, non-neutralising antibodies bind to
virus and enhance viral uptake via Fc receptors resulting in enhanced viral replication and higher antigen load which lead
to an exaggerated activation of cross-reactive dengue-specific T cells. Dengue virus may have direct effects on endothelial
cells such as modulation of cell surface molecule and cytokine receptor expression. Biological mediators released by T cells
and by virus-infected cells along with complement activation by viral proteins and immune complexes, may result in
enhanced vascular permeability and coagulopathy
Srikiatkhachorn, 2009
PLEURAL EFFUSION
Accumulation of fluid between the layers
of the membrane that lines the lungs and
the chest cavity
Pathophysiology
Normal: 1 mL of pleural fluid
Balance between hydrostatic/oncotic forces
and lymphatic drainage
Abnormal: Pleural effusion
Disruption of balance
 Pathogenesis of pleural effusion

Elevated capillary hydrostatic pressure (cardiac failure)

Reduced capillary oncotic pressure (hypoalbuminemia)
Enhanced capillary permeability (inflammation)
Obstructed lymphatics (tumor)
Movement of fluid from extrathoracic site (pancreatitis)
 363 (DHF) Chest photo thorax 25%
with pleural effusion, mostly on the right
side (Wang, 2007)

Pleural effusion is mostly on the right

side, as a constant finding, but in shock
bilateral pleural effusion is a common
finding (Srikiatkhachorn, 2009)
 SUMMARY
Dengue hemorrhagic fever (DHF) is acute febrile
disseases which occur in the tropics, can be life-
threatening, and are caused by four closely related
virus serotypes of the genus Flavivirus, family
Flaviviridae.

Around the time of defervescence, DHF patients

localised plasma leakage manifested as
accumulation of fluid in pleural and abdominal
cavities and haemoconcentration.
 ...Contd
The extent of plasma leakage varies
between individual patients and can lead to
intravascular volume depletion requiring
fluid resuscitation.

Pleural effusion is mostly on the right side,

as a constant finding, but in shock bilateral
pleural effusion is a common finding.
Light, R. W. N Engl J Med 2002;346:1971-1977
Light , 2002
 Hemorrhagic fevers
Family Genus Virus Disease Incubation Vector
Filoviridae Filovirus Ebola Ebola HF 2-21 Unknown
Marburg Marburg HF 2-14 Unknown
Arenaviridae Arenavirus Lassa Lassa fever 5-16 Rodent
New World New World HF 7-14 Rodent
Arenaviridae (Argentinean HF,
Bolivian HF, etc.)
Bunyaviridae Nairovirus Crimean-Congo Crimean-Congo HF 3-12 Tick
hemorrhagic
fever
Phlebovirus Rift Valley fever Rift Valley Fever 2-6 Mosquito
Hantavirus Agents of HFRS HF renal syndrome/ 9-35 Rodent
and HPS Hantavirus
pulmonary syndrome
Flaviviridae Flavivirus Dengue DF, DHF, DSS 5-8 Mosquito
Yellow fever Yellow fever 3-6 Mosquito
Omsk HF Omsk HF 2-9 Tick

Kyasanur Forest Kyasanur Forest 2-9 Tick

disease disease
 Bone Marrow
Stem cell
Macrophage

Lymphocytes

Ag-Ab complex

Platelets

Thrombocytopenia
 Hepatic disfunctions in dengue
Hepatocellular injury manifested by
hepatomegaly, elevation of ALT, and
coagulopathy are common in DHF
and even in DF, although
hepatomegaly is absent.

Co-infection in dengue patients Management

Co - infection can modify clinical
presentations of dengue disease Successful treatment of DHF
and result in missed or delayed depends on early recognition and
diagnosis and treatment and possible careful monitoring of the
misinterpretation as unusual development of shock.
manifestations.

J Med Assoc Thai 2002; 85: S298 J Med Assoc Thai 2002; 85: S298- 301. Pediatr Pediatr Infect Infect Dis Dis J 1998; 17: 81 J 1998; 17: 81- 2. Med J Med J Aust Aust 1994; 160: 22 1994; 160: 22-6. 6.
 DENGUE-MONOCYTES
Complement
C3a, C5a
PLA2 Lymphocytes Proinflammatory
activation cytokine

Protein Binding IL-1

TNF-
IL -6

Arachidonat metab

Malfunction dystruction
endothel endothel
Eicosanoid

Prostacyclin INCREASED VASCULAR

Thromboxsane
Leucotrienes PERMEABILITY

CAPILLARY LEAKAGE

Dengue shock syndrome

Nasronudin, 2005
 Immune Response to Dengue infection

Primary infection: Secondary infection:

High level of IgM that appears 4-6 Low levels of IgM (may not be produced or
days after symptoms and may persist at undetectable levels in 20% of patients).
for up to 10 weeks. IgG rise rapidly 1-2 days after onset of
Antibody level

IgG appears 2 weeks after onset and symptoms at higher levels than primary
persists for life. infection.

Clinical Symptoms, Clinical Symptoms,

Fever Fever
IgG antibodies

NS1 Ag NS1 Ag

Virus Virus
IgM antibodies

Primary Infection Secondary Infection

 SUMMARY
Points of Events

Sept, 25 Sept, 27 Oct, 5 Oct, 9 Oct, 14

ICU Setting

Tamiflu (Oseltamivir)

Antibiotics

Ventilatory Support

H5N1 positive H5N1 negative

 PROGRESSION
BLOOD GAS ANALYSIS

O2 Saturation 99

pH 7.559 7.48

pO2 109 7.46

34 34
CO2
26.4 59
Saturation
54
<60 <60

Sep, 25 2006 Sep, 26 2006 Sep, 27 2006

Intermediate Care Intensive Care