CASE SCENARIO A 33 years old Malay man was admitted to a hospital with a history of fever for 5 days and

maculopapular rash for 2 days. Physical examination showed a positive tourniquet test with petechial haemorrhages over his arms and legs. There were no investigations showing leukopenia and thrombocytopenia with increase in haematocrit concentration.

1. What is the most likely diagnosis? Explain your answer. Dengue fever Reason : Topical country Fever for 5 days Maculopapular rash for 2 days Positive tourniquet test Petechial haemorrhages Leukopenia and thrombocytopenia High haematocrit concentration

2. What is the causative organism? Dengue virus (causes dengue and dengue haemorrhagic fever) Have 4 serotypes (DEN-1, DEN-2, DEN-3, DEN-4) Small enveloped virus (40-50nm)

3. What is the mode of transmission? Transmitted by mosquitos: Aedes aegypti Aedes albopictus Distinct physical feature (black & white stripes on its body and legs) Bites during the day Lays its eggs in clean, stagnant water Only the female feeds on blood i. ii. iii. Mosquito bites and sucks blood containing the virus from an infected person Virus is carried in its body And passes the virus to healthy people when it bites them

4. Discuss the clinical symptoms of this disease. Plasma leakage Hepatomegaly Low blood pressure Hypovolemic shock Death

5. Mention the types of dengue infection. i. Dengue without warning signs ii. Dengue with warning signs iii. Severe dengue

6. What are the principles of treatment? There is no specific treatment for dengue infection Only supportive (treatment of symptoms) Assess for dehydration and ability to drink fluids Therapy for pain (avoid aspirin because of exacerbating haemorrhagic tendencies) Fluid replacement through IV Medication to reduce fever

7. What are the measurements of prevention? Vector control: Improved water storage practice Eliminate any sources that may collect water, such as tins, bottles & old tires Insecticides such as larvicides Introduction of mosquito eating fish Always clean and check drains to ensure they are not blocked especially during rainy season Vaccination: No licensed commercialized vaccine Needs to prevent all 4 serotypes (tetravalent)

MCQ (1) Regarding Viral Haemorrhagic Fevers: a) b) c) d) e) Caused by several distinct families of RNA viruses Only effect humans Bleeding often occurs depending on the virus Natural reservoir host plays important role in the survival of haemorrhagic viruses Mainly transmitted by person to person contact T F T T F

MCQ (2) Regarding Yellow Fever: a) b) c) d) e) Transmitted by female Anopheles mosquito Caused by Rift Valley Fever virus Virus can be cultured in early blood samples Preventable by immunization Treated by specific anti-viral drug F F T T F

MCQ (3) Regarding Dengue Fever: a) Endemic in more than 100 countries b) Caused by dengue viruses that belong to family Flaviviridae c) Growth of global travel plays an important role in increasing the incidence of the infection d) Preventable by immunization e) Mainly treated by specific anti-viral drug T T T F F

MCQ (4) Regarding Dengue Fever a) b) c) d) e) Secondary infections tend to produce DHF DSS results due to severe plasma leakage Presence of IgM is an indication of secondary infection Virus isolation only useful during the convalescence stage of infection Tetravalent vaccine is necessary for effective immunization

MCQ (5) In viral myocarditis: a) b) c) d) e) Coxsackievirus B is one of the most implicated viruses Incidence can be effected by the level of provided health services as immunization Immunocompromised patients are more susceptible to the infection Easy to diagnose because majority of the cases are symptomatic One causes of sudden death T T T F T

MCQ (6) Regarding Viral Myocarditis: a) b) c) d) e) Histopathology is a useful identification of causative agent Necrosis can be due to both inflammatory response and viral damage of myocytes Highly associated with pericarditis Patient mainly suffering from excessive fatigue ECG shows right and left S3 & S4 gallops F T T T T

MCQ (7) Regarding Epstein-Barr Virus: a) b) c) d) e) Associated with several human tumours such as Burkitts lymphoma Spread in the body by infected circulating T cells Member of the family Herpesviridae Spread by contact with oral secretions Endemic in topical and sub-topical countries only T F T T F

MCQ (8) Regarding Epstein-Barr virus: a) b) c) d) e) Phagocytosis control proliferating infected B lymphocytes Lymphocytosis results due to uncontrolled proliferation of infected B cells Infection complication include Guillain-Barre syndrome Preventable by immunization Pharyngitis is less frequently seen in infectious mononucleosis F T T F F

MCQ (9) Regarding IM: a) b) c) d) e) Presence of Downey cells is helpful in diagnosis Is a self-limiting disease and require supportive & symptomatic treatments Excessive aerobics activity is highly recommended during the course of infection Antibodies against early antigens is useful in serological diagnosis Is a disease of young adults T T F T T

MCQ (10) Regarding malignant diseases associated with EBV infection: a) b) c) d) e) Includes nasopharyngeal carcinoma T African lymphoma characterized by malignant B-cell neoplasm T Nasopharyngeal carcinomas highly associated with reactivation of latent EBV infection T Burkitts lymphoma is a slow growing tumor and seldom respond to treatment F B cell lymphomas are more prevalent in immunocompromised patients T

MCQ (11) Regarding viral infections of upper respiratory tract: a) b) c) d) e) Alveolar macrophages are the main defence mechanism Interferon and antibodies play the major role in recovery Viruses are the most common invader of the nasopharynx Spread by aerosol and contaminated hands Pharyngoconjunctival fever caused by Coxsackie A16 F T T T F

MCQ (12) Regarding common cold: a) b) c) d) e) Transmitted by blood transfusion Treatment basically is symptomatic with rest Diagnosis is clinically based on characteristics typical symptoms of Rhinorrhoea Preventable by immunization Pharyngitis is less frequently seen in infectious mononucleosis F T T F F

MCQ (13) Regarding pharyngitis: a) b) c) d) e) 70% of acute sore throats are caused by viruses Occur due to inflammatory and immune responses in the lymphoid tissues More severe than common cold in case of Rhinoviruses Due to multiplication of EBV and CMV in the pharynx Occurs in 70-90% of glandular fever patients T T F T T

MCQ (14) Regarding croup: a) b) c) d) e) The most common pathogen is parainfluenza viruses It is common in both adult and children Steeple sign is the main diagnostic criteria Spread by aerosol and contaminated hands Mainly treated with anti-viral drugs such as ribavirin T F T T F

MCQ (15) Regarding respiratory syncytial virus (RSV): a) Belongs to orthomyxovirus family b) Pathogenesis mainly based on the attachment to the host cells using haemagglutinin and neuraminidase c) Important causes of both upper and lower respiratory infection d) Preventable by immunization e) Transmitted by droplets contaminated hands F F T F T

MCQ (16) Regarding SARS: a) Caused by influenza viruses b) Transmitted through droplet transmission c) Inflammatory and immune responses play an important role in infection pathogenesis d) Mechanical ventilation is required in patients management especially in respiratory failure e) It is a serious and life-threatening infection F T T T T