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Case Study: dengue fever

Abstract
Dengue virus infection is an increasingly important tropical
disease, causing 100 million cases each year. Symptoms range
from mild febrile illness to severe hemorrhagic fever. The
pathogenesis is incompletely understood, but immunopathology is
thought to play a part, with antibody-dependent enhancement and
massive
immune
activation
of
T
cells
and
monocytes/macrophages leading to a disproportionate production
of proinflammatory cytokines. We sought to investigate whether a
defective population of regulatory T cells (T reg cells) could be
contributing to immunopathology in severe dengue disease.
CD4+CD25highFoxP3+ T reg cells of patients with acute dengue
infection of different severities showed a conventional phenotype.
Unexpectedly, their capacity to suppress T cell proliferation and to
secrete interleukin-10 was not altered. Moreover, T reg cells
suppressed the production of vasoactive cytokines after denguespecific stimulation. Furthermore, T reg cell frequencies and also
T reg cell/effector T cell ratios were increased in patients with
acute infection. A strong indication that a relative rise of T reg
cell/effector T cell ratios is beneficial for disease outcome comes
from patients with mild disease in which this ratio is significantly
increased (P < 0.0001) in contrast to severe cases (P = 0.2145).
We conclude that although T reg cells expand and function
normally in acute dengue infection, their relative frequencies are
insufficient to control the immunopathology of severe disease.

Case Study: dengue fever

CERTIFICATE
This is hereby to certify that, the original and genuine
investigation work has been carried out to investigate about the
subject matter and the related data collection and investigation
has been completed solely, sincerely and satisfactorily by
regarding his project titled Study on Dengue fever.

Principals Signature

Teachers Signature

OBJECTIVES

Case Study: dengue fever

General:
This case presentation aims to identify and determine the general
health problems and needs of the patient with an admitting
diagnosis of Dengue Fever. This study also intends to help
promote health and medical understanding of such condition
through the application of the nursing skills.

Specific:
To enhance knowledge and acquire more information about
Dengue Fever.
To give an idea of how to render proper nursing care for
clients with this condition thus it can be applied for future
exposures of students.
To gather the needed data that can help to understand how
and why the disease occurs.
To identify laboratory and diagnostic studies used in Dengue
Fever.
To enumerate the clinical manifestations of the disease so as
to provide prompt intervention of its occurrence.

ACKNOWLEDGEMENT

Case Study: dengue fever

First and foremost, I would like to express my sincerest

gratitude to our Almighty God for giving me the ability and chance
to finish this study and for guiding me in my everyday life and
activities.
I also wish to express my deepest gratitude to my family for
providing me everything I need and for their untiring support.
I also thank my friends for their constant encouragement.
And to the patient and his mother, I want to extend my
gratitude for their cooperation and for giving me the information I
need to finish this requirement.
It is also my pleasure to thank the Doctor Satheesh Nayak
for being always considerate and approachable and for
establishing a good quality of education in our department. And to
all our instructors/faculty members, I thank them for their
guidance and all the knowledge, discipline, and lessons they have
shared to us.
Finally, I thank my most beloved teachers and those special
people who made me feel that they believe in me more than I do
to myself.

Case Study: dengue fever

INTRODUCTION:
Background of the
Disease

Dengue Virus Infection and Dengue Hemorrhagic

Fever

Case Study: dengue fever

Definition
Dengue fever and dengue hemorrhagic fever (DHF) is acute febrile diseases which
occur in the tropics and can be life-threatening. It occurs in tropical and sub-tropical
areas of the world. Dengue fever is a febrile illness that affects infants, young children
and adults.
Dengue is a mosquito-borne infection that in recent decades has become a major
international public health concern.
Dengue fever syndrome is the type of dengue without significant hemorrhages.
Dengue hemorrhagic fever is a severe, potentially deadly infection with gross
hemorrhages spread by certain species of mosquitoes.
Other Names
Hemorrhagic Fever or H-fever, Acute Infectious Thrombocytopenic Purpura, Dengue
Shock Syndrome, Breakbone Fever, Bonecrusher Disease, Dandy Fever,
Philippine/Thai/Singapore Hemorrhagic Fever.
Etiologic Agent
Four closely related virus serotypes of the genus Flavivirus, family Flaviviridae
(Dengue Virus I, II, III, and IV).
Three other arboviruses (Chikungunya, Onyong-nyong and West Nile Fever,
have been identified with dengue-like diseases.
Mode of Transmission
Dengue viruses are transmitted to humans through the bites of infective female Aedes
mosquitoes. Mosquitoes generally acquire the virus while feeding on the blood of an
infected person. After virus incubation for eight to 10 days, an infected mosquito is
capable, during probing and blood feeding, of transmitting the virus for the rest of its life.
Infected female mosquitoes may also transmit the virus to their offspring by transovarial
(via the eggs) transmission.

Case Study: dengue fever

Incubation Period
The incubation period of Dengue fever is usually 5 to 6 days but may vary from 3 to 10
days.
Portal of Entry
Skin
Period of Communicability
Infected person with Dengue becomes infective to mosquitoes 6 to 12 hours before the
onset of the disease and remains up to 3 to 5 days.
The mosquito becomes infective from day 8-12 after the blood meal and remains
infective throughout life.
Pathology
- Generalized vasculitis and effusion in serous cavities are important postmortem
findings among those who die in shock without evidence of gross hemorrhages.
- In frank hemorrhagic cases the upper GIT may show hemorrhages.
- There is subcapsular hemorrhage of the liver with fatty metamorphosis or focal
coagulation necrosis.
- There are occasional basophilic and acidophilic cells with cytoplasmic
vacuolation in the sinusoids.
- There is proliferation of Kuffer cells with lymphocytic infiltration and plasma cells
around the portal area.
- The lungs show marked congestion with focal hemorrhages and blood may fill up
the alveolar spaces.
- The adrenals show stimulation of the zona fasciculate and zona reticularis do not
show much change; these findings are interpreted as a response to stress.
- Enlarged and prominent lymphoid follicles in the ileum, Peyers patches, and
mesenteric lymph nodes are described.
- In the bone marrow, maturational arrest of megakaryocytes is observed.
- In the different organs, perivascular edema and diapedesis of red blood cells are
noted.
- Immunoflourescent direct staining allows the identification and localization of
dengue antigen in the tissues of fatal cases.
Pathognomonic sign
Hermans sign - is classically a widespread erythema with small white patches of edema
'in a sea of red'.
Clinical Manifestations
The disease manifests as a sudden onset of severe headache, muscle and joint pains
(myalgias and arthralgiassevere pain that gives it the nickname break-bone fever or

Case Study: dengue fever

bonecrusher disease), fever, and rash. The dengue rash is characteristically bright red
petechiae and usually appears first on the lower limbs and the chest; in some patients, it
spreads to cover most of the body. There may also be gastritis with some combination
of associated abdominal pain, nausea, vomiting, or diarrhea.
Some cases develop much milder symptoms which can be misdiagnosed as
influenza or other viral infection when no rash is present. Thus travelers from tropical
areas may pass on dengue inadvertently, having not been properly diagnosed at the
height of their illness. Patients with dengue can pass on the infection only through
mosquitoes or blood products and only while they are still febrile. The classic dengue
fever lasts about two to seven days, with a smaller peak of fever at the trailing end of
the disease (the so-called "biphasic pattern"). Clinically, the platelet count will drop until
the patient's temperature is normal. Cases of DHF also show higher fever, variable
hemorrhagic phenomena, thrombocytopenia, and hemoconcentration. A small
proportion of cases lead to dengue shock syndrome (DSS) which has a high mortality
rate.
DENGUE FEVER
Abrupt onset of high fever
Severe frontal headache
Pain behind the eyes(retro-orbital pain) which worsens with eye movement
Muscle and joint pains
Loss of sense of taste and appetite
Measles-like rash over chest and upper limbs
Nausea and vomiting
Minor hemorrhagic manifestations like petechiae, bleeding from nose or gums
may occur.
Lymphadenopathy with leukopenia and relative lymphocytosis are common.
Thrombocytopenia (platelet count 100x10 3) and raised transaminases occur
less frequently.
Plasma leakage indicated by small pleural effusion or ascites. Hepatomegaly is
common but is not accompanied by jaundice.

Patient may go into shock manifested by :Pale, cold or clammy skin, sleepiness
and restlessness, patient feels thirsty and mouth becomes dry, rapid weak pulse
and difficulty in breathing.
Complications
Encephalopathy
Liver damage
Residual brain damage
Seizures
Shock

CASE DEFINITIONS
DENGUE FEVER:

Case Study: dengue fever

Suspect case: Acute onset and high fever of 2-7 days duration, and two or more of the
following:
Headache, retro-orbital pain, myalgia, arthralgia, rash, hemorrhagic manifestations, and
leucopenia.
Probable case: Suspect case and one or more of the following:
Occurrence of confirmed cases of dengue in the same place and time. Detection of IgM
antibody. IgM antibody indicates current or recent infection and is detectable 6-7 days
after onset of illness. If available Mc- Elisa test is more specific.
Confirmed case: Suspect or probable case and one or more of the following:
Isolation of virus or detection of viral genomic sequences. Fourfold rise in titres of IgG or
IgM antibody. For this at least 2 samples are to be taken- one at the time at the time of
reporting to a clinic or a hospital and second shortly before discharge. The optimum
interval between two samples should be 10 days. Although serological tests are simpler,
they can give false positive results due to cross reaction between antibodies against
dengue and other flaviviruses. Confirmatory tests are not necessary for management of
cases and should be done to confirm the aetiology of the outbreak.
DENGUE HAEMMORHAGIC FEVER
Probable or confirmed case of dengue, and
Hemorrhagic tendencies as described under DHF.
Thrombocytopenia(platelet count 100x10 3 ).Evidence of plasma leakage
due to increased vascular permeability, manifested one or more of the
following: a rise in average haematocrit for age and sex 20%, a 20% drop in
haematocrit following volume replacement compared to baseline, signs of
plasma leakage indicated by pleural effusion or ascites
( demonstrated by ultrasonography or x-ray), hypoproteinemia. Slight
elevation of liver enzymes, hypoproteinemia and low levels of C 3
complement proteins are commonly observed. Prothrombin, partial
thromboplastin, thrombin times may be prolonged in many cases. While a
normal WBC count or leukopenia with neutrophils predominating is common
initially, a relative lymphocytosis with more than 15% atypical lymphocytes is
common when fever subsides.
DENGUE SHOCK SYNDROME
All the criteria for DHF
Evidence of circulatory failure as detailed under DSS

Classification
o Severe, frank type
With flushing, sudden high fever, severe hemorrhage, followed by sudden drop of
temperature, shock and terminating in recovery or death.
o Moderate

Case Study: dengue fever

0
With high fever, but less hemorrhage, no shock
o Mild
With slight fever, with or without petechial hemorrhage but epidemiologically
related to typical cases usually discovered in the course of investigation of typical
cases.
Diagnosis
A physical examination may reveal:

Enlarged liver (hepatomegaly)

Low blood pressure
Rash
Red eyes
Red throat
Swollen glands
Weak, rapid pulse

Tests may include:

Arterial blood gases
Coagulation studies
Electrolytes
Hematocrit
Liver enzymes
Platelet count
Serologic studies (demonstrate antibodies to Dengue viruses)
Serum studies from samples taken during acute illness and convalescence
(increase in titer to Dengue antigen)
Tourniquet test/Rumpel Leads Test (causes petechiae to form below the
tourniquet)
X-ray of the chest (may demonstrate pleural effusion)

Nursing Management
Any disease or condition associated with hemorrhage is enough cause for alarm.
Immediate control of hemorrhage and close observation of the patient for vital signs
leading to shock are the nurses primary concern. Nursing measures are directed
towards the symptoms as they occur but immediate medical attention must be sought:
For Hemorrhage
- Keep the patient at rest during bleeding episodes.

Case Study: dengue fever

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For nose bleeding, maintain an elevated position of trunk and promote
vasoconstriction in nasal mucosa membrane through an ice bag over the
forehead.
- For melena, ice bag over the abdomen.
- Avoid unnecessary movement
- If transfusion is given, support the patient during the therapy.
- Observe signs of deterioration(shock) such as low pulse, cold clammy
perspiration, prostration.
For Shock
- Prevention is the best treatment
- Dorsal recumbent position facilitates circulation
- Adequate preparation of the patient, mentally and physically prevents
occurrence of shock.
- Provision of warmth through lightweight covers (overheating causes
vasodilation which aggravates bleeding)
Diet
- Low fat, low fiber, non-irritating, non-carbonated
- Noodle soup may be given
For Fever
- Cooling measures(tepid sponge bath)
- Administer prescribed drugs
- Encourage fluid intake unless contraindicated
-

Prognosis
With early and aggressive care, most patients recover from dengue hemorrhagic
fever. However, half of untreated patients who go into shock do not survive.

Case Study: dengue fever

Personal
Background of the
Patient

PERSONAL DATA
Name:

George

Address:

Kaipanchery,S.Bathery,Wayanad,Kerala

Occupation:

none (student)

Religion:

Roman Catholic

Nationality:

Indian

DEMOGRAPHIC DATA
Date of Birth:

December 14, 1996

Place of Birth:

Bathery

Age:

19 years old

Case Study: dengue fever

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Gender:

Male

Civil Status:

Single

PATIENT PROFILE
Date Admitted:

May 15, 2014

12:43 pm

Attending Physician:

Dr. Satheesh Nayak

Room/Ward:

OP

Hospital Record No:

495501

HOME ENVIRONMENT AND OCCUPATION

Physical Environment:

He is studying in a public school and he is

living with his parents and other siblings and
their families.
He

doesnt

beverages.

smoke

or

drink

alcoholic

Case Study: dengue fever

HISTORY OF PRESENT ILLNESS

Reason for seeking medical care: Persisting on and off Febrile
episodes
One week prior to admission, the patient had a night swimming with
his friends. He slept on the seashore and had a fever the next morning.
Four days PTC, the patient also experienced abdominal pain, loose
bowel movement (2x), vomiting approximately 1cup/about every after
feeding. He had self medication of Paracetamol 500mg BID.
Two days PTC, patient still has intermittent fever.
Upon admission, vomiting and diarrhea were still present on the first
two days.
D5 0.3NaCl @ KVO rate upon admission
D5 0.3NaCl x 8 (5/16/10)
D5 LR 1L (5/17/10)

Case Study: dengue fever

PHYSICAL
EXAMINATION

Vital Signs
Temperature
Pulse
Respiration
Blood Pressure
HEIGHT: 176cm
WEIGHT: 52kg

Upon Admission
38.1C
80beats/min
38breaths/min
110/60mmHg

Latest
36.5C
76beats/min
29breaths/min
90/60mmHg

Case Study: dengue fever

Anatomy
And
Physiology

Case Study: dengue fever

PATHOPHYSIOLOGY

Pathophysiology

Case Study: dengue fever

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Bite of Virus-Carrying Mosquito
Mosquito injects salivary secretion into skins blood vessel

Virus enters the bloodstream and initial replication occurs

Viremia occurs lasting until the fourth or fifth day after onset

Antibodies are produced principally against the virus

And strong immune complex reaction occurs

Immune complex produce toxic substances like histamine, serotonin, bradykinin

Injured platelet

Thrombocytopenia

Proteinuria(+2)

Fever

Headache

Case Study: dengue fever

Pathophysiology
An infected Aedes Aegypti bites and injects salivary secretion (which
contains an anticoagulant substance and dengue virus) into the skins
blood vessel. The anticoagulant substance in the mosquitoes saliva helps
suck blood well. As the virus enters the bloodstream, the initial replication
occurred. The replication in the blood vessels results to viremia that lasts
until the fourth or fifth day after onset.
Recent reports show that at first attack, neutralizing antibodies are
produced principally against this virus type inoculated by the mosquito
vector. The inflammants such as histamine, serotonin and bradykinin cause
toxicity to the blood and blood vessels. There is thrombocytopenia due to
diminished production and destruction of platelets. There is also fever and
headache related to the immune response of the body against the invading
microorganism. Thrombocytopenia may lead to signs and symptoms of
bleeding such as proteinuria.

Case Study: dengue fever

Prevention
And Treatment

Prevention
Vaccine development

Case Study: dengue fever

1
There is no tested and approved vaccine for the dengue flavivirus. There are
many ongoing vaccine development programs. Among them is the Pediatric Dengue
Vaccine Initiative set up in 2003 with the aim of accelerating the development and
introduction of dengue vaccine(s) that are affordable and accessible to poor children in
endemic countries. Thai researchers are testing a dengue fever vaccine on 3,0005,000
human volunteers after having successfully conducted tests on animals and a small
group of human volunteers. A number of other vaccine candidates are entering phase I
or II testing.
Mosquito control and other measures
Use of mosquito repellent creams, liquids, coils, mats etc.
Wearing of full sleeve shirts and full pants with socks
Use of bed nets for sleeping infants and young children during day time to
prevent mosquito bite
As Aedes aegypti breeds in containers and receptacles detection & elimination of
mosquito breeding sources is the most important activity.
Management of roof tops, porticos and sunshades
Proper covering of stored water
Reliable water supply
Observation of weekly dry day
Remove water from coolers and other small containers at least once in a week
Use aerosol during day time to prevent the bites of mosquitoes
Do not wear clothes that expose arms and legs
Children should not be allowed to play in shorts and half sleeved clothes
Use mosquito nets or mosquito repellents while sleeping during day time
Avoid too many hanging clothes
Destruction of breeding places
Mesocyclops
In 1998, scientists from the Queensland Institute of Medical Research (QIMR) in
Australia and Vietnam's Ministry of Health introduced a scheme that encouraged
children to place a water bug, the crustacean Mesocyclops, in water tanks and
discarded containers where the Aedes aegypti mosquito was known to thrive. This
method is viewed as being more cost-effective and more environmentally friendly than
pesticides, though not as effective, and requires the continuing participation of the
community.
Even though this method of mosquito control was successful in rural provinces,
not much is known about how effective it could be if applied to cities and urban areas.
The Mesocyclops can survive and breed in large water containers but would not be able
to do so in small containers that most urban dwellers have in their homes. Also,
Mesocyclops are hosts for the guinea worm, a pathogen that causes a parasite
infection, and so this method of mosquito control cannot be used in countries that are

Case Study: dengue fever

2
still susceptible to the guinea worm. The biggest dilemma with Mesocyclops is that its
success depends on the participation of the community. This idea of a possible parasitebearing creature in household water containers dissuades people from continuing the
process of inoculation and, without the support and work of everyone living in the city,
this method will not be successful.
Wolbachia
In 2009, scientists from the School of Integrative Biology at The University of
Queensland revealed that by infecting Aedes mosquitos with the bacterium Wolbachia,
the adult lifespan was reduced by half. In the study, super-fine needles were used to
inject 10,000 mosquito embryos with the bacterium. Once an insect was infected, the
bacterium would spread via its eggs to the next generation. A pilot release of infected
mosquitoes could begin in Vietnam within three years. If no problems are discovered, a
full-scale biological attack against the insects could be launched within five years.
Mosquito mapping
In 2004, scientists from the Federal University of Minas Gerais, Brazil,
discovered a fast way to find and count mosquito population inside urban areas. The
technology, named Intelligent Monitoring of Dengue (in Portuguese), uses traps with
kairomones that capture Aedes gravid females, and upload insect counts with a
combination of cell phone, GPS and internet technology. The result is a complete map
of the mosquitoes in urban areas, updated in real time and accessible remotely, that can
inform control methodologies. The technology was recognized with a Tech Museum
Award in 2006.
Potential antiviral approaches
Dengue virus belongs to the family Flaviviridae, which includes the hepatitis C
virus, West Nile and Yellow fever viruses among others. Possible laboratory
modification of the yellow fever vaccine YF-17D to target the dengue virus via chimeric
replacement has been discussed extensively in scientific literature, but as of 2009 no
full scale studies have been conducted.
In 2006 a group of Argentine scientists discovered the molecular replication
mechanism of the virus, which could be specifically attacked by disrupting the viral RNA
polymerase. In cell culture and murine experiments. Morpholino antisense oligomers
have shown specific activity against Dengue virus.
In 2007 virus replication was attenuated in the laboratory by interfering with
activity of the dengue viral protease, and a project to identify drug leads with broad
spectrum activity against the related dengue, hepatitis C, West Nile, and yellow fever
viruses was launched

Case Study: dengue fever

3
Treatment
Because Dengue hemorrhagic fever is caused by a virus for which there is no known
cure or vaccine, the only treatment is to treat the symptoms.
A transfusion of fresh blood or platelets can correct bleeding problems
Intravenous (IV) fluids and electrolytes are also used to correct electrolyte
imbalances
Oxygen therapy may be needed to treat abnormally low blood oxygen
Rehydration with intravenous (IV) fluids is often necessary to treat dehydration
Supportive care in an intensive care unit/environment
Aspirin and non-steroidal anti-inflammatory drugs should be avoided as these
drugs may worsen the bleeding tendency associated with some of these
infections. Patients may receive paracetamol preparations to deal with these
symptoms if dengue is suspected
Oral fluid and electrolyte to prevent and correct dehydration
Antipyretics/acetaminophen for fever
Anticonvulsant like Dilantin for convulsions
Sedatives may be needed to allay apprehension or agitation

EVALUATION

Case Study: dengue fever

4
Upon admission, the patient was diagnosed with Dengue Fever, intermittent
fever, diarrhea and vomiting were present. A D5 0.3NaCl was hooked at KVO rate.
Decreased platelet (51x109/L) count and +2proteinuria were shown on the laboratory
result. It is also shown in the results that there are decreased values of MCV and MCH
which are indicative of anemia. WBC and neutrophils were decreased while monocytes
were increased, which indicate severe viral infection. On the second day of
confinement, diarrhea and vomiting were still present. The IV fluid infusion rate was
changed to 40-41gtts/min and based on the laboratory result, the platelet count
continued to decrease to 36x10 9/L. The patient is on DAT diet with restriction on darkcolored foods. On his third day on the hospital, the patient had no fever, diarrhea and
vomiting but a great decreased on the platelet count (20x10 9/L) was noted. The patient
should be observed and closely monitored for signs and symptoms of bleeding. Health
teachings should be provided to the patient as well as to the family since they are the
primary care giver, in order to prevent the development of further complication and to
prevent any other family member from acquiring the same disease. And they should
comply with the therapeutic regimen as ordered. They should be instructed to report any
signs of bleeding to provide prompt intervention.

BIBLIOGRAPHY
Book References:
Brunner and Suddarths Textbook of Medical and Surgical Nursing
Tenth Edition
Suzanne C. Smeltler, Brenda G. Bare
Essentials of Anatomy and Physiology
8th Edition
Elaine Marieb

Eternal Links:
www.nlm.nih.gov/medlineplus/ency/article/000223.htm
en.wikipedia.org/wiki/Stomach_cancer
emedicine.medscape.com/article/375384-overview
www.google.com

Others:
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