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CHAPTER IV
DISCUSSION

Patient with intial D, 9 year and 1 month boy is presented with a diagnose
of DHF without shock + Expanded Dengue Syndrome. According to the previous
epidemiological study dengue is widespread throughout the tropics, with local
variations in risk influenced by rainfall, temperature and unplanned rapid
urbanization. Medan is one of the areas considered endemic in the province of
North Sumatra with 1270 dengue cases reported in 2013.

Moreover, this patient had the same clinical findings as DHF clinical
findings. Clinical findings that can be found in a DHF case are a 2-7 day illness
with high fever headache, retro-orbital pain, myalgia, arthralgia/ bone pain, rash
and haemorrhagic manifestations example positive tourniquet test, or petechial,
with evidence of plasma leakage. There are some criteria that need to be include
for us to diagnose a patient with DHF. Example, high fever or recent history of
acute fever, haemorrhagic manifestations, thrombocytopenia of 100,000
cell/mm, objective evidence of leaky capillaries.2

Patient D had fever for 7 days which is a sudden continuous high fever,
headache and joint pain found this 1 week and had spontaneous bleeding from the
nose before admitting to hospital. Patients chief complaint is hematemesis.
Thrombocytopenia also found on this patient with the value of just 28.000. But
there is no seizure or shock is found on this patient. Odem is also found on this
patients below extremities. Patient also suffered from increased breathing rate
and felt limp. This maybe because of infection in lungs or edema. So these
scenarios concludes on enforcing the diagnose of DHF without shock on this
patient.

These clinical manifestations shall become more severe during the day 3-5
where it can lead to shock. If the shock previously not treated properly it will
follow the next symptom is bleeding from the gastrointestinal tract. GI bleeding
can be mild or severe depending on how long the shock occur until treated
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appropriately. Decreased levels of oxygen in the blood will lead to bleeding, the
lower the oxygen levels in the blood, the more severe the bleeding that occurs. At
the beginning of GI bleeding is not visible from the outside, therefore occurs in
the stomach. It will look just stomach increasingly bulge and pain when touched.
Later on, there will be vomiting blood and dysentery or black stools. 4,5 According
to this case report, this patient had these severe clinical manifestations such as
hematemesis and melena.

Nosebleed, mostly caused by the rupture of blood vessels in the nasal

mucous membrane because of the stimulation either from within or from outside
the body such as high fever. High temperature causes drying out of mucous
membrane inside the nostrils until it can be damaged and causes bleeding.
Nosebleeds also occur when the capillaries in the nose lining burst. These
capillaries are fragile and can break easily causing bleeding.9, 10
In this case,
previously patient had epistaxis before came to hospital. This situation may occur
because of the high temperature that has been suffering for days.

Acording to Guidelines for Diagnosis and Management of Dengue

Infection in Children dengue or DHF are caused by virus dengue which is from
Flavivirus gene and there are 4 distinct, but closely related, serotypes of the virus
that cause dengue or DHF (DEN-1, DEN-2, DEN-3 and DEN-4). However DEN-
3 is the most common that found. Other than anamnesis, clinical findings some
supportive investigations such as virus isolation, nucleic acid detection (RT-PCR),
virus antigen detection (NS1), immunoserology test (IgG, IgM anti dengue),
hemolisis analysis parameter. If anti dengue IgM positive shows that current
infection of the dengue virus and if the anti dengue IgG is positive it shows that
past there was past infection before this. In this case, immunoserology test has
been conducted on patient whereas found out that anti dengue IgG is positive and
anti dengue IgM is negative. This shows that the patient has a past infection. Any
other test never been conducted on patient.
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As in previous explanation, expanded dengue fever is an unusual clinical

manifestation with severe organ involvement such as liver, kidneys, brain, or heart
associated with dengue infection. These unusual manifestations sometimes
associated with co-infections, co-morbidities or complications of prolonged shock
and can be clubbed under expanded dengue syndrome. 4 As for this patient, found
out that fever has prolonged more than 7 days. This may because of infection
apart from dengue virus.
Treatment of DHF is symptomatic and supportive, therapy supportive
such as rehydration using fluid. Type of fluid that need to infused is isotonic fluid
according to the need of the patient. Volume of fluid can be calculated by body
weight and clinical condition of the patient.9 In this case, Ringer Lactate has been
given to the patient with 3cc/Kg/hour so that it can overcome the dehydration
occurrence and shock. Other than that, administration of antipyretics may
consumable by patients with DHF so that it can lower risk of the clinical
symptoms.10 As for this patient given paracetamol with 3x350mg according to his
body weight with an interval of 6 hours.