CASE REPORT

DENGUE FEVER (A90) +

NOSOCOMIAL CONDITION (Y95)
Edina Theodora Agustina Sagala
I11110007

LECTURE :
dr. Hilmi Kurniawan Riskawa, Sp.A, M. Kes

Department of Pediatric
Kartika Husada Hospital
Faculty of Medicine Tanjungpura University
December 21, 2015 – February 26, 2016 1
IDENTITY

K, 3 year 3 month old boy, Medical Record number 090223,

was hospitalized at Dahlia Room Kartika Husada Hospital
for 8 days from December 29, 2015 until January 5, 2016

2
CHIEF COMPLAINT

 Fever

3
 PRESENT ILLNESS HISTORY
5 days  Patient present with continuous high fever
before Complaints fever accompanied by decrease appetite and drink, vomiting
hospitalized 1 time contain consumed food, headache, and painful muscle

Defecation and micturition are within normal limit

Other complaints such as retro orbital pain, joint pain, abdominal pain,
rash, nosebleed, gums bleed, blood vomiting, and dark color feces denied
by patient

There is no cough, loss of consciousness, and seizure

Patient consumed drug to treat fever since 5 days before hospitalized

but the complaint does not improved so patient was brought to
Day
pediatric policlinic Kartika Husada Hospital and advised to be
hospitalized
hospitalized because of trombocytopenia
PRESENT ILLNESS HISTORY

 Patient has experienced fever complaints 6 months before,

but reduce simultaneously after given antipyretic
 Patient have no history of dengue fever, seizure, allergy,
asthma, or hospitalization
 No family members with similar complaints
 History of growth and development are age appropriate
 Completed vaccination as schedule
 Breastfeeding until 1,5 years old, followed by condensed milk
 Normal pregnancy and delivery with normal birth weight
PHYSICAL EXAMINATION
(DECEMBER 29, 2015)
 General appearance : Moderate sick
 Awareness : Compos mentis
 Anthropometric
 Weight : 14 kg
 Height : 95 cm
 Nutrition Status (WCGS, 2007) : Normal
 Weight for age : 0 SD until – 2 SD
 Height for age : 0 SD until – 2 SD
 Weight for Height : 0 SD
 Vital Sign:
 Heart Rate : 136 x/min, regular, strong in palpable
 Respiration Rate : 44 x/min, regular rhytm, abdominothoracal
 Temperature : 38,3°C
 Blood pressure : 110/70 mmHg
6
 Head : Normocephal
 Eyes : Conjuctiva not anemic, sclera not icteric, eyes not sunken
 Ear : There is no secrete, auricula not hyperemic, tympani membrane intact
 Nose : There is no secrete, nasal mucosa not hyperemic
 Mouth : Mucousa of the mouth dan lips moist, there is no dirty tongue
 Throat : Pharyng not hyperemic, tonsil T1/T1
 Neck : There is no enlargement of lymph node
 Lung
 Inspection : Symmetric shape and motion
 Palpation : Same tactile fremitus of right and left lung
 Percution : Sonor in both lung fields
 Auscultation : Vesicular breath sound, there is no ronkhi and wheezing
 Heart : Heart sound S1 and S2 single, regular, there is no murmur and gallop
7
 Abdomen
• Inspection : Flat, no mass
• Auscultation : Bowel sound normal
• Percution : Timpani in all field of abdomen
• Palpation : Liver and spleen not palpable, there is no
tenderness and ascites
 Anus and genitalia : Male genitalia, there is no abnormality
 Extremities : Warm, Capillary Refill Time (CRT) less than 2
second, there is no cyanosis, edema, or petechiae
 Rumple Leede Test : Negative 8
LABORATORY EXAMINATION
(DECEMBER 29, 2015)
Haematologi Value Normal Value
Leucocyte 1.900 / mm3 4.000-12.000 /mm3
Erytrocyte 4.84 million/mm3 4,0-5,2 million/mm3
Haemoglobin 12,9 g/dl 11,5-14,5 g/dl
Mean Corpuscular Hemoglobin 26,7 pg 26-30 pg
Mean Corpuscular Hemoglobin Concentration 34,6 g/dl 32-36 %
Mean Corpuscular Volume 77,1 fl 76-90 fl
Haematocrite 37,3 % 33-43%
Trombocyte 99.000 /mm3 150.000-400.000 /mm3
%Lymphocyte 66,3 % 15-61%
%Granulocyte 20,3 % 33-81%
Glucose 110 mg/dl 100-200 mg/dl
Salmonella typhi H 1/100 -
Salmonella typhi O - -
9
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
 Dengue Fever
 Dengue Haemorrhagic Fever
 Chikungunya Fever
 Zika Disease
 Leptospirosis

WORKING DIAGNOSIS
 Dengue Fever

10
TREATMENT

 Intra Venous Fluid Drop (IVFD) Ringer Laktat 30 cc/hour

 Ampicillin 4x500 mg Intra Venous (IV)
 Paracetamol 4x175 mg IV
 Folium Extract 2x1/2 tea spoon

ADVICE
 Dengue serology, Chikungunya titer, Reverse Transcription Polymerase
Chain Reaction (RT-PCR) Zika virus, Microscopic Agglutination Test
(MAT) Leptospira
11
FOLLOW UP

30- 1/1/16 2/1/16 3/1/16 4/1/16 5/1/16

31/12/15
S Fever – Fever – Fever + Fever – Fever – Fever –
U Eat as usual Eat as usual Eat as usual Eat as usual Eat as usual Eat as usual
Drink + Drink + Drink + Drink + Drink + Drink +
B
Nausea - Nausea - Nausea - Nausea - Nausea - Nausea -
J Vomiting - Vomitus - Vomitus - Vomitus - Vomitus - Vomitus -
E Defecate + Defecate - Defecate + Defecate - Defecate - Defecate +
C Urinate + Urinate + Urinate + Urinate + Urinate + Urinate +
T Headache + Headache - Headache - Headache - Headache - Headache -
I Muscle pain + Muscle pain + Muscle pain - Muscle pain - Muscle pain - Muscle pain -
V
E
 PHYSICAL EXAMINATION
Vital Sign 30/12/15 31/12/15 1/1/16 2/1/16 3/1/16 4/1/16 5/1/16
BP 110/70 110/80 110/70 110/70 110/60 110/70 110/70
HR 130 x/m 126 x/m 104 x/m 120 x/m 110 x/m 130 x/m 106 x/m
RR 40 x/m 38 x/m 30 x/m 32 x/m 30 x/m 40 x/m 30 x/m
T 36,2ºC 37,3ºC 36,0ºC 38,9ºC 37,0ºC 36,2ºC 36,1ºC

30/12/15 31/12/15 1/1/16 2/1/16 3/1/16 4/1/16 5/1/16

O
B
J
E
C
Conjunctiva not anemic, no bleeding sign, extremities warm,
T CRT less than 2 second
I
V
E
 LABORATORY EXAMINATION

Date of Examination
Haematology
30/12/15 31/12/15 1/1/16 2/1/16 3/1/16 4/1/16

Leucocyte 3.500/mm3 3.800/mm3 2.700/mm3 2.600/mm3 3.310/mm3 3.100/mm3

Erytrocyte 4.61 4.84 4.62 4.69 3.61 4.09

million/mm3 million/mm3 million/mm3 million/mm3 million/mm3 million/mm3
Haemoglobin 12,0 g/dl 12,8 g/dl 12,2 g/dl 12,3 g/dl 10,5 g/dl 11,1 g/dl

Trombocyte 93.000/mm3 89.000/mm3 73.000/mm3 84.000/mm3 112.000/m 159.000/m

m3 m3
Haematocrite 37,5% 37,9% 35,0% 38,9% 37,5% 31,1%
14
PROGNOSIS

 Ad Vitam : ad Bonam
 Ad Functionam : ad Bonam
 Ad Sanactionam : dubia ad Bonam

15
FINAL DIAGNOSIS

 Dengue Fever + Nosocomial Condition

HOME THERAPY
 Azitromycin 2 x 1 tablet, Imunos syr 1 x 1 tea spoon, Sanmol
syr 3 x 1 tea spoon

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PROBLEM OF CASE

 Diagnose
 Treatment
 Prognose
 DIAGNOSE
Probable diagnosis:
Acute febrile illness with ≥ 2:
• headache • retro-orbital pain
• myalgia, • arthralgia/bone pain Patient sign and symptom:
• rash
• leucopenia,
• haemorrhagic manifestations
• thrombocytopenia
Acute febrile illness
• rising haematocrit Headache
and at least 1:
• serology serum Myalgia
• occurrence at the same location and time as
confirmed cases of dengue fever.
 Leucopenia
Thrombocytopenia
Confirmed diagnosis:
Probable case with at least 1:
• isolation of dengue virus
• ≥4 x increase in serum IgG Serology
• detection of dengue virus or antigen
• detection of dengue virus genomic sequences
 DIAGNOSE
Chikungunya Fever:
• Fever • Artralgia (87%)
• Nosocomial infection =
• Backache (67%) Hospital Acquired Infection
• Diagnosis: Isolation of virus, PCR,
detection IgM,, rising IgG • Infection occurring in patient in
a hospital in whom the infection
Zika Disease:
was not present or incubating
• Fever, rash, conjunctivitis, muscle
and joint pain, malaise, headache at the time of admission
• Diagnosis: RT-PCR, PRNT
• Most frequent nosocomial
Leptospirosis: infections : infections of surgical
• Jaundice • Conjunctiva suffusion wounds, UTI, and lower
• Diagnosis: Serodiagnosis, bacteri
respiratory tract infections
culture
 TREATMENT
Medication Function

IVFD RL 30 cc/hour Rehydration , facilitate administration of drug by IV injection

Gelofusine 40 cc/hour Plasma replacement

Ampicillin 4x500 mg iv Prevention nosocomial infection

Amikacin 3x50 mg IV Eradication nosocomial infection

Cefotaxime 3x700 mg iv Eradication nosocomial infection

Azitromycin 2x1 tablet Eradication infection that still exist

PCT inf 4x125 mg iv Antipyretic, analgetic

Folium extract 2x1/2 tea spoon Stimulate thrombocyte precursor

Imunos syr 1x1 tea spoon Immunostimulator

PROGNOSE

 Quo ad vitam : bonam

Patient condition not life threatening
 Quo ad functionam : bonam
Functional vital organ
 Quo ad sanactionam : dubia ad bonam
Recurrent infection can happen from another dengue viral
serotype. Adequate treatment and good sanitation can
prevent recurrence
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