Chua Hock Hin, HSAJB Suresh Kumar, HSB Case Presentation 1 Chua Hock Hin, HSAJB Suresh Kumar, HSB

Presenting Symptoms ( Admit 20/5/08 8pm ) V.S / Indian / Female / 39 years Fever x 4/7 a/w chills but no rigors Diarrhoea and vomiting x 2 days No bleeding tendency No SOB No chest pain LMP : 16/5/08 ( currently day 4 menstruation ) Not staying at dengue area ( No recent fogging ) No history of recent travel No family members with similar problem

Social History Working in Taman University ( dengue area ) in a textile factory Recently engaged Currently lives with family

Physical Examination Conscious , alert GCS full BP : 126/75 PR : 58 (good volume) T : 37 GM : 6.9 CRT < 2 sec Clinically pink, no jaundice Dehydrated CVS : DRNM Lungs : Clear, A/E equal Abd : Soft, non- tender No rashes/ bruises seen No lymphadenopathy Estimated body Wt - 50kg

Diagnosis Dengue Fever Differential : Acute gastroenteritis FBC from A&E : Hemoglobin 144 G/L Hematocrit 39.9 Platelet 15 G/L WCC 2.2

What is the diagnosis?

What phase of Dengue illness is the patient in now? Insert graph

Investigations taken FBC BUSE/ Creatinine/ LFT Dengue Serology BFMP x 3 CXR Stool Ova and cyst, C & S

Plan of management Hourly vital signs monitoring until stable Notify as Dengue Haemorrhagic Fever Run 2 pint NS fast Maintenance IVD 8 pints Normal Saline over 24 H IV Maxolon 10 mg tds T. Ranitidine 150 mg bd 4 hourly FBC TDS MO review

Comment on the management ? Does the patient fulfill the criteria for DHF ?

Comment on these orders ‘T. Ranitidine 150 mg bd’ ‘4 hourly FBC’ ‘TDS MO review’

Next review - 13 hours defervescence– Day 5 fever onset ( 21/5/08 , 9am ) Vomit x 1 , Epigastric pain No diarrhoea or hematuria BP : 107/70 mmHg PR : 81 sPO2 100% ↓Room Air Lungs : clear Order ( by doctors ) Trace FBC taken at 7.00AM T Omeprazole 40mg OD ( off T Ranitidine ) Watch out for bleeding tendency Cont IVD 8 pint Normal Saline over 24 hours Transfer to Dengue Ward after review result Calculate hours of defervescence

Monitoring in dengue Comment on the review frequency

What are the signs of deterioration that were not appreciated by the doctor?

18 hours defervescence(21/5/08, 2pm ) Not transferred to Dengue Ward yet Blood Investigations taken at 7.00AM reviewed : ALT : 407 / AST : 1230 CK : 359 / LDH : 1912 WCC : 2.10 Hb : 13.6 Hct : 39.3 Plt : 19.4 Cr: 70 / Urea :3 / K :2.85 PT:15 / PTT:76.6 / INR : 1.3 CXR : Clear lung fields

25 hours defervescence(21/5/08, 9pm) Reviewed by doctor on call : Comfortable ????? sPO2 99% ( room air ) BP : 116/52mmHg PR : 104 /min T : 37.7oC ABG : pH 7.43 pCO2 44 PO2 153 HCO3 28 BE 4 Order – Continue ward management

Comment on the use of ABG at this stage

What will be correct diagnosis of the current patient condition? DATE / TIME 20/5 21/5 7PM 7AM 5PM HCT 39.9 39.3 35.5 HB 14.4 13.6 11.8 PLT 15 19 13 WCC 2.2 2.1 4.2

36 hours defervescence( 22/5/08, 8am ) – Day 6 fever onset Still abdominal pain T : 38oC BP 130/60 mmHg PR 92/min Abdomen – distended and tender but soft Lungs – clear Mild pedal oedema Order by doctor PR to look for malena ↓IVD to 6 pints/24 hours Refer HDU/ICU care

What do you think is happening? What will be the appropriate management at this stage?

48 hours post defervescence ( 22/5/08, 1pm ) – Day 6 fever onset Noted lungs crepts Periorbital swelling Bilateral leg and arm oedema Order by doctor DIVC screen GXM 2 pint pack cells Off IVD IV frusemide 40mg stat IV antibiotics – Ceftriaxone after blood culture Ultrasound abdomen urgent Group screen and hold required for all DHF grade3&4

DATE / TIME 20/5 21/5 22/5 7PM 7AM 5PM 12AM 12PM HCT 39.9 39.3 35.5 32.5 29.5 30.6 HB 14.4 13.6 11.8 11.7 10.4 PLT 15 19 13 22 26 24 WCC 2.2 2.1 4.2 7.6 12.9 14.9

Comment on the usage of frusemide at this stage

Date 20/5 21/5 22/5 T. Bil 22 53 107 ALT 407 491 2476 AST 1230 1573 -2* CK 359 - LDH 1912 Creat 0.07 0.03 0.06 PTT 76.6 62.4 INR 1.3 2.11

What else is happening

Day 3 at 57 hours post admission ( 23/5/08, 5am ) – Day 7 fever onset Staff nurse noted patient become more unwell Doctor ( on call ) review Septic looking E4M4V4 BP 149/72mmHg PR 84/min ( good volume ) Lungs clear CRT < 2 sec Order Put back IVD 5 pint over 24 hours Continue antibiotic Hourly vital sign monitoring ABG stat – compensated severe metabolic acidosis pH 7.38 HCO3 8 BE -14

Ultrasound report U/S Abd done 22/5/08 4.30 p.m. Normal liver echotexture Ascites with minimal bilateral perinephric fluid ?cause Thickened gallbladder wall may represent acute cholecystitis or due to presence of ascites Evidence of liver abscess not seen Hypoechoic lesion posterior wall of uterus, possibly a fibroid

D3 admission (23/5/08, 8am )- at 60 hours post defervescence Abdominal pain persistent Clinically : Septic looking; T : 37.4oC E4V2M5 BP : 140/89 mmHg PR : 92/min Warm peripheries , CRT < 2 sec Spo2 100% , N/prong oxygen 10L/min Lungs- rhonchi with ↓ air entry left basal Abdomen – soft, distended Bilateral pedal oedema

Investigation results ABG – worsening compensated metabolic acidosis pH 7.36 HCO314 BE -9 pCO2 27 Dengue serology : Ig M/G – Non reactive Management : IV frusemide 40mg stat Transfer to HDU IVD 1 pint over 24 hours IV NaHCO3 50cc slow bolus Repeat dengue serology

Further management at D3 admission (23/5/08, 11.15am ) at HDU Planned for 1 pint PC and 2 units FFP transfusion IVD 4 pints Normal Saline / 24 H Intubated for Type 1 respiratory failure at 65 hours of admission ( 1pm ) CXR – bilateral pleural effusion

Further management at D3 admission (23/5/08) at ICU ( 69 hours post admission ) Septic workup – then IV Tazocin 2.25g QID for ? Acute cholecystitis ( ultrasound findings ) / Nosocomial infection IV Gelafundin bolus 250cc IV Frusemide 40mg stat Referred to surgical team – conservative management for ? Acute cholecystitis

D4 admission (24/5/08) – 85 hours post admission Day 8 Illness GC worsened BP : 135/83 mmHg, PR : 131/min Not on inotropic support ABG : Compensated metabolic acidosis Hb reducing trend (Hb : 14  10.6  7.4) Abdomen more distended Urine output ↓↓  Anuric PT/PTT/INR : 32.5 / 65.8 / 3.44

Further management IV frusemide 80 mg stat Reduce IVD 42 ml/hour + oral feeding 40ml/hour – 2litre /day Started CVVHDF Given DIVCx2 regime with Whole blood 6 pints of blood in total – first pint whole blood given at 11.30am, 24/5/08 ( 87 hours post admission ) Started on inotropic support – Dopamine with added on Noradrenaline Needing increase ventilatory support , BP ↓ and developed AF

Further management Started IV amiodarone Bleeding tendency – oozing from femoral site Hypothermic BP dropping despite inotropic support. Patient succumb to her illness at 112 hours post admission Liver biopsy tissue sample sent for : Dengue PCR  Dengue Type 1 detected

Results Dengue Serology (21/5/08) –day 4 illness Ig G : Non – reactive Ig M : Non – reactive Dengue Serology (26/5/08) – day 9 illness Ig G : Reactive Blood C&S (22/5/08)  No sample Blood C&S (23/5/08)  No growth