1. D NGUE WORKSHOP 2015 ID HSB 2015

2. OPD – CASE 4 ID HSB 2015

3. Mdm QRS, 45 years old Hypertension under KK follow up. On T. Amlodipine 5mg OD Fever with myalgia and arthralgia Day 2 of illness –went to KK, FBC not taken, –Diagnosed as UTRI ID HSB 2015

4. When to suspect dengue Fever with two or more of the following manifestations: - headache - retro-orbital pain - myalgia - arthralgia - rash - haemorrhagic manifestations - leukopenia/ Thrombocytopenia ID HSB 2014

5. What is your comment about the diagnosis? Fever + Myalgia + Arthralgia Diagnosis : TRO Dengue fever, day 2 fever Check vital signs Take FBC Dengue rapid test ( if available) Notify as Dengue ID HSB 2015

6. Deside if admission is required If admission is not required : Provide Home care advice leaflet to patient Advise patient to seek treatment if fever persists or presence of warning signs ID HSB 2015

8. Day 4 of illness –She went to Hospital Apple, as she “was not feeling well “ – 1pint NS was given – She was discharged home. FBC taken, but result not available Day 5 of illness - she returned to KK – BP 101/76, PR 93, T 39°C, – HCT 43.7, PLT 105, WBC 3.0 –Again,she was given IVD and discharged. ID HSB 2015

9. When is IVD indicated ? Patient is dehydrated Patient could not tolerate orally Presence of warning signs Evidence of plasma leakage Dengue with compensated shock Dengue with decompensated shock Severe dengue with bleeding, while waiting for blood transfusion ID HSB 2015

10. It is NOT a routine to prescribe bolus IVD at clinic. Unless patient is being monitored at outpatient observation ward. In this case patient will be observed for a longer period of time. Patient will be reassessed again at regular intervals depends on the drip regime. Consider admission if patient requires IVD ID HSB 2015

11. Day 6 of illness –Fever had subsided. –However, she felt unwell. –She had chest pain, aggravated by inspiration. The pain was more excruciating when she lied supine. –There was no cough, no palpitation –No headache ID HSB 2015

12. Day 7 of illness She contacted her son, her son brought her to hospital Durian. BP 116/79, PR 92-104/min, poor volume SPO2 97% on RA CVS :heart sounds were muffled Lungs : clear CXR : Cardiomegaly, no pleural effusion ECG done : –small QRS complex with ST elevation at V4-6 ID HSB 2015

13. Blood Investigations WBC 2.8, HCT 51.1, Plt 80. NS1 : Positive Diagnosis : Dengue Fever, Day 7 illness, with warning signs ( high HCT, low platelet), in compensated shock TRO myocarditis -repeated FBC, HCT 45.8, Hb 15.4, Plt 77. ID HSB 2015

14. Run fluid 5ml/kg/h Repeated FBC, HCT 45.8, Hb 15.4, Plt 77. Patient was referred to the nearest specialist hospital ID HSB 2015

15. Arrived at Hospital Coconut Patient was alert, but lethargic looking With cold clammy peripheries, all of her peripheral pulses were not palpable, BP : not recordable, PR about 140-160 on cardiac monitor. ID HSB 2015

16. Diagnosis Diagnosis : Dengue Fever, Day 7 illness, with warning signs ( high HCT, low platelet), in decompensated shock with peri-myocarditis repeated FBC, HCT 45.8, Hb 15.4, Plt 77. ID HSB 2015

17. Decompensated shock ! IVD 20ml/kg/h GXM/VBG were dispatched After first cycle of fluid resuscitation : BP 80/60mmHg, PR 140/min, weak pulse Lungs: clear, CVS: heart sounds : muffled. ECG: Sinus tachycardia with non specific ST segment elevation. Low voltage complex ID HSB 2015

18. Day 5Day 7 10.00pm Day7 12.00pm Day7 2.30pm WBC3.02.8 3.2 HCT43.751.145.839.2 Platelet105807788 HCO38.2 BP PR 101/76 93 116/79 100 BP not recordable Run 20ml/kg 80/60 140 CRP and LFT : Normal ID HSB 2015

19. What is your diagnosis Dengue fever, Day 7 of illness, Day 2 defervesence, decompensated shock with severe metabolic acidosis secondary to a)Plasma leakage b)Ongoing bleeding c)Cardiogenic shock d)Septic shock ID HSB 2015

20. Bedside Echo at ED pericardial fluid collection noted (no left ventricle end diastolic collapse) IVC patent. Bedside U/S: No fluid in intra-peritoneal region, minimal fluid in right pleural space Troponin T : Positive ID HSB 2015

21. ECG : suggestive of pericarditis Patient was transferred to ICU 1 Pint WB was transfused while waiting for ECHO ECHO : LVH Global pericardial effusion(0.6cm) No RA/RV collapse No RWMA EF 58% Day 7 10.00pm Day7 12.00pm Day7 2.30pm WBC2.8 3.2 Hb18.315.214 HCT51.145.839.2 Platelet807788 HCO38.2 BP PR 116/79 100 BP not recordable Run 20ml/kg 80/60 140 ID HSB 2015

22. Patient was admitted to ICU Despite 4 inotropic support, MBP 50- 60mmHg PR : feeble She was intubated and ventilated CVVH was commenced. She was anuric with metabolic acidosis. ID HSB 2015

23. VBG pH 7.137, pCO2 22.7, pO2 204, HCO3 10.3, SPO2 98.2, lactate 6 Impression : DHF with myocarditis and pericarditis in Cardiogenic Shock with metabolic acidosis ID HSB 2015

24. Repeated ECHO LVEF 33% Chambers normal size Valves - normal minimal Pleural Effusion seen Global hypokinesia LV wall She succumbed to illness on day 7 of ICU admission ID HSB 2015

26. Cause of death : Severe Dengue with myopericarditis complicated with cardiogenic shock, with multi-organ failure ID HSB 2015

27. Severe Dengue with target organ involvement Severe Dengue with myocarditis Severe Dengue with hepatitis Severe Dengue with encephalitis ID HSB 2015

28. Cardiac complication in Dengue Myocarditis is the most common documented cardiac pathology in Dengue infection Be aware if patient complains of chest pain, palpitation, shortness of breath ID HSB 2015

29. Cardiac rhythm disorder may occur in dengue infection : AV blocks, VPCs, ect Pericarditis can be seen in dengue infection, usually as a form of extension of myocarditis to pericardium ID HSB 2015

30. Dengue and CNS ( encepahlitis) Be aware if patient presents with headache, vomiting, altered sensorium or seizure If a patient presents with viral encephalitis, rule out dengue fever with CNS manifestation. ID HSB 2015

31. Hepatitis in Dengue Infection: Hepatitis is common in patients with DF/DHF and may be mild or severe regardless of the degree of plasma leakage. In some cases, liver failure may occur. Patients with liver failure have a high propensity to bleed, especially gastrointestinal bleeding ID HSB 2015

32. Peak transaminase enzyme usually occurred later ( Day 4- 10 of illness) than other complications. Clinically severe liver involvement may result in severe bleeding. Chronic co-infection with hepatitis B or C may be associated with modestly but significantly increased levels of alanine aminotransferase. ID HSB 2015

33. THANK YOU ID HSB 2015