DENGUE HEMORRHAGIC FEVER – A CASE REPORT AND MANAGEMENT APPROACH

INTRODUCTION

Dengue Hemorrhagic Fever (DHF) is a severe and potentially life-threatening form of dengue fever, characterized by high fever, bleeding, and low platelet count. It can lead to organ failure, and death if not treated promptly.

CASE PRESENTATION

HISTORY AND CLINICAL EXAMINATION:

A 20 Year lady presented to the ER with history of high-grade fever with chills and rigors on and off past 4 days.

She had recurrent seizures the previous night of admission, and was taken to a nearby hospital, in view of low GCS, patient was intubated. Her BP was not recordable she received IV Fluids and was started on Noradrenaline infusion. Was also noted to have profuse bleeding following Ryles tube. Patient was referred here for further management.

PRIMARY SURVEY

AIRWAY – Intubated(outside). Had bloody secretions.

BREATHING – RR :18/M SPO2 98% on mechanical ventilation TV 480ml
PEEP 6 ON with FiO2 100%
B/L crepitation with basal decreased AE

CIRCUATION: – PR 166/m BP  100/60 mmhg with
INJ NORADRENALINE 10ML/HR
B/L peipheral pulse feeble with cold peripheries

DISABILITY: GCS E1 VT M1
B/L PERTL {2mm}
CBG : 104 mg/l

EXPOSURE: Febrile, 16 Fr Ryles tube in situ
14 Fr Foleys catheter in situ ,high coloured urine noted.
Tongue laceration 3*1 cm no active bleed

She was not known to have any drug allergies , no significant past medical or surgical history, and not on any regular medication.

Outside lab values of Dengue NS1 positive, Initial Hb-12.5,TC -2980, Platelet count -11,000

INVESTIGATION:

POCUS – B/L B lines with mild Pleural effusion IVC >50%collapsible with free fluid in the abdomen

ECG: Sinus tachycardia, Normal Axis , Global ST depression

ABG with 100%Fio2: PH-7.08, PO2-68mmhg, PCO2-48mhg, HB-10.6,
Na-136, K-3.0, CL-110, HCT-29, LAC-6.3, HCO3-12.9, CREATININE-1.4,

PT-40.9, INR-3.6, TROPONIN-13.86

ECHO-Global hypokinesia of left ventricle with regional variation Severe lv dysfunction, No PAH

USG ABDOMEN-Gall bladder wall edema, adjacent bowel wall edema , free fluid in the abdomen.

CT BRAIN – Normal

DIAGNOSIS: Based on the Clinical findings, investigations, diagnosis of Dengue Hemorrhagic Fever  with myocarditis was made.

TREATMENT AND OUTCOME:

• Patient was treated with IV fluids, inotropes support to maintain MAP >65mmhg,Inj Paracetamol, Inj Vitamin K , Inj Levipil, Inj Tranexamic acid, Inj soda bicarbonate, 1 SDP, 4 FFP and PRBC reservation was made.
• Patient was shifted to ICU
• In view of persistent severe metabolic acidosis and anuria patient was planned for CRRT.
• Eventually patient went into Coagulopathy, MODS requiring triple inotropes, despite efforts she couldn’t be revived.

DISCUSSION:

• DHF is characterized by increased vascular permeability leading to plasma leakage, thrombocytopenia, and DSS occurs when the plasma leakage is so severe that it causes circulatory failure, resulting in a dangerous drop in blood pressure (shock).
• The major pathophysiological changes that determine the severity of DHF and differentiate it from DF and other viral haemorrhagic fevers are abnormal haemostasis and leakage of plasma selectively in pleural and abdominal

CLASSIFICATION OF DENGUE

EXPANDED DENGUE SYNDROME: Unusual manifestations of patients with severe organ involvement such as liver, kidneys, brain or heart associated with dengue infection have been increasingly reported in DHF.

MANAGEMENT OF MILD DENGUE PATIENT

Treated symptomatically,

• Patients should be followed up for close monitoring of progression of the disease from mild to moderate or severe.
• During this time, clinical examination along with CBC and hematocrit should be advised according to the patient condition.

MANAGEMENT OF DENGUE PATIENTS WITH WARNING SIGNS

MANAGEMENT OF SEVERE DENGUE WITH COMPENSATED SHOCK

MANAGEMENT OF SEVERE DENGUE WITH DECOMPENSATED SHOCK

CHECK AND CORRECT ABCS (ACIDOSIS, BLEEDING, CALCIUM, SUGAR )

SUMMARY:

• Despite calculated fluid administration, if the Hematocrit falls with No improvement Clinically. The Patient needs Blood transfusion (PRBC) @5ml/kg.
• If Hypotension (Refractory) persist, after the above measure – Check ABCS and manage
• Only if all of the above fails, start inotrope with maintenance Crystalloid fluid.

REFERENCE:

https://ncvbdc.mohfw.gov.in/Doc/National%20Guidelines%20for%20Clinical%20Management%20of%20Dengue%20Fever%202023.pdf

Dr. Karthik Raja
Emergency Medicine Resident,
Department of Emergency Medicine,
Kauvery Hospital, Alwarpet

Dr. Ashok Nandagopal
Clinical Lead & Consultant,
Department of Emergency Medicine,
Kauvery Hospital, Alwarpet Chennai