Primary Impression: Dengue Hemorrhagic Fever Differentials: Disease Typhoid Fever - a Rule In Fever Rash (but not as common)

vomiting Rule Out Fever, slow progressive rise Gastroenteritis Non-bloody diarrhea Cough Difficulty in breathing No rash

common worldwide illness, transmitted by the ingestion of food or water contaminated with the feces of an infected person.

Pneumonia inflammatory condition of the lung. It is often characterized as including inflammation of the parenchyma of the lung (that is, the alveoli) and abnormal alveolar filling with fluid (consolidation and exudatio n).

Chills Fever

Dengue - disease

manifests as fever of sudden onset associated with headache, muscle and joint pains, distinctive retroorbital pain, and rash. The classic dengue rash is a generalized maculopapular rash with islands of sparing

Maculopapular rash Fever NS1 positive Decreasing platelet count headache

Pathophysiology: Dengue viruses are transmitted by the bite of infected Aedes mosquito. Aedes mosquito species have adapted well to human habitation, often breeding around dwellings in small amounts of stagnant water found in old tires or other small containers discarded by humans. Female Aedes mosquitoes are daytime feeders. They inflict an innocuous bite and are easily disturbed during a blood meal, causing them to move on to finish a meal on another individual, making them efficient vectors. Once inoculated into a human host, dengue has an incubation period of 3-14 days (average 4-7 d) while viral replication takes place in target dendritic cells. Infection of target cells, primarily those of the reticuloendothelial system, such as dendritic cells, hepatocytes, and endothelial cells, result in the production of immune mediators that serve to shape the quantity, type, and duration of cellular and humoral immune response to both the initial and

subsequent virus infections. Following incubation, a 5- to 7-day acute febrile illness ensues. Recovery is usually complete by 7-10 days. Diagnostic Plan: - CBC - NS1 (if done within the first 4 days from the onset of fever) - Electrolytes (Na, K) - Pt, PTT

Management: Dengue is usually a self-limited illness and only supportive care is required. Antipyretics can be given to relieve the patient of the symptoms of fever. The use of aspirin, nonsteroidal anti-inflammatory drugs and corticosteroids should be avoided. As part of the supportive care, the patients should be closely monitored. Their platelet count and hematocrit should be measured daily especially from the start of the third day of illness until 1-2 days. A rising hematocrit level or falling platelet count should have intravascular volume deficits replaced. Successful management of severe dengue requires careful attention to fluid management and proactive treatment of hemorrhage. Intravascular volume deficits should be corrected with isotonic fluids such as Ringers lactate solution. Boluses of 10-20 mL/kg should be given over 20 minutes and may be repeated. If this fails to correct the deficit, the hematocrit value should be determined, and, if it is rising, limited clinical information suggests that a plasma expander may be administered. Dextran 40, or albumin 5% at a dose of 10-20 mL/kg may be used. If the patient does not improve after this, blood loss should be considered. Patients with internal or gastrointestinal bleeding may require transfusion. Patients with coagulopathy may require fresh frozen plasma.

Prognosis: The prognosis of patients with dengue fever is excellent, with complete recovery being the norm. Patients with dengue hemorrhagic fever or dengue shock syndrome who do not die usually recover without sequelae. Prevention: Educate patients, especially those who have experienced prior dengue fever, to avoid mosquito bites when traveling to dengue-endemic areas. Current

evidence suggests that those with a history of dengue fever are at highest risk for dengue hemorrhagic fever or dengue shock syndrome if they are infected with a different dengue strain. In the case of G.J.M., since he has already been had dengue hemorrhagic fever, the likelihood that the next time he will get dengue will give a worse prognosis is higher. Reference: Nelsons Pediatrics 18th edition