Case Report

Dengue Haemorragic Fever

Pembimbing :
dr. Alfred Siahaan, Sp.A
Disusun oleh :
Dwitya Noviari
Kepaniteraan Klinik Ilmu Kesehatan Anak
Periode 15 Desember 2014 28 Februari 2015
Fakultas Kedokteran Universitas Kristen Indonesia

Introduction
Dengue virus infection, is a global
health problem. In the last three
decades an increase in the incidence
of the disease in the various
countries which can lead to the
death of about less than 1%.
Outbreak of disease has often been
reported by various countries.

Case Report

 Name
: An. K.D
Sex
: Male
Date of birth : 11 September 2006
Age : 8 years and 4 months
Address
: Jl. Suwiryo, Menteng
Religion
: Moslem
Entered RS C on January 12, 2015.

Case Report
History patients alloanamnesis done
with the patient's mother, Mrs. D,
age 41 years

HISTORY OF DISEASE
Patients come escorted by her mother to
the hospital emergency room with
complaints of fever C since 3 days before
admission. Complaints felt appear slowly
and felt all day. The patient had never
previously measured body temperature.
Two days before admission, the patient
went to the clinic and was given a Pct and
antibiotics, but the complaint did not
improve.

HISTORY OF DISEASE
In addition, patients also complain of
nosebleeds since 1 before entering
the hospital, complaints felt the
blood out of your right nostril 4
times, each 1 time nosebleeds out
for about 5 minutes. Then at the
nosebleed to 5 out of the nose right
and left, and already spent 1 pack of
tissue. New experienced nosebleeds
occur first.

HISTORY OF DISEASE
In addition, three days before admission, the
patient's home held fogging, no bleeding gums,
red spots on the skin denied, body-ache ache
denied, no abdominal pain, dizziness, nausea,
vomiting does not exist, coughs and colds do
not exist, history is traveling out of the city in
the last one week there, bowel and bladder
were no complaints, pain when urinating no
complaints, no swallowing pain, decreased
appetite, weight loss for no apparent reason
denied, tightness breath denied.

HISTORY OF DISEASE
Allergy denied and denied a history of
other diseases. The patient has not
experienced the same complaints before
and have never been hospitalized before
In a family there who have the same
complaint, and the patient's mother did
not know if in the neighborhood there
are
also
experiencing
the
same
complaint.

Physical Examination

General condition : looked moderate ilness

consciousness composmentis
Blood presure : 110/80 mmHg
Pulse 93x / min (strong lift, content
enough, regular)
Temperature of 38,8 0C (axillary)
RR 20x / min.
Weight 22 kg.
Height 122 cm.

 nutritional status based CDC impression

good nutrition
head circumference 50 cm impression
normocephali
pale conjunctiva eye - / -, sclera jaundice - / -,
tenderness retro orbital - / -, pupils isokor,
3mm / 3mm
Ear and throat examination within normal
limits
the nose was found bleeding ex + / +
oral examination no cyanosis, tongue coated
tongue
no palpable lymph nodes in the neck
enlarged, axila, and inguinal

 thorax examination within normal

limits, the heart of the normal limits
abdomen within normal limits
liver and spleen not palpable enlarged
acral extremities warm, capillary refill
time of less than 2 seconds, and no
edema
petechiae
obtained
integument
examination + on the volar forearm
right and left, and in the legs bottom
right and left.

Laboratory tests on 12 January 2015

ESR 8 mm / h
hemoglobin 10.2 g / dl
leukocytes 4700 / uL
3.97 million red cells /
uL
30% hematocrit
reticulocyte 4 per mil
basophils 0%

0% eosinophils
neutrophil rod 0%
segment neutrophils
56%
Lymphocytes 33%
Monocytes 11%
platelets 155,000 / uL
MCV 74 fL
MCH 25.7 pg
MCHC 34.6 g / dl.

HISTORY OF DISEASE
The diagnosis is dengue fever patients were
grade II
Patient was treating in ER
IVFD : Asering 20 dpm (macro)
Medica mentosa
Propiretik supp 240mg

FOLLOW UP 1 dated 13 January 2015

PP: 4
patients still complained of fever, nosebleeds first
time at 01.00 pm out of the right nostril and lasts
approximately 1 minute, headache, body ache-ache,
nausea +
General codition semed mild pain
consciousness composmentis
blood pressure 110 / 80 mmHg, pulse 88 / min
(strong lift, content enough, regular)
respiratory rate 23 / min (regular, adequate), 37,7C
body temperature (axillary), the former examination
found bleeding nose +/-, examination thorax, heart,
abdomen, and extremities within normal limits. The
liver and spleen not palpable enlarged.

Laboratory tests on 13 January 2015

hemoglobin 9.6 g / dl
hematocrit 28%
leukocytes 2,100 / uL
platelets 130,000 / uL.

Diagnosis of dengue fever patients

were grade II

 Diet : Usual
intravenous fluids Asering 20 dpm
(macro)
medical :
paracetamol 4 x tab (PO)
enervon-C 1 x 1 SDO (PO)
paracetamol drip 4 x 250 mg (IV)

FOLLOW UP 1 dated 14 January 2015

PP: 5
Patients complained of fever is gone, nosebleeds 1 time
out of your right nostril and lasts approximately 1
minute, dizziness reduced, body-ache ache is gone, no
nausea
General condition seemed mild pain
awareness komposmentis
pressure blood 110/80 mm Hg
pulse 93 / min (strong lift, content enough, regular)
respiratory rate 20 / min (regular, adequate)
36,3C body temperature (axillary)
on examination found the former nose bleeding + / examination of the thorax, heart, abdomen, and
extremities within normal limits. The liver and spleen
not palpable enlarged.

Laboratory tests on 14 January 2015

hemoglobin 9.6 g / dl
hematocrit 29%
leukocytes 3,100 / uL
platelets 114,000 / uL
Dengue blot test Ig and Ig G + M +
impression of secondary infection

 Diagnosis of dengue fever patients

were grade II. Usual diet,
intravenous fluids Asering 20 dpm
(macro)
medical paracetamol 4 x tab (PO),
enervon-C 1 x 1 SDO (PO),
paracetamol drip 4 x 250 mg (IV) in
the stop instruction at the time of
visit dr. Sp, A.

FOLLOW UP 3 dated 15 January 2015

Pp: 6
patients complained of fever is gone, nosebleeds 1 no,
dizziness reduced, body-ache ache is gone, no
nausea, and found the general condition seemed mild
pain
komposmentis awareness
blood pressure 120/80 mm Hg
pulse 87 x / minutes (strong lift, content enough,
regular)
respiratory rate 21 / min (regular, adequate), 36,7C
body temperature (axillary)
the former examination found bleeding nose - / Examination thoracic, cardiac, abdominal, and
extremity within normal limits. The liver and spleen
not palpable enlarged.

Laboratory tests on 15 January 2015

hemoglobin of 10 g / dl
hematocrit 29%, leukocytes 4,900 /
uL
platelets 113,000 / uL

 Diagnosis of dengue fever patients were

grade II
Diet : Usual
intravenous fluids Asering 20 dpm (macro)
Medical:
paracetamol 4 x tab (PO) if fever
enervon-C 1 x 1 SDO (PO)
allowed to go home instruction from dr. Sp,
A.

LITERATURE STUDY

DEFINISI
Dengue fever (DD) and Dengue
Hemorrhagic Fever (DHF) is a
contagious disease that disesabkan
dengue virus, including virus family
Flaviviridae, genus Flavivirus, has 4
types of serotypes that den-1, den-2,
3
and
den-den-4
through
intermediaries
bite
aegipty
Stegomiya mosquito vector (formerly
called Aedes aegipty) and Stegomiya
1

 Dengue virus serotypes (DEN-1, DEN2, DEN-3 and DEN-4) are

antigenically very similar to each
other, but can not produce a
complete cross-protection after
infection by one type. These four
serotypes of the virus can be found
in various regions in Indonesia.
Serotype DEN-3 is the predominant
serotype and is the strain that

Epidemiology
Tabel 1. Jumlah dan kasus dan angka kematian DBD di Indonesia, tahun
2008-2012
Year

CASES

Mortality rate (%)

2008

137.469

0,86

2009

154.855

0,89

2010

156.086

0,87

2011

65.725

0,80

2012

90.245

0,88

Sumber : Data Ditjen PP-PL Kemenkes RI 2012; Buku Informasi PP-PL Kemenkes RI 2013

 In 2008 the reported number of

dengue cases 137 469 people, then
increased in 2009 and 2010. In 2011
a decline in the number of cases
more than half, but increased again
in 2012, the mortality rate dropped
to below 1%.

 pathogenesis of dengue virus infection

associated with:
1. Factor viruses, namely serotypes, number,
virulence.
2. The host factors, genetics, age, nutritional
status, comorbid
diseases
and the
interaction between virus and host.
3. Environmental factors, season, rainfall,
temperature, density, population morbidity
and health lingkungan.

 In general pathogenesis of dengue virus infection

caused by the interaction of the various components
of the immune response or inflammatory reaction
which occurs in immune terintergrasi.sel most
important in interacting with dengue virus that
dendritic
cells,
monocytes
/
macrophages,
endothelial cells, and platelets.
As a result of these interactions will be issued various
mediators include cytokines, increase the excessive
activation of immune cells, will be produced
cytokines
(particularly
proinflammatory),
chemokines, and other inflammatory mediators in
large quantities. Various excessive production will
produce a variety of forms, signs and symptoms of
viral infection dengue.

 Humoral immune response played by B

lymphocytes,
by
producing
specific
antibodies against dengue virus. Antidengue antibodies are formed generally in
the form of IgG with different activities.
Antibodies against the NS-1 serves to lyse
infected cells via complement assistance.

 Cellular immune response plays a

role that T lymphocytes (T cells). T
cells can lyse cells infected with
dengue virus, as well as producing
various
cytokines.
Cytokines
produced by T cells play a role in
triggering
the
excessive
inflammatory response and increase
the permeability of the endothelial
cells.

Main Symptoms
1. Fever
Sudden high fever, continue - constantly lasts
for 2-7 days, up and down (biphasic fever).
Sometimes - sometimes very high body
temperature up to 400C and can occur kejan
fever. Final phase of fever is a critical phase
in dengue hemorrhagic fever. At the time of
febrile phase has begun to decline, and the
patient recovered as heart - the heart
because of that phase as the initial shock of
events, usually on the third day of fever

2. Signs of bleeding
Most types of bleeding is bleeding under
the skin such as petechiae, purpura,
ecchymosis and bleeding conjuctiva.
petechial hemorrhage is a common sign.
Appear on the first day of fever but can
also be found on days 3,4,5 fever. Other
bleeding that is, epitaxis, bleeding
gums, melena and hematemesis.

Hepatomegaly
In general can be found at the
beginning of the disease varies from
a palpable danger to 2-4 cm below
the arch of the right costa. The
degree of hepatomegaly is not
parallel to the severity of the disease,
but the tenderness in the edge region
of the liver associated with bleeding

4.Shock
In mild and moderate cases, all signs and clinical
symptoms disappeared after the fever down with
perspiration, changes in pulse and blood pressure,
acral cool clammy skin accompanied by
congestion. These changes showed symptoms of
circulatory disorders, as a result of plasma
perembasan which can be mild or transient.
In severe cases, the patient's general condition
suddenly became worse after a few days of fever
during or shortly after the temperature drops,
between 3-7, there are signs of circulatory failure,
terabab cold and moist skin, especially on the
fingertips and toes, cyanosis around the mouth, the
patient became agitated, rapid pulse, weak little to
no palpable. At the time there will be shock
patients complaining of abdominal pain.

Additional Examination
In dengue hemorrhagic manifestations
accompanied or suspicion of coagulation
disorders, can be examined hemostasis (PT,
APTT, Fibrinogen, D-dimer, or FDP). Other
tests that can be done is albumin, SGOT /
SGPT, urea / creatinine.
The following laboratory results are a risk
factor for DSS: Increased hematocrit> 20%,
platelet count <40,000 / mm3, aPTT> 44
seconds, PT> 14 seconds, TT> 16 seconds.
Other tests that can be done is albumin,
SGOT / SGPT, urea / creatinine.

 To prove the etiology of dengue

fever, a diagnostic test can be done
through inspection virus isolation,
serology or molecular biology.
virus isolation
examination
transcriptionpolymerase
reverse polymerase chain reaction (RTPCR)
IgM dan IgG-dengue

 Radiological
examination
(radiographic
PA
upright and lateral decubitus right) can be
performed to see whether there is a pleural
effusion, especially in the hemithorax and the
great state of plasma leakage, effusion can be
found on both hemithorax.
Ascites and pleural effusion can also be detected
by ultrasound. Laboratory tests are often found
in patients with DHF are thrombocytopenia
(<100,000
/
ul)
and
hemoconcentration
(hematocrit levels over 20% of normal).

 One of the latest inspection method

that is growing is the dengue virusspecific antigen test, namely antigen
nonstructural protein 1 (NS1). NS1
antigen expressed on the surface of
cells infected with dengue virus.

Discussion
KD patients, male, 8 years old, came with
complaints of fever 3 days before admission.
Complaints felt appear slowly and felt all day,
patients also complain of nosebleeds since 1 day
before entering the hospital, up to 5 times and
complained of stiffness in the joints.
Fever of less than 7 days and nosebleeds
(spontaneous bleeding) is a clinical symptoms of
dengue fever, dengue fever but to enforce the
necessary 2 clinical symptoms and laboratory 2
symptoms. In this case the patient's platelets
155,000 / ul and hematocrit 30% of patients, not
indicating the presence of plasma leakage.

 Then on the second day follow-up of patients still

complain obtained fever (fever day 4) nosebleed
first time, body ache, good vital signs, laboratory
tests found on platelets 130,000 / ul, leukopenia
which leukocytes 2,100 / ul, hematocrit 28%.
Platelets on the fourth day of illness trip down, it
should be wary, but if you see the hematocrit
value is not increased, so there was no sign of
leakage of plasma. So we have not been able to
diagnose the patient is experiencing dengue
fever, but we have to stay tuned H2TL. On the
second day Sp.A doctors advise for inspection
IgM and IgG anti-dengue. The results of the
examination of anti-dengue IgM and IgG is
positive.

It has been found that the symptoms and lab results;

1. fever of less than 7 days
2. Spontaneous bleeding, myalgia and arthralgia, but
there was no warning sign
3. Thrombocytopenia <150,000 / ul but not less than
100,000 / ul, the presence of leukopenia <4000 / ul
4. Anty-dengue IgM and IgG positive, and
5. No plasma leakage
indicates the patient is not suffering from dengue
fever but suffer from dengue fever, according to
WHO criteria in 2009 and the Guidelines for
Diagnosis and management of dengue Virus
infection in Children IDAI 2014.

 for its management according to the theory we use in the

management of dengue virus infection, and the patient
can be treated the way. Education for parents to
outpatients; child should rest, drink enough water in
addition can also be given milk, fruit juice, liquid
electrolytes, water starch. Simply take characterized by
frequency of urination every 4-6 hours, paracetamol 10
mg / kg / times given> 380C, apply warm compresses,
should control every day and assessed by health workers
to pass through the crisis phase, the patient should be
immediately taken to the hospital if found one or more of
the following circumstances; when the temperature drops
to deteriorate the situation of children, severe abdominal
pain, persistent vomiting, cold hands and feet and moist,
the child seemed limp, bleeding, shortness of breath, do
not urinate more than 6 hours.

Tatalaksana Tersangka infeksi Dengue

Demam tinggi, mendadak 2-7 hari,nyeri kepala,nyeri
retroorbita, perdarahan, lekosit <4000/ul, DHF di lingkungan

Umum

menolak makan dan minum, muntah persisten

Warning sign

nyeri perut hebat, hepatomegali yang nyeri, letargi, gelisah, akumulasi cairan, Ht awal tinggi, demam
turun klinis memburuk
Tanda dan gejala syok

Terkompensasi dan dekompensasi

Tanda keterlibatan organ expanded dengue syndrome

Ensefalitis ensefalopati, perdarahan hebat seperti melena hematemesis, hematokezia, hematuri,

hemoglobinuria, ganggaun jantung, gagal ginjal akut, Hemolityc uremic syndrome
Indikasi sosial

Rumah jauh atau tidak ada orang tua/wali yang dapat diandalkan untuk merawat di rumah

ya

tidak

Rawat
jalan

Warning
sign +?

ya

Rawat inap
DD, DHF,
DHF+syok,
expanded dengue

Conclusion
Dengue fever (DD) and Dengue Hemorrhagic Fever (DHF) is
an infectious disease caused by a virus of the genus Flavivirus
family Flaviviridae, has 4 types of serotypes that den-1, den-2,
den-den-3 and 4 through the intermediary of the Aedes
aegypti
mosquito
bites
.
To diagnose it takes two clinical symptoms and laboratory
tests positive two. In the case of KD patients more lead to
dengue fever, because it has been found that the symptoms
and lab results; fever of less than 7 days, spontaneous
bleeding, myalgia and arthralgia, but there was no warning
sign, thrombocytopenia <150,000 / ul but not less than
100,000 / ul, the presence of leukopenia <4000 / ul, antidengue IgM and IgG positive, and no plasma leakage. Patients
can be treated the way and be educated about home care.

Reference
1. Hadinegoro, Sri Rezeki H. Soegianto, Soegeng. Suroso,
Thomas. Waryadi, Suharyono. Pedoman Diagnosis dan
Tatalaksana Infeksi Virus Dengue pada Anak. Badan
Penerbit Ikatan Dokter Anak Indonesia. 2014.
2. World Health Organization, 2005. Dengue, Dengue
Hemorrhagic Fever, and Dengue Shock Syndrome in
the Context of the Integrated Management of
Childhood Illness. World Health Organization.
3. Suhendro, Nainggolan L, Chen K, Pohan HT. Demam
berdarah dengue. Dalam: Sudoyo, A. et. al. (editor).
Buku Ajar Ilmu Penyakit Dalam Jilid II. Edisi 4. Jakarta:
Pusat Penerbitan IPD FKUI, 2006. p. 1774-9