A Case of N.E.16 y.o Male

cc: fever x 3 days

History of Present Illness

3 days PTC: (+) fever with chills

(Tmax 39.5ºC)(+) headache (+) generalized

weakness(+) myalgia (+) sore throat(+) cough with

productive sputum (whitish)

(-) epistaxis(-) gum & aural bleeding(-) hematemesis(-) hematuria(-) hematochezia(-) melena(-) petechiae/ ecchymoses/ rash

Px has a neighbor diagnosed with Dengue

History of Present Illness

3 days PTC: (+) fever with chills

(Tmax 39.5ºC)(+) headache (+) generalized

weakness(+) myalgia (+) sore throat(+) cough with

productive sputum (whitish)

• (-) calf pain• (-) abdominal pains• (-) jaundice• (+) good urine output• (-) hx of wading through

the floodwaters

History of Present Illness

3 days PTC: (+) fever with chills

(Tmax 39.5ºC)(+) headache (+) generalized

weakness(+) myalgia (+) sore throat(+) cough with

productive sputum (whitish)

Medications taken:

Paracetamol 500mg/tab every 4 hours for fever with minimal relief

Review of Systems

(-) dizziness(-) difficulty of breathing(-) chest pains(-) palpitations(-) weight loss >20%(-) decrease in appetite

Past Medical History

(-) hypertension, diabetes, liver, lung and kidney disease

(-) asthma, allergies to food and drugs (-) previous hospitalizations and surgeries

Birth and Maternal History

Pt was born FT at Fabella hospital by an OB-Gyne via SVD to a then G1P0 mother.

(-) maternal illness, exposure to chemicals, radiation

(-) exposure to measles and varicella infection

Immunization History

completed the EPI c/o LHC(+) MMR c/o private pediatrician

Nutritional History

Px was fed with both breastmilk and formula since birth.

The patient’s current diet consists of rice, meat, fish, poultry, with minimal fruits and vegetables

Personal and Social History

H - good rel’p with parents & siblingsE - 2nd year HS, satisfactory performance, (-)

failing gradesA - basketball, computer gamesD - no use of illicit drugsS - has groups of friends in school and

neighborhoodS - not sexually activeS - no suicidal thoughts

Personal and Social History

Non-smoker, occasional alcoholic beverage intake

Px lives with his mother and 2 other siblings at home in Pasay City

Mother is the breadwinner of the family and works in a factory

Px’s family gets monthly stipend from relatives who work abroad

GenogramHPNAsthma

CVDPTB

32 30 27 24 16

7 9

Physical ExaminationBP 90/60 HR 120s RR 20 T 38.6Px is awake, coherent, oriented, weak-lookingPinkish conjunctivae, anicteric sclerae, (+) pharyngeal

injection, (-) cervical lymphadenopathies, (-) anterior neck masses, (-) nasoaural bleeding, (-) gum bleeidng

Equal chest expansion, clear breath sounds, (-) wheezes, (-) crackles, (-) retractions

Adynamic precordium, distinct heart sounds, tachycardic, regular rhythm, no murmurs

Soft and flat abdomen, normoactive bowel sounds, (-) masses/ tenderness, liver and spleen nonpalpable

Full and equal pulses, pinkish nailbeds, (-) cyanosos, (-) clubbing, (-) edema, (-) rash, (-) petechiae/ ecchymoses, (-) calf tenderness, (+) flushed skin

Tourniquet Test

negative (<20 spots in 1 square inch)

Assessment

R/O Dengue Fever/ Dengue Hemorrhagic Fever

Plan

For CBC with platelet countParacetamol 500mg/tab 1 tab every 4

hours for feverTepid sponge bathSupportive therapy

Increase oral fluid intakeAvoid dark colored foodsWOF bleeding episodes

Questions Questions…..

What if the CBC was normal? It has only been a 3 day Hx of fever..

A negative tourniquet test doesn’t necessarily r/o DF/DHF.. What now?

Its too early to say.. What can we do at this point? Is watchful waiting enough to prevent the complications of DF/DHF?

Recent dengue cases are noted to be more virulent than the past (cross-immunities etc)

DF/DHF Epidemiology

10,383 cases of DF/DHF noted by Nat’l Epidemiological Center of DOH (Jan-June 20)

104 deaths (case fatality of 1%)Most cases were at NCR, Region 4A, 5,6Most deaths are caused by complications

secondary to DHF and DSSMost are diagnosed LATE

Bio-Rad Dengue NS1 Antigen Test

New offer at PGH Central Lab!!Used in private hospitals since 2007 serum available in minutesMay detect 4 dengue serotypes in the

first 5 days of viremia (febrile phase)

Diagnostic Dilemma

P - pediatric patients with clinical signs of Dengue Fever, in the first 3 days of fever

I - Dengue NS1Antigen testC - virus isolation testO - sensitivity and specificity in diagnosis

of Dengue FeverM - cross sectional study

Clinical Question (Diagnostics)

What is the sensitivity and specificity of Dengue NS1Antigen test versus a viral isolation test in the diagnosis of DF/DHF in pediatric patients with clinical signs of DF in the first 3 days of viremia in a cross sectional study?

Therapeutic Dilemma

P - Pediatric patients with clinical signs of systemic viral infection (SVI)

I - ImmunologicalsC - placeboO - shortening the course of the diseaseM - RCTs

Clinical Question (Therapeutics)

In pediatric patients with clinical signs of systemic viral infection, is there a significant difference in giving immunologicals versus placebo in shortening the course of fever seen in randomized controlled trials?