Title: dengue hemorrhagic fever

Summary

A body of adult male with medium build that fits the descriptions of its appearance and age

presented with reddish, congested appearance and blood oozing from body cavities. Internal

examination revealed congested organ and multiple haemorrhages in the intestinal, 80% block of

the left coronary artery. Result of dengue Igm serology came out positive.

Introduction

a. Background of case

Dengue, the most common arboviral illness transmitted worldwide, is caused by infection

with 1 of the 4 serotypes of dengue virus, family Flaviviridae, genus Flavivirus (single-

stranded nonsegmented RNA viruses). Dengue is transmitted by mosquitoes of the genus

Aedes, which are widely distributed in subtropical and tropical areas of the world, and is

classified as a major global health threat by the World Health Organization (WHO).

Initial dengue infection may be asymptomatic (50%-90%),1 may result in a nonspecific

febrile illness, or may produce the symptom complex of classic dengue fever (DF). A

small percentage of persons who have previously been infected by one dengue serotype

develop bleeding and endothelial leak upon infection with another dengue serotype. This

syndrome is termed dengue hemorrhagic fever (DHF), although dengue vasculopathy has

been proposed as a better term, as fluid loss into tissue spaces can lead to prolonged

shock and complications, including gastrointestinal bleeding, a greater fatality risk than

bleeding per se.2

b. Rational and significance of choosing the case

Estimated 2.5-3 billion people in approximately 110 tropical and subtropical countries

worldwide are at risk for dengue infection. Yearly, approximately 50-100 million people

are infected with dengue, and 250,000 individuals develop dengue hemorrhagic fever.

Annually, approximately 500,000 individuals are hospitalized with the infection, and

24,000 deaths are attributed to dengue worldwide.

Currently, dengue hemorrhagic fever is one of the leading causes of hospitalization and

death in children in many Southeast Asian countries, with Indonesia reporting the

majority of dengue hemorrhagic fever cases. Of interest and significance in prevention

and control, 3 surveillance studies in Asia report an increasing age among infected

patients and increasing mortality rate.

Scene

The event occurs at intensive care unit of Hospital Serdang

History of admission

a. Patient biography

Name initials : Mr. BPR

Age : 38 y/o

Sex : Male

Religion : Hindu

Civil status : Single

Race : Nepalese

Occupation : General worker

b. History of event

The deceased was admitted into intensive care unit of emergency department for 3 days

before finally succumb to the disease. Patient was diagnosed for tetanus by the specialist

in-charge and was managed as what have been diagnosed for. However, it seems that the

deceased was not complying to the treatment and eventually died from shock.

Prior to the event, the deceased was living in a sharing house in Putra Permai –a very

high risk area for dengue and crimes. According to the inspector, the area was known for

high prevalence of dengue cases in the area. In fact, two of the deceased housemates was

admitted for dengue fever before.

The deceased himself was having fever lasted for three days and this was confirmed by

his supervisor. He was taking a leave and rest at home. At the fourth day, the fever was

already subsided so he came to work. Suddenly during work, he fainted and immediately

being sent to Hospital Serdang by his colleagues –to be admitted into intensive care unit

then.

External examination

Upon examination, it reveals that the body was belongs to an adult male with medium

built, with complete rigor mortis and minimum post-mortem hypostasis. The deceased

was wrapped in hospital white bed sheet. The deceased was Nepalese with dark fair-

brown skin colour. His height was 164 cm with weight of 55 kg. His hair was black with

short haircut. There was a few facial hair. The eye was black, with dilated pupil. The

mouth was foamy, but the deceased was not on denture. The deceased had sign of

treatment on right neck, right and left brachial and right and left radial as well as left

femoral intravenous insertion.

The deceased face was congested and pale; the temperature of the body was following the

room temperature. The whole body appears congested especially at the area surrounding

the limbs and abdomen. The hypostasis was collected at lower part of the body mostly –

as following the gravity and there was no definite contact pallor. There was blood oozing

from all over the body cavities.

Examination of the finger revealed that there is no change of coloration or disfigurement.

Examination of lower limbs also revealed the same thing and there was no evidence of

injury. Examination of the genital revealed there was no evidence of seminal discharge at

the glans-penis –no evidence of myocardial infarction. The penis was not circumcised –

the skin was retractable.

Not it is obvious, but the deceased skin is indeed appeared reddish and swollen.

Internal examination

The internal examination starts with the opening of the thorax through a Y-incision

through the midclavicular line and down to the suprapubic fossa without cutting the

umbilical into two. The thoracic cavity is the opened by cutting through the ribs and the

heart was then revealed. Upon the incision, the bodily fluid came running through the

opening of the incision.

The head was opened through incisions that run through the vertex from mastoid to

mastoid. However, the brain was normal with no remarkable findings. The weight was

1240 gram.

Upon the bodily examination, it revealed that the patient’s whole body was congested

with fluids –pleural effusion was noted. The lung was congested and there was petechial

haemorrhage noted at the lung. Respectively, the weight of right and left lungs was 634

gram and 500 gram. There was in fact laryngeal oedema. Incision of the trachea revealed

normal trachea with blood staining. Examination of the heart revealed no pericardial

effusion. However, the coronary artery examination shows 80% blockage of left coronary

artery yet right coronary artery was still intact. The heart is weight 292 gram.

Incision of the abdomen and the intestinal has revealed ascites. There were indeed

multiple haemorrhages seen in the small intestines and colon in form of ecchymoses –

findings very common in dengue haemorrhagic fever. Examination of liver revealed

multiple adhesions. The liver was normal, no nodule and fatty liver. The weight was 1916

kg. The spleen was congested with 242 gram. The kidneys appeared normal with 116

gram for right and 134 for left kidney respectively.

Other investigation

Cerebrospinal fluid was taken for culture and biochemistry. Blood sample was taken for

dengue Igm serology test and the result came out as positive.

Summary

A body of adult male with medium build that fits the descriptions of its appearance and

age presented with reddish, congested appearance and blood oozing from body cavities.

Internal examination revealed congested organ and multiple haemorrhages in the

intestinal, 80% block of the left coronary artery. Result of dengue Igm serology came out

positive.

Cause of death

The cause of death was dengue hemorrhagic fever

The deceased was presented with redness all over the body, congested body and limbs

and oozing of blood from body cavities.

Internal examination revealed that deceased have organ congestion –lung, spleen,

pancreas, pleural effusion, laryngeal oedema, and ascites. There were multiple

haemorrhage noted in the intestinal especially colon. There was adhesion at the liver.

80% of the left coronary artery was blocked.

Dengue Igm serology test came out as positive.

Mechanism of death

The deceased was died from dengue hemorrhagic shock after failed to be resuscitated.

The haemorrhage that occurs inside the body was not visible from the outside. The

haemorrhage cause the body to loss the blood volume resulted hypovoleumic shock.

Manner of death

Natural death

Discussion

Dengue has been called the most important mosquito-transmitted viral disease in terms of

morbidity and mortality. Dengue fever is a benign acute febrile syndrome occurring in

tropical regions. In a small proportion of cases, the virus causes increased vascular

permeability that leads to a bleeding diathesis or disseminated intravascular coagulation

(DIC) known as dengue hemorrhagic fever (DHF). Secondary infection by a different

dengue virus serotype has been confirmed as an important risk factor for the development

of DHF. In 20-30% of DHF cases, the patient develops shock, known as the dengue

shock syndrome (DSS). Worldwide, children younger than 15 years comprise 90% of

DHF subjects3

Dengue hemorrhagic fever or dengue shock syndrome usually develops around the third

to seventh day of illness, approximately at the time of defervescence. The major

pathophysiological abnormalities caused by dengue hemorrhagic fever and dengue shock

syndrome include the rapid onset of plasma leakage, altered haemostasis, and damage to

the liver, resulting in severe fluid losses and bleeding. Plasma leakage is caused by

increased capillary permeability and may manifest as hemoconcentration, as well as

pleural effusion and ascites. Bleeding is caused by capillary fragility and

thrombocytopenia and may manifest in various forms, ranging from petechial skin

haemorrhages to life-threatening gastrointestinal bleeding.

Similar to the deceased, it appears that dengue shock syndrome abruptly reflect itself

after 3 days of his medical leave. The shock is then resulted hyper permeability, and

bleeding inside the body –presentation in the intestinal might be cause by disseminated

intravascular coagulation.

Factors believed to be responsible for the spread of dengue include explosive population

growth, unplanned urban overpopulation with inadequate public health systems, poor

standing water and vector control, viral evolution, and increased international

recreational, business, and military travel to endemic areas. All of these factors must be

addressed to control the spread of dengue and other mosquito-borne infections.1

Reflecting to the case, lack of hygiene in the share house –usually involving working

immigrants cause the prevalence of hemorrhagic fever in the area. This unnecessary

death can be avoided if the area itself is cleaned and hygiene was one of the things that

deeply considered.

Conclusion

Dengue fever is a benign acute febrile syndrome occurring in tropical regions. In a small

proportion of cases, the virus causes increased vascular permeability that leads to a

bleeding diathesis or disseminated intravascular coagulation (DIC) known as dengue

hemorrhagic fever (DHF). Incubation periods take place 3-4 days –presented as fever

whereas patients usually fall into shock after the third day and died from dengue. The

major pathophysiological abnormalities caused by dengue hemorrhagic fever and dengue shock

syndrome include the rapid onset of plasma leakage, altered haemostasis, and damage to the liver,

resulting in severe fluid losses and bleeding.

References

1. Kyle JL, Harris E. Global spread and persistence of dengue. Annu Rev Microbiol. 2008;62:71-92.Ross R. Atherosclerosis--an inflammatory disease. N Engl J Med. Jan 14 1999;340(2):115-26.

2. Statler J, Mammen M, Lyons A, Sun W. Sonographic findings of healthy volunteers infected with dengue virus. J Clin Ultrasound. Sep 2008;36(7):413-7.

3. Malavige GN, Fernando S, Fernando DJ, et al. Dengue viral infections. Postgrad Med J. Oct 2004;80(948):588-601.