Dengue fever with thrombocytopenia

 I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan

K.shirisha

Rollno;68

Chief complaints:

A 28 year old female staff nurse by occupation came to the casuality with complaints of 

Fever since 4 days

Body pains since 4 days

Vomitings since yesterday night

Pain in lower abdomen since yesterday night

HISTORY OF PRESENT ILLNESS :

 Patientwas apparently alright 4days ago

then she developed low grade fever, intermittent  type which progressed to highgrade fever, continuous type since last night

 Also associated with  chills,

bodypains, Burning micturition and pain in lower Abdomen (since yesterday) dull aching type

H/O vomitings since yesterday night contained food particles,non bilious,non projectile associated with nausea.patient was referred from outside hospital to our hospital due to fever with thrombocytopenia (58,000)

No c/o hematmesis,melena, bleeding gums.

No h/o giddiness,

HISTORY OF PAST ILLNESS 

No H/o Tb,asthma,Dm, Hypertension,CVA,cad,epilepsy

Surgeries: H/o 3 lscs 3 years back

1. 2014-may 2

2. 2017-oct 18

3. 2020-feb 7

personal history:

Appetite decreased since 4 days

Diet: mixed

Bowel and bladder: regular

Sleep: adequate

No addictions

Family History:

Her father is a k/c/o DM2 since 7 years

Mother is a k/c/o hypertension since 3 years

General examination:

Patient is conscious coherent cooperative

Pallor: present

No icterus, cyanosis, clubbing, lymphadenopathy,edema

Vitals:

Temp: 100F

PR: 113bpm

RR: 18cpm

Bp:100/70 mmHg

Spo2:100% on Ra

Grbs:106 mg/dl

Systemic examination:

Cvs:

S1,S2 +, no murmurs

Rs: clear,Bae+

CNS: HMF+

Tone : normal in all limbs

Power: RT. LT

U/L. 5/5. 5/5

L/L. 5/5. 5/5

Reflexes:

B. T. S. K. A. P

R. ++. ++. ++. ++. ++. Flexion

L. ++. ++. ++. ++. ++. Flexion

P/A:

Inspection;

Shape; distended due to fluid

Umbilicus; slightly retracted and inverted

Movements ; normal

No visible pulsations or engorged veins,no visible peristalsis

Skin over abdomen ;normal

✓Palpation;

Soft, tenderness in right hypochondrium, epigastrium, suprapubic region

Local rise of temperature +

No organomegaly

✓Percussion ;

Liver; dullnote heared,

shifting dullness- +

No fluid thrills,

Auscultation:

Bowel sounds: heard

Diagnosis:

Dengue NS1 positive with thrombocytopenia 

Investigations:

Hemogram:

             D-1.    D-2.    D-3.     D-4.             D-5.      D-6

HB.    15.5.    15 .6.    13.4.     12.5 13.4.     13.3.  13

TLC.    5,600. 5,600    6100.     4000 3900.   4200 2,900

PC.      58000 64000.   60,000. 49000 42000 45000 80000

I:.        Ncnc thrombocytopenia

RBS: 89 mg/dl

16/1/23

HB: 14.1

TLC:5,600

PC:1.41 lakhs

RFT:

Blood urea: 48

Serum creatinine: 1.1

Na: 136

K: 3.4

Cl:100

ICA: 0.85

LFT:

TB: 0.90

DB:0.20

AST:66

ALT:31

ALP:205

TP:6.1

Albumin:3.18

A/G:1.09

Serology: negative

NS1 Antigen: positive

Cue:

Colour: pale yellow

Albumin : present +

Sugars: nil

Pus cells: 6-8

Epithelial cells:2-4

Chest x ray:

ECG:

2d echo:

USG Abdomen:

Treatment:

IVF NS RL @ 75ml/hr

Inj Neomol 1 gm iv/sos if temp > 101 F

Tab Dolo 650 mg po/BD

Inj Zofer 4mg iv/bd

8am- 8pm

Inj pan 40mg /iv/od

8am

Grbs,pr,bp,temp monitering 4th hrly

13/1/23 Ward patient Unit 2 Dr.Aashitha sr Dr .manasa pgy3 Dr. Hari priya , pgy2 Dr. Lohith pgy1 Dr Nithin pgy1 Dr.shirisha intern Dr.vishal intern Dr.preethi intern S: ℅ dry cough pain abdomen,tightness of abdomen Stools passed O: Patient was conscious ,coherent, cooperative Vitals: Temperature: afebrile 98.7f Bp: 110/70 mmHg supine 110/80 mmHg standing HR: 78 BPM supine 88bpm standing RR:20cpm P/A: soft ,distended Tenderness present in epigastrium and hypogastrium No guarding rigidity Bowel sounds: heared Cvs: S1,S2+, no murmurs CNS: No focal neurological deficit RS: clear,BAE+ A: Viral pyrexia with thrombocytopenia Dengue NS1 positive P: IVF NS RL @ 100ml/hr Inj Neomol 1 gm iv/sos if temp > 101 F Tab Dolo 650 mg po/BD Inj Zofer 4mg iv/bd 8am- 8pm Inj pan 40mg /iv/od 8am Tepid sponging Grbs,pr,bp,temp monitering 4th hrly

14/1/23 Ward patient Unit 2 Dr.Aashitha sr Dr .manasa pgy3 Dr. Hari priya , pgy2 Dr. Lohith pgy1 Dr Nithin pgy1 Dr.shirisha intern Dr.vishal intern Dr.preethi intern S: ℅ dry cough (relieved) pain abdomen,tightness of abdomen( relieved) No fever spikes Stools passed O: Patient was conscious ,coherent, cooperative Vitals: Temperature: afebrile 98.7f Bp: 100/70 mmHg supine 90/70 mmHg standing HR: 78 BPM supine 88bpm standing RR:20cpm P/A: soft ,distended Non Tender No guarding rigidity Bowel sounds: heared Cvs: S1,S2+, no murmurs CNS: No focal neurological deficit RS: clear,BAE+ A: Dengue NS1 positive with thrombocytopenia P: IVF NS RL @ 100ml/hr Inj Neomol 1 gm iv/sos if temp > 101 F Tab Dolo 650 mg po/sos Inj Zofer 4mg iv/sos Inj pan 40mg /iv/od 8am Tepid sponging Grbs,pr,bp,temp monitering 4th hrly

16/1/23

:

Loose stools since yesterday ( 5-7 episodes)

2 episodes since morning( resolved)

 Tightness of abdomen ( decreasing)

No fever spikes

O:

Patient was conscious ,coherent, cooperative

Vitals:

Temperature: afebrile 98.7f

Bp: 120/80mmHg supine

      110/80 mmHg standing

HR: 78 BPM supine

       88bpm standing

RR:18cpm

P/A: soft ,distended

 Non Tender

No guarding rigidity

Bowel sounds: heared

Cvs: S1,S2+, no murmurs

CNS: No focal neurological deficit

RS: clear,BAE+

A:

Dengue NS1 positive with thrombocytopenia

P:

IVF NS RL @ 100ml/hr

Inj Neomol 1 gm iv/sos if temp > 101 F

Tab Dolo 650 mg po/sos

Inj Zofer 4mg iv/sos

Inj pan 40mg /iv/od

8am

Tepid sponging

Grbs,pr,bp,temp monitering 4th hrly

Course in hospital A 28 years old female came with history of fever and generalised weakness,on routine investigations was found to be Dengue NS1 positive and further management has been done based on the hydration status and platelet counts and no history of giddiness,loose stools ,significant postural hypotension and bleeding manifestations,and her platelets trends being,

On day-1: 58,000

On day-2: 64,000

On day-3: 60,000

On day-4: 48,000

On day-5: 45,000

On day-6: 80,000

On day-7:1.4 lakhs

No SDP transfusions were done,and the patient is being discharged as the vitals are stable and patient is relieved,and platelet counts are increased.

Question

Why thrombocytopenia is a common in dengue infection

Thrombocytopenia is a common laboratory finding in dengue infection. It usually reaches its nadir during the critical phase and resolves subsequently. The pathophysiology of thrombocytopenia in dengue infection is not clearly understood. It is believed that it rests mainly on two events: 

1)decreased in bone marrow production and/or2) increased peripheral destruction and clearance of platelets.

Immune-mediated clearance of antibody-coated platelets has been proposed as one of the mechanisms leading to thrombocytopenia. The cross-reactivity of antibodies directed against NS-1 antigen and platelets suggests the role of antiplatelet antibody in the pathogenesis of thrombocytopenia.In addition, complement-mediated platelets destruction plays an important role during dengue infection.

Why polyserositis is seen in dengue?

Most critical future in dengue remains the leakege of plasma .This leakage of plasma is due to increased endothelial capillary permeability.This may present as ascites,pleural effusion,pedal edema and hemoconcentration.

Conclusion:

The reported women with Dengue fever with thrombocytopenia have been managed by fluids correction based on her hydration status to maintain sufficient urinary output and perfusion

In the above patient poly serositis is due to dengue fever leading to increased endothelial permeability And plasma leakage

Serositis is the predictor of impending dengue shock syndrome and was treated successfully with fluid replacement therapy.

Once dengue shock syndrome was treated serositis resolves on its own .