Case Presentation 1 Chua Hock Hin HSAJB Suresh

Case Presentation 1 Chua Hock Hin, HSAJB Suresh Kumar, HSB 1

Presenting Symptoms ( Admit 20/5/08 8 pm ) V. S / Indian / Female / 39 years Fever x 4/7 – a/w chills but no rigors Diarrhoea and vomiting x 2 days No bleeding tendency No SOB No chest pain LMP : 16/5/08 ( currently day 4 menstruation ) Not staying at dengue area ( No recent fogging ) No history of recent travel No family members with similar problem • • • 2

Social History Working in Taman University ( dengue area ) in a textile factory Recently engaged Currently lives with family 3

Physical Examination Conscious , alert GCS full BP : 126/75 PR : 58 (good volume) T : 37 GM : 6. 9 CRT < 2 sec Clinically pink, no jaundice Dehydrated • • • 4 • • • CVS : DRNM Lungs : Clear, A/E equal Abd : Soft, non- tender No rashes/ bruises seen No lymphadenopathy Estimated body Wt - 50 kg

Diagnosis Dengue Fever Differential : Acute gastroenteritis FBC from A&E : 5 Hemoglobin 144 G/L Hematocrit 39. 9 Platelet 15 G/L WCC 2. 2

What is the diagnosis? 6

What phase of Dengue illness is the patient in now? 7

Investigations taken FBC – BUSE/ Creatinine/ LFT – Dengue Serology – BFMP x 3 – CXR – Stool – • 8 Ova and cyst, C & S

Plan of management Hourly vital signs monitoring until stable Notify as Dengue Haemorrhagic Fever Run 2 pint NS fast Maintenance IVD 8 pints Normal Saline over 24 H IV Maxolon 10 mg tds T. Ranitidine 150 mg bd 4 hourly FBC TDS MO review • • 9

Comment on the management ? Does the patient fulfill the criteria for DHF ? 10

Comment on these orders ‘T. Ranitidine 150 mg bd’ ‘ 4 hourly FBC’ ‘TDS MO review’ 11

Next review - 13 hours defervescence– Day 5 fever onset ( 21/5/08 , 9 am ) Vomit x 1 , Epigastric pain No diarrhoea or hematuria BP : 107/70 mm. Hg PR : 81 s. PO 2 100% ↓Room Air Lungs : clear Order ( by doctors ) 12 Trace FBC taken at 7. 00 AM T Omeprazole 40 mg OD ( off T Ranitidine ) Watch out for bleeding tendency Cont IVD 8 pint Normal Saline over 24 hours Transfer to Dengue Ward after review result

Monitoring in dengue Comment on the review frequency 13

What are the signs of deterioration that were not appreciated by the doctor? 14

18 hours defervescence(21/5/08, 2 pm ) • • • Not transferred to Dengue Ward yet Blood Investigations taken at 7. 00 AM reviewed : – ALT : 407 / AST : 1230 – CK : 359 / LDH : 1912 – WCC : 2. 10 Hb : 13. 6 Hct : 39. 3 Plt : 19. 4 – Cr: 70 / Urea : 3 / K : 2. 85 – PT: 15 / PTT: 76. 6 / INR : 1. 3 CXR : Clear lung fields 15

25 hours defervescence(21/5/08, 9 pm) • Reviewed by doctor on call : • Comfortable ? ? ? • s. PO 2 99% ( room air ) • BP : 116/52 mm. Hg • PR : 104 /min • T : 37. 7 o. C • ABG : p. H 7. 43 p. CO 2 44 PO 2 153 HCO 3 28 BE 4 • Order – Continue ward management 16

Comment on the use of ABG at this stage 17

What will be correct diagnosis of the current patient condition? 18 DATE / TIME 20/5 21/5 7 PM 7 AM 5 PM HCT 39. 9 39. 3 35. 5 HB 14. 4 13. 6 11. 8 PLT 15 19 13 WCC 2. 2 2. 1 4. 2

36 hours defervescence( 22/5/08, 8 am ) – Day 6 fever onset Still abdominal pain T : 38 o. C BP 130/60 mm. Hg PR 92/min Abdomen – distended and tender but soft Lungs – clear Mild pedal oedema Order by doctor PR to look for malena ↓IVD to 6 pints/24 hours Refer HDU/ICU care 19

What do you think is happening? What will be the appropriate management at this stage? 20

48 hours post defervescence ( 22/5/08, 1 pm ) – Day 6 fever onset Noted lungs crepts Periorbital swelling Bilateral leg and arm oedema Order by doctor DIVC screen GXM 2 pint pack cells Off IVD IV frusemide 40 mg stat IV antibiotics – Ceftriaxone after blood culture Ultrasound abdomen urgent 21

DATE / TIME 7 PM 7 AM 5 PM 12 AM 7 AM 12 PM HCT 39. 9 39. 3 35. 5 32. 5 29. 5 30. 6 HB 14. 4 13. 6 11. 8 11. 7 10. 4 PLT 15 19 13 22 26 24 WCC 2. 2 2. 1 4. 2 7. 6 12. 9 14. 9 22 20/5 21/5 22/5

Comment on the usage of frusemide at this stage 23

24 Date 20/5 21/5 22/5 T. Bil 22 53 107 ALT 407 491 2476 AST 1230 1573 -2* CK 359 - - LDH 1912 - - Creat 0. 07 0. 03 0. 06 PTT - 76. 6 62. 4 INR - 1. 3 2. 11

What else is happening 25

Day 3 at 57 hours post admission ( 23/5/08, 5 am ) – Day 7 fever onset Staff nurse noted patient become more unwell Doctor ( on call ) review 26 Septic looking E 4 M 4 V 4 BP 149/72 mm. Hg PR 84/min ( good volume ) Lungs clear CRT < 2 sec Order Put back IVD 5 pint over 24 hours Continue antibiotic Hourly vital sign monitoring ABG stat – compensated severe metabolic acidosis p. H 7. 38 HCO 3 8 BE -14

Ultrasound report • 27 U/S Abd done 22/5/08 4. 30 p. m. – Normal liver echotexture – Ascites with minimal bilateral perinephric fluid ? cause – Thickened gallbladder wall may represent acute cholecystitis or due to presence of ascites – Evidence of liver abscess not seen – Hypoechoic lesion posterior wall of uterus, possibly a fibroid

D 3 admission (23/5/08, 8 am )- at 60 hours post defervescence • • Abdominal pain persistent Clinically : • Septic looking; T : 37. 4 o. C E 4 V 2 M 5 • BP : 140/89 mm. Hg PR : 92/min • Warm peripheries , CRT < 2 sec • Spo 2 100% , N/prong oxygen 10 L/min • Lungs- rhonchi with ↓ air entry left basal • Abdomen – soft, distended • Bilateral pedal oedema 28

Investigation results ABG – worsening compensated metabolic acidosis p. H 7. 36 HCO 314 BE -9 p. CO 2 27 Dengue serology : Ig M/G – Non reactive Management : IV frusemide 40 mg stat Transfer to HDU IVD 1 pint over 24 hours IV Na. HCO 3 50 cc slow bolus Repeat dengue serology 29

Further management at D 3 admission (23/5/08, 11. 15 am ) at HDU Planned for 1 pint PC and 2 units FFP transfusion IVD 4 pints Normal Saline / 24 H Intubated for Type 1 respiratory failure at 65 hours of admission ( 1 pm ) CXR – bilateral pleural effusion 30

Further management at D 3 admission (23/5/08) at ICU ( 69 hours post admission ) Septic workup – then IV Tazocin 2. 25 g QID for ? Acute cholecystitis ( ultrasound findings ) / Nosocomial infection IV Gelafundin bolus 250 cc IV Frusemide 40 mg stat Referred to surgical team – conservative management for ? Acute cholecystitis 31

D 4 admission (24/5/08) – 85 hours post admission Day 8 Illness GC worsened BP : 135/83 mm. Hg, PR : 131/min Not on inotropic support ABG : Compensated metabolic acidosis Hb reducing trend (Hb : 14 10. 6 7. 4) Abdomen more distended Urine output ↓↓ Anuric PT/PTT/INR : 32. 5 / 65. 8 / 3. 44 32

Further management IV frusemide 80 mg stat Reduce IVD 42 ml/hour + oral feeding 40 ml/hour – 2 litre /day Started CVVHDF Given DIVCx 2 regime with Whole blood 6 pints of blood in total – first pint whole blood given at 11. 30 am, 24/5/08 ( 87 hours post admission ) Started on inotropic support – Dopamine with added on Noradrenaline Needing increase ventilatory support , BP ↓ and developed AF 33

Further management Started IV amiodarone Bleeding tendency – oozing from femoral site Hypothermic BP dropping despite inotropic support. Patient succumb to her illness at 112 hours post admission Liver biopsy tissue sample sent for : 34 Dengue PCR Dengue Type 1 detected

Results Dengue Serology (21/5/08) –day 4 illness Dengue Serology (26/5/08) – day 9 illness Ig G : Non – reactive Ig M : Non – reactive Ig G : Reactive Ig M : Non – reactive Blood C&S (22/5/08) No sample Blood C&S (23/5/08) No growth 35