FEVERA CASE

PRESENTATIONMona Jamtani

1006803266

CASE ILLUSTRATION Identity

Name: Ch. D AAge: 10 yoAddress: Kelapa Gading TimurReligion: MoslemMedical Record: 1249xxx

CASE ILLUSTRATION Chief Complaint

Fever since 2 days prior to admission

CASE ILLUSTRATION History of Present Illness

Two days prior to hospital admission, patient complained of a high fever that occurred suddenly and persisted. Temperature was not measured. Patient went to a clinic and was given medicine (antibiotics and fever medicine) but the fever remained.

Signs of acute systemic infection: Headache (+), muscle aches (+), loss of appetite(+)

Other symptoms: stomach ache (+), diarrhea (+) 1 x liquid with pulp, brown color, vomiting (-), cough (-), flu (+), pain in swallowing (-). Signs of bleeding; nosebleed (-), bleeding gums (-), petechiae (-). Pain on urination (-), pelvic pain (-)

CASE ILLUSTRATION

Previous History of IllnessPatient has never had a similar illness

Family History of IllnessThere is no similar illness in the familyThere is no history of TB in the family

CASE ILLUSTRATION Immunization History

Complete

Growth and Development HistoryWithin normal limits

CASE ILLUSTRATION Physical Examination

General condition: compos mentis, looks moderately ill

BP: 110/70 mmHgPulse: 120x/minuteRR: 40 x/ minuteTemp: 38.9CWeight: 24.5 kg

CASE ILLUSTRATION Physical ExaminationHead: normocephal, deformity (-)Eyes: anemic conjunctiva -/-, icteric sclera -/-ENT: nasal flare (-), secret (-), cerumen (-)Neck: suprasternal retraction (-)Lymph Nodes: No EnlargementChest: Symmetrical, static and dynamicHeart: S1-2 (N), murmur (-), gallop (-)Lungs: vesicular/vesicular, rhonki -/-, wheezing -/-Abdomen: supple, bowel sounds (+) normal, Pain

on palpation (+) epigastrium, good turgorNo enlargement of the liver spleen or kidneysExtremities: warm, CRT< 2”

CASE ILLUSTRATION Working Diagnosis

Fever ec Dengue Hemorrhagic Fever Differential Diagnosis

Urinary Tract Infection Work-up Plan:

Urinalysis, CBC/12 hoursTherapy Plan: IVFD RL 30 drops/minuteParacetamol ½ cth whenever there is feverRanitidin 3 x 1 amp

CASE ILLUSTRATION Laboratory Results Urinalyisis: ? CBC:

Hb 12.6 g/dL Ht 35%Leu 4700 /ulThrombo 73 000 / ul

CASE ILLUSTRATION Follow ups 24/9/10 S: fever (+) cough (-) stomach ache (+) vomit(-) O: compos mentis, looks moderately ill BP: 110/70 mmHg Pulse: 120 x /minute RR:

40x/ minute Temp: 38.9 C Hb: 16.4 g/dL Ht: 45% Leu: 6130/ uL

Thrombo: 49 000/uL A: DHF susp typhoid fever P: IVFD RL 30 drops/minute PCT 3 x 1 tab Ranitidine 3 x ½ amp

CASE ILLUSTRATION 25/9/10 S: Fever (+), flu (-), cough (-), stomach ache

(+), nosebleed (-), vomit (-) O: compos mentis, looks mildly ill BP: 110/80mmHg Pulse: 90 x/ minute RR:

32x/ minute Tem: 38C Hb: 13.6 g/dL Ht: 37% Leucocyte

6830/ uL Thrombocyte: 45 000 /uL A: Dengue Fever susp Paratyyphoid P: RL 30 drops/minute Ranitidine 3 x ½ amp If fever spikes, consider cefixime administration

2 x 125 mg

CASE ILLUSTRATION 26/9/2010 S: Fever (D6) (-), cough (-), flu (-), stomach

ache (-), urineation (+) normal O: Compos Mentis BP: 100/70Pulse: 88x/minute RR: 40

x/minute Temp: 37 C Hb: 12.9 g/dL Ht: 36 % Leu: 67900/ uL

Thrombo: 57 000 / uL A: Demam Dengue + Susp Paratyphoid P: RL 30 drops/minute Ranitidine 3 x ½ amp If fever spikes, consider Cefixime 2 x 125 mg

CASE ILLUSTRATION 27/9/10 S: fever (-), complains (-), urination (+) O: compos mentis, looks well BP: 110/70 mmHg Pulse: 80x/minute

RR: 32x/minute Temp: Afebrile Extremeties: petechiae (+)legs, phlebitis (+)

on hands, Rumpal Leed (+) Hb: 13.1 g/dL Ht: 36% Leu: 8560 /

uL Thrombo: 99 000 A: DF P: educate to drink lots of fluids Ranitidine 3 x 25 mg if stomach ache present

LITERATURE REVIEW

FEVER Controlled elevation of temperature >

37.5C , due to increase in temperature regulatory set point

Achieved & maintained the same way as normal body temperature: redirecting blood to or from cutaneous vascular

beds, increased or decreased sweating, behavioral responses such as seeking a warmer

or cooler environmental temperature. Hyperthermia: normal setpoint but

incapability to maintain temperature (heat stroke, drugs)

FEVER: PATHOGENESIS Regulated like body temperature, at a

higher set point Set point is reset by endogenous pyrogens

(IL-1, IL-6, TNF-a, TNF-b, and IFNg) Endogenous Pyrogens stimulate organum

vsculosum laminae terminalis (OVLT) surrounding the preoptic nucleus, anterior hypothalamus and septum palusolum

Triggered OVLT synthesis of PG (PGE2) preoptic nucleus fever

Sooo… endogenous pyrogens PG fever

FEVER: PATHOGENESIS Fever Active generation of heat &

retaining heat Blood temperature in brain must match

the set point Vasoconstriction reduces heat loss Shivering produce heat from muscle

movements When the fever stops hypothalamic

setting is set lower vasodilation, sweating

FEVER: IMMUNE RESPONSE Fever improves specific and non-specific

immune responses Non-specific; incr. phagocytic

recruitment, phagocytic capacity and elimination of pathogen (provides a bad condition for pathogens)

Specific; incr. T-cell proliferation, cytokine expression, cytotoxic function and antibody secretion

FEVER: IMMUNE RESPONSE Heat Shock Response:

Allows cells to remain thormotolerantProduces Heat Shock Proteins

HSP cell repair post-stress, regulates steroid receptors, reduces levels of cytokines in blood, reduces further stress

FEVER: MANIFESTATIONS Intermittent: exaggerated circadian

rhythm includes period of normal temperature. Wide fluctuations maybe termed septic or hectic fever

Sustained: persistent and does not vary by more than 0.5C/day

Remittent: persistent and varies by more than 0.5C/day

Relapsing: febrile periods separated by intervals of normal temperature

FEVER: MANIFESTATIONS Tertian fever: occurs on 1st and 3rd days

(P. vivax) Quartan fever: occurs on 1st and 4th days

(P. malariae) Biphasic: camelback pattern (same

illness, 2 distict periods; Poliomyelitis) Periodic: fever syndromes with regular

periodicity & recurrent fever not necessarily periodic

FEVER: TREATMENT Antipyretic; indicated in high-risk

patients (cardiopulmonary disease, metabolic disorders, neurologic disease with risk of febrile seizure)

Fever> 41C (hyperpyrexia) sever infection, hypothalamic disorders, CNS hemorrhage always given antipyretics

Acetaminophen, aspirin, ibuprofen inhibit hypothalamic cyclo-oxygenase no PGE2

FEVER OF UNCERTAIN SOURCE Acute febrile Illness, etiology unknown

after hhistory and physical examination Sick/toxic child suspect severe

bacterial infection Sometimes focal infections do not

explain severity of condition/fever laboratory diagnoses

DENGUE Dengue Fever is Sudden high fever

accompanied by: Headache Retroorbital pain Musculoskeletal pain Skin rash Manifestations of bleeding Leukopenia Positive IgG/IgM

DHF is accompanied by signs of plasma leakage, hemocentration, pleural effusion, ascites, hypoproteinemia

DENGUE: MANIFESTATIONS Febrile phase:

Dehydration, febrile seizures Critical Phase:

Shock, plasma leakage, severe hemorrhage, organ impairment

Recovery PhaseHypervolemia (too much IV fluids?)

DENGUE: LABORATORY CHANGES Dengue fever;

pancytopenia may occur after the 3–4 days of illness. Neutropenia may persist or reappear during the latter stage of the disease and may continue into convalescence with white blood cell counts of <2,000/mm3.

Platelets rarely fall below 100,000/mm3. Venous clotting, bleeding and prothrombin times, and

plasma fibrinogen values are within normal ranges. The tourniquet test result may be positive. Mild acidosis, hemoconcentration, increased

transaminase values, and hypoproteinemia may occur during some primary dengue virus infections.

The electrocardiogram may show sinus bradycardia, ectopic ventricular foci, flattened T waves, and prolongation of the P-R interval.

DENGUE: LABORATORY CHANGES DHF & DSS Hemoconcentration: increase >20% in

hematocrit Thrombocytopenia Prolonged bleeding time Moderate incr tansaminase levels,

consumption of complements, hypoalbuminemia

Pleural effusions

DENGUE: TREATMENT Group A – patients who may be sent home adequateoral fluids, urinate/6 hours, no warning

signs, must be reviewed daily for disease progression (decreasing white blood cell count, defervescence and warning signs) until they are out of the critical period. Oral intake of ORS, juices, etc [Caution: fluids

containing sugar/glucose may exacerbate hyperglycaemia of physiological stress from dengue and diabetes mellitus.

Paracetamol for high fever if the patient is uncomfortable.

Hospitalize if: no clinical improvement, severe abdominal pain, persistent vomiting, cold and clammy extremities, lethargy or irritability/restlessness, bleeding , not passing urine for more than 4–6 hours.

DENGUE: TREATMENT Group B – patients who should be

referred for in-hospital management critical phase; patients with warning

signs, with co-existing conditions complicating management Serial CBC Give only isotonic solutions such as 0.9%

saline, Ringer’s lactate, or Hartmann’s solution. Start with 5–7 ml/ kg/hour for 1–2 hours, then reduce to 3–5 ml/kg/hr for 2–4 hours, and then reduce to 2–3 ml/kg/hr or less according to the clinical response

DENGUE: TREATMENT Group B

Reassess the clinical status and repeat the haematocrit. If the haematocrit remains the same or rises only minimally, 2–3 ml/kg/hr) for another 2–4 hours.

If the vital signs are worsening and haematocrit is rising rapidly, 5–10 ml/kg/hour for 1–2 hours.

Minimum IV fluid to maintain good perfusion and urine output of about 0.5 ml/kg/hr.

Encourgae oral fluids

DENGUE: TREATMENT Group C – patients who require

emergency treatment and urgent referral when they have severe dengue

There should be continued replacement of further plasma losses to maintain effective circulation for 24–48 hours. Blood transfusion should be given only in cases with suspected/severe bleeding.

If resuscitation needed 10-20ml/kg for limited period under close observation

Goal: Improve central and peripheral circulation, achieve stable consciousness

DENGUE: TREATMENT Discharge Criteria

No fever for 48 hours Improvement in clinical stats (general well

being, good appetite, stable haemodynamic, urine output, no respiratory distress)

Increasing trend of platelet countStable hematocrit w/o IV fluids

COMPLICATIONS & PROGNOSIS DF; self-limiting and benign (usually) Febrile convulsions, epistaxis, GI

bleeding

Death occurs in 40-50% pts with shock Survival related to early and proper care

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