A 3-year-old girl with dyspnea for 6 hours
Prepared by...
Virat Sirisanthana, M.D.
Department of Pediatrics, Chiang Mai University
 
A 26 month-old-girl was admitted at CMU hospital in Aug 2001.
Address: Ampur Muang, Chiang Mai
 

CC: dyspnea 6 hours prior to admission
PI: 6 days PTA she developed abrupt onset of high fever with poor feeding. The diagnosis "DHF" was made at another hospital and she was given supportive and symptomatic treatment. Six hours prior to admission she developed "impending shock", HCt was 49%, so dextran and haemacel were given at the rate about 8 cc/kg/hr for 6 hours (total volumn = 700 cc in 6 hours). Since the condition deteriorated she was transfered to CMU hospital. Her mother denied any bleeding symptom except for some petechia
at the skin.
 
Past History: was unremarkable
 

Significant PE: agitated, drowsy consciousness girl
BW 14 kg (75%tile for age), T. 37.5 C., HR 160/min, RR 70/min, BP 75/55 mmHg, not pale, no jaundice
Cheast: decreased BS on the right side
Abdomen: mild distention, liver 5cm. below RCM (liver span 14 cm), ascitic fluid +
Skin: petechia at the Lt. axillary region
PR: no melena
 
Summery of problems.
1. History of fever for 6 day
2. Impeding shock with narrow pulse pressure (BP 75/55)
3. Rt. pleural effusion
4.
 Hepatomegaly ( liver 5 cm. below RCM), with ascitic fluid
 

Initial laboratory investigations: on admission
CBC: Hct 47%, WBC 8,200/cbmm (N 58%, L 42%), platelet count 32,000/cbmm.
PBS: RBC normochromic normocytic
UA: sp. gr.1.035, no WBC, no RBC
CXR: Rt. pleural effusion

 
Course in the hospital:
For the first 48 hours of admission (D7-D8 of fever) his vital signs demonstrated "impending shock".
The NSS was given at the adjusted rate, started at 20 mm/kg/hr for the first haft hour, then slowly decreased to keep vital sign in the acceptable range. On the second day of admission (D8 of fever), although her vital signs were maintained, her Hct dropped abruptly (47%-45%-33%-25%). Oro-gastric tube suction obtained "coffee ground" secretion. Later on that day she also passed "melena" and became "pale". Whole blood and concentrated platelet were given. Since later on admission day, she had fever (38.7C) with pulmonary infiltration and pleural effusion, she was started on cefotaxime intravenously.
On the 3-7th day of admission (D9-D13 of fever), the fever persisted, her Rt. pleural effusion persisted
with pulse rate of 140-150/minher, the abdomen was more distended and liver was palpable 12 cm. below RCM (on admision, it was 5cm). Ultrasound of the liver show enlarged liver without focal mass. On the 7th day of admission (D13 of fever), cefotaxime was switched to meropenem and amikacin for "feared" of supperimposed bacterial infection. Less than 12 hours after the initiation of meropenem and amikacin,
after the result of the platelet count was known (45,000/cbmm), the pleural tap was done. There was no inflammatory cells in the fluid.
 
 

Course in the hospital (continued):
Although fever persisted, she gradually improved. Pleural fluid and ascitic fluid slowly decreased. On the 20th day of the disease there was no pleural fluid and there was only minimal ascitic fluid. Her CXR shows mild cardiomegaly, but she is not in respiratory distress. She urinated well and was discharged after she was afebrile for 5 days.
 
 
Day 7 of fever
Day 9 of fever
Day 12 of fever
 
Day 15 of fever
Day 20 of the disease
 
Others laboratory investigations:

CBC: WBC 9,700-4,000/cbmm, PMN 40-58%, atypical L was <10%
 
Serum electrolytes and glucase: WNL
Liver function tests: on day 8 of fever: AST 1042 (normal 3-35 U/L), ALT 428 (normal 7-33 U/L),
others: WNL.
ASL decreased to 575 368 and 136 U/L and ALT decreased to 258, 210, 190.
The highest total bilirubin was 1.01 mg/dl with the highest direct bilirubin 0.5 mg/dl.
H/C before starting cefotaxime : no growth
Repeated H/C before switching antibiotics: no growth
ESR (Day 13 of fever): 35 mm.(normal <20mm.)
CRP (Day 13 of fever): 3.5 (normal <6.0)
Pleural fluid: RBC 2507/cbmm, WBC 5/cbmm (all mono), protein: pleural fluid/serum = 3.1/5 = 0.62,
LDH: pleural fluid/serum = 732/1148 = 0.63. Gram stain : no organism seen. Culture : contaminated.
 
Dengue HI titer:
Day 8 of fever
Day 15 of fever
D1
D2
D3
D4
D1
D2
D3
D4
1:80
1:160
1:160
1:160
1:1280
1:1280
1:1280
1:>2560
 
Diagnosis : Dengue hemorrhagic fever with DSS
 
What did we learn from this case?
1.
In severe case of DHF/DSS, extravasation can be enormous........ leading to the delay of dissapearance of pleural effusion and ascitic fluid.
2.
Fever can persisted in severe case.
3.
In this case there was evidence of acute liver damage (marked hepatomegaly with serum ASL of
1042 IU/L).

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