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Prepared by...
Alanh Khounnasene, MD* Thanyawee Puthanakit, MD** |
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*Division of
Postgrad Studies and Research,
Faculty of Medical Sciences, National University of Laos |
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**Department of Pediatrics, Chiang
Mai University
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Case 1: A 13-year-old boy
with high grade fever
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Patient: A 13-year-old boy |
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| Address: Chiang Mai | |
| CC: Fever for 4 days |
| PI: | ||
| 4 days PTA: | he started to have high grade fever with chills, and headache | |
| 2 days PTA: | while his high grade fever
persisted he developed right upper quadrant pain, vomiting (2 times), no hematemesis anorexia. |
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| 1 day PTA: | because of his persistent
high grade fever he was taken to the community hospital. Vital sign: BT 38.5 C, BP 100/65 mmHg, PR 90/min PE: tenderness at right upper quadrant, liver just palpable, tourniquet test positive, CBC: Hb 14.9g/dl, Hct 48%, WBC 5,800/mm3 (Neu 49%, Lymp 39%), Platelet 82,000/ mm3. He was diagnosed as "dengue hemorrhagic fever". |
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| PH: | ||
| Underlying disease: asthma,
normal development, complete immunization He lives in Vieng Hang district, Chiang Mai, no history of traveling in the past month |
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| PE: | ||
| GA : | normal consciousness, well nourished, BW 42 kg (percentile 50th) | |
| V/S : | BT 39 C, BP 118/68 mmHg, PR 102/min, RR 24/min | |
| HEENT: | no pale conjunctiva, no
icteric sclera , pharynx not injected, no tonsil enlargement, cervical lymph nodes not palpable |
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| Heart: | normal S1 S2, no murmur | |
| Lung: | clear, no adventitious sound | |
| Abdomen: | liver just palpable, spleen not palpable, mild tenderness at right upper quadrant. | |
| Extremities: | no edema, no petechia
except at the left ante cubital area (TT+), capillary refill < 2 sec. |
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| Skin: | no eschar, no rash, normal skin turgor | |
| Initial Laboratory investigations: | ||
| CBC: | Hb 13.4g/dl, Hct 38%, WBC 3,900/mm3 (Neu 56%, Lymp 32%, Mono 10%, Eo 2%), Platelet 53,000/ mm3 | |
| UA: | RBC: 0-1, WBC: 1-2, PH: 6.5, Sp.gr: 1.015, Alb: +1, Sugar: +1, Epi:2-5cells/HPF | |
| What is your provisional diagnosis? | ||
| Dengue hemorrhagic fever grade I | ||
| Treatment: Supportive treatment; hydration and monitoring on dengue chart | ||
| Progression on day 2 of admission: | ||
| Patient still had high grade fever | ||
| VS: | BT 39.5 C , BP 100/60 mmHg, PR 120/min, RR 24/min | |
| CBC: | Hb 12.5g/dl, Hct 38%, WBC 4900/mm3 (Neu 59%, Lymp 27%, Mono 11%, Eo 3%), Platelet 67,000/ mm3 | |
| Rapid test for Dengue
IgG, IgM negative Peripheral blood smear showed as figure 1. |
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| Figure 1: Amoeboid form of Plasmodium vivax in enlarged red blood cell. | ||
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| Definite Diagnosis: | ||
| Malaria infection; Plasmodium vivax | ||
| Treatments: | ||
| 1. | Chloroquine 25 mg base/kg [Day1: 10 mg/kg/dose then 5 mg/kg/dose 6 hour later, Day 2 and 3: 5 mg/kg/dose] |
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| 2. | Primaquine 0.3 mg base/kg x 14 days | |
| Discussion 1: Diagnosis of P.vivax | |
| > | Malaria may be misdiagnosed as a number of other conditions, most importantly meningitis, typhoid fever and septicemia. Other differential diagnoses include haemorrhagic fevers, influenza, hepatitis, scrub typhus, or viral encephalitis. |
| > | Usually the manifestation of P. vivax infection is not typical signs; this case presented with high grade fever for 4 days, tourniquet test positive, hemoconcentration and thrombocytopenia. The clinical symptoms that against DHF are hematocrit decreased while the patient still had high grade fever and other abnormal clinical signs, and predominate polymorphonuclear cell. The blood smear for plasmodium species is necessary for the patient who has fever, especially in endemic areas. |
| > | The characteristics of 4 plasmodium species
responsible for human malaria are shown in table 1 |
| Table 1 The characteristics of 4 plasmodium species responsible for human malaria | |
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| Copy from: Barnett Ed. Malaria. In: Feigin RD, Cherry JD, Demmler GJ, Kaplan SL. Textbook of Pediatric Infectious Disease. 5th ed. Philadelphia: Suanders; 2004. p. 2717. | |
| Discussion 2: Treatment of P.vivax | |
| > | Chloroquine is the drug of choice for P.vivax infection in Thailand. |
| > | Primaquine is highly effective against the gametocytes of all plasmodia and thereby prevents spread of the disease to the mosquito from the patient. It is also effective against the dormant tissue forms (hypnozoite) of P. vivax and thereby offers radical cure and prevents relapses. Patients with deficiency of G6 PD may develop hemolytic anemia on taking usual doses of primaquine, therefore patients should be tested for G6 PD deficiency before administering primaquine. If patient has G6PD deficiency, the primaquine should be given 0.9 mg base/kg once a week for 8 weeks. |