A Case of N.E. 16 y.o Male cc: fever x 3 days

History of Present Illness (-) epistaxis (-) gum & aural bleeding (-) hematemesis (-) hematuria (-) hematochezia (-) melena (-) petechiae/ ecchymoses/ rash Px has a neighbor diagnosed with Dengue 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized weakness (+) myalgia (+) sore throat (+) cough with productive sputum (whitish)

History of Present Illness (-) calf pain (-) abdominal pains (-) jaundice (+) good urine output (-) hx of wading through the floodwaters 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized weakness (+) myalgia (+) sore throat (+) cough with productive sputum (whitish)

History of Present Illness Medications taken: Paracetamol 500mg/tab every 4 hours for fever with minimal relief 3 days PTC: (+) fever with chills (Tmax 39.5ºC) (+) headache (+) generalized weakness (+) myalgia (+) sore throat (+) cough with productive sputum (whitish)

Review of Systems (-) dizziness (-) difficulty of breathing (-) chest pains (-) palpitations (-) weight loss >20% (-) decrease in appetite

Past Medical History (-) hypertension, diabetes, liver, lung and kidney disease (-) asthma, allergies to food and drugs (-) previous hospitalizations and surgeries

Birth and Maternal History Pt was born FT at Fabella hospital by an OB-Gyne via SVD to a then G1P0 mother. (-) maternal illness, exposure to chemicals, radiation (-) exposure to measles and varicella infection

Immunization History completed the EPI c/o LHC (+) MMR c/o private pediatrician

Nutritional History Px was fed with both breastmilk and formula since birth. The patient’s current diet consists of rice, meat, fish, poultry, with minimal fruits and vegetables

Personal and Social History H - good rel’p with parents & siblings E - 2nd year HS, satisfactory performance, (-) failing grades A - basketball, computer games D - no use of illicit drugs S - has groups of friends in school and neighborhood S - not sexually active S - no suicidal thoughts

Personal and Social History Non-smoker, occasional alcoholic beverage intake Px lives with his mother and 2 other siblings at home in Pasay City Mother is the breadwinner of the family and works in a factory Px’s family gets monthly stipend from relatives who work abroad

Genogram HPN CVD Asthma PTB 9 7 16 32 30 27 24

Physical Examination BP 90/60 HR 120s RR 20 T 38.6 Px is awake, coherent, oriented, weak-looking Pinkish conjunctivae, anicteric sclerae, (+) pharyngeal injection, (-) cervical lymphadenopathies, (-) anterior neck masses, (-) nasoaural bleeding, (-) gum bleeidng Equal chest expansion, clear breath sounds, (-) wheezes, (-) crackles, (-) retractions Adynamic precordium, distinct heart sounds, tachycardic, regular rhythm, no murmurs Soft and flat abdomen, normoactive bowel sounds, (-) masses/ tenderness, liver and spleen nonpalpable Full and equal pulses, pinkish nailbeds, (-) cyanosos, (-) clubbing, (-) edema, (-) rash, (-) petechiae/ ecchymoses, (-) calf tenderness, (+) flushed skin

Tourniquet Test negative (<20 spots in 1 square inch)

Assessment R/O Dengue Fever/ Dengue Hemorrhagic Fever

Plan For CBC with platelet count Paracetamol 500mg/tab 1 tab every 4 hours for fever Tepid sponge bath Supportive therapy Increase oral fluid intake Avoid dark colored foods WOF bleeding episodes

Questions Questions….. What if the CBC was normal? It has only been a 3 day Hx of fever.. A negative tourniquet test doesn’t necessarily r/o DF/DHF.. What now? Its too early to say.. What can we do at this point? Is watchful waiting enough to prevent the complications of DF/DHF? Recent dengue cases are noted to be more virulent than the past (cross-immunities etc)

DF/DHF Epidemiology 10,383 cases of DF/DHF noted by Nat’l Epidemiological Center of DOH (Jan-June 20) 104 deaths (case fatality of 1%) Most cases were at NCR, Region 4A, 5,6 Most deaths are caused by complications secondary to DHF and DSS Most are diagnosed LATE

Bio-Rad Dengue NS1 Antigen Test New offer at PGH Central Lab!! Used in private hospitals since 2007 serum available in minutes May detect 4 dengue serotypes in the first 5 days of viremia (febrile phase)

Diagnostic Dilemma P - pediatric patients with clinical signs of Dengue Fever, in the first 3 days of fever I - Dengue NS1Antigen test C - virus isolation test O - sensitivity and specificity in diagnosis of Dengue Fever M - cross sectional study

Clinical Question (Diagnostics) What is the sensitivity and specificity of Dengue NS1Antigen test versus a viral isolation test in the diagnosis of DF/DHF in pediatric patients with clinical signs of DF in the first 3 days of viremia in a cross sectional study?

Therapeutic Dilemma P - Pediatric patients with clinical signs of systemic viral infection (SVI) I - Immunologicals C - placebo O - shortening the course of the disease M - RCTs

Clinical Question (Therapeutics) In pediatric patients with clinical signs of systemic viral infection, is there a significant difference in giving immunologicals versus placebo in shortening the course of fever seen in randomized controlled trials?