1. CASE PRESENTATION - 4

2. Day 3 onset of fever, 0730am C/O: Fever-3 days Nausea and vomiting Myalgia. O/E Comfortable Pulse 98/min BP= 98/60mmHg T=37.5 Lungs -clear 26/M/F, university student, staying at Gombak Came back to Kelantan on D2 of fever S/B MA at A&E, DH

3. Given IV fluid 1pint N/S fast. Repeat BP 102/60 Plan: FBC Allow discharged (before review of FBC)

4. Q1: What is the pitfall in the management ?

5. District Hospital Day 5 (1430, 31 hours defervecence) (Referral letter) Admitted yesterday. C/O: fever for 4 days, vomiting and abdominal pain headache and fainting episodes No bleeding No diarrhoea 2 siblings also had fever. Still at home.

6. Cont……. Admitted for 24 hours. BP =80-90/50-60mmHg, HR=105/min Leptospirosis TRO dengue IV fluid 1pint N/S bolus followed by 5 pint N/S over 24 hours IV C Penicillin 2.0 mega 6hourly Referred for persistent thrombocytopenia IX17302200 WCC8.38.9 Hb13.214.1 Hct38.442.0 Platelet75 Urea12.0 Lactate11.2 INR1.8 APTT112 IX (Day 5)08301200 WCC7.87.1 Hb14.516.6 Hct44.050.0 Platelet5613 Urea9.0 Lactate INR APTT

7. Q2: Comment on the referral letter?

8. Q3: Comment on diagnosis Q4: How would you manage? Q5: What other investigations would you request?

9. GH: Day 5 (1630,33 hours defervecence) Has PV bleed. 4 pads soaked today Examination: Obese wt 79kg Alert but restless Afebrile BP 80/60 PR 98/min RR 22/min SPO2:98% on O2 nasal prong Generalized macular rash Lungs: clear Abdomen: soft, mild tenderness Hess test: POSITIVE

10. Assessment : DSS Fluid resuscitation: 10ml/kg bolus given for 2 cycles (1L N/S then 1L voluven). Continued with 1.5 IV fluid maintenance. ABG: PO2 105 PCO2 25 HCO3 15mmol/l

11. Day 5 (22.00, 37 hours defervesence) More restless. BP 146/110mmHg Pulse 105/min RR 25/min. SpO2 95% on HFL Lungs: Rhonchi. Bilateral pleural effusion Abdomen: Distended and tender. Ascites present Left ankle- bruises

12. Day 5 (22.30) Chest X ray: Bilateral pleural effusion and collapsed consolidation of left lower lobe ABG: PO2 130 PCO2 21 HCO3 13mmol/l GXM -3 pint packed cell 6hourly FBC/BUSE Blood C&S Echocardiogram: good LV function EF 68% IX17302200 WCC8.38.9 Hb13.214.1 Hct38.442.0 Platelet75 Urea12.0 Lactate11.2 INR1.8 APTT112 IX17302140 WCC8.38.9 Hb13.214.1 Hct38.442.0 Platelet75 Urea12.0 Lactate11.2 INR1.8 APTT112

13. Q6: Discuss on hemodynamic status of this patient? Q7: Would you transfuse blood and blood products?

14. Day 5 (23.30) BP 82/60 Pulse 112/min RR 30/min Treatment: IVD 2 pints NS/2H (6ml/kg /hour) 2 pints packed cell transfused Refferred to anesthetist: NO BED IN ICU Q7: How would you manage the patient?

15. Day 6 (0230) More restless and tachypnoeic Ventilated in HDW Urine output: 20ml/hour Assessment: DSS with ARF and acute liver failure (transaminitis and coagulopathy) IX17302200 WCC8.38.9 Hb13.214.1 Hct38.442.0 Platelet75 Urea12.0 Lactate11.2 INR1.8 APTT112 IX1730 D5 2140 D5 0100 D6 WCC8.38.917.8 Hb13.214.113.0 Hct38.442.041 Platelet757 Urea12.013 Creatini300 Lactate11.2 INR1.8 APTT112 AST1213 ALT2303

16. Day 6 (0900) Transferred to ICU Noted blood clots from the ETT and RT-coffee ground aspirate Bleeding from nasal and oral cavity and from the puncture sites BP=105/55 HR 98/min. Urine output (20ml/h) ABG: pH 7.096 pCO2 18.4 pO2 192.9 HCO3 5.5 BE - 24.2 IX17302200 WCC8.38.9 Hb13.214.1 Hct38.442.0 Platelet75 Urea12.0 Lactate11.2 INR1.8 APTT112 IX2140 D5 01000600 D6 WCC8.917.822.8 Hb14.113.010.0 Hct42.041.028 Platelet577 Urea1323 Creatini300480 Lactate11.211.3 INR APTT AST1213 ALT2303

17. CVVHDF commenced Blood transfusion: 4 pints PC, 4u platelet, 4u FFP Fluid therapy reduced to 500ml/24 hours Referred to gastro team

18. Day 7 (0230) Assessment: DSS with ARF and acute liver failure (transaminitis and coagulopathy) IX17302200 WCC8.38.9 Hb13.214.1 Hct38.442.0 Platelet75 Urea12.0 Lactate11.2 INR1.8 APTT112 IX1100 D6 1500 D6 2200 D6 WCC18.318.917.8 Hb12.012.111.0 Hct34.442.033.1 Platelet272527 Urea8.07.86.5 Creatinine120 Lactate4.0 INR1.6 APTT71 AST1713 ALT1203

19. Q9: Did you agree with the gastro referral? Q10: Why did you think the patient deteriorated despite stable BP?

20. Day 8(Recovery phase:1000) BP:100/50mmHg on NA infusion. T 35C HR 102/min. Temp=36C. Ventilated. Anuric. CXR: worsening pleural effusion, ARDS features ABG: Ph 6.9, PCO2 58 P02 90 HC02 9 WCC 3.84 Hb 12.2 HCT 36.2 Platelet 16 Hematologist: 2 cycles DIVC regimes and IV tranxanemic acid.

21. Day 8(1800) General condition deteriorating further: BP lowish despite 4 max intropes Bleeding from oral and nasal cavity, ETT Generalized oedema, peripheral cyanosis Pupils fixed and dilated Confirm death at 2025h Cause of death: DENGUE SHOCK SYNDROME

22. Day 9 (0930) Dengue IgM: (D5) borderline Blood C&S: D5: No growth D7:Kleb Pneum Urine C&S: D7 Kleb Pneum TA C&S: Kleb Pneum IX17302200 WCC8.38.9 Hb13.214.1 Hct38.442.0 Platelet75 Urea12.0 Lactate11.2 INR1.8 APTT112 IX D8060010001600 WCC5.213.844.1 Hb11.612.19.0 Hct34.436.027.1 Platelet251527 Urea6.06.86.5 Creatini90 Lactate3.7 INR1.61.8 APTT7160 AST1868 ALT833

23. Q9: Can you comment on borderline Dengue IgM serology?

24. FINAL CAUSE OF DEATH DENGUE SHOCK SYNDROME WITH SEPTICAEMIA