1. D NGUE WORKSHOP 2015 ID HSB 2015

2. OPD – CASE 3 ID HSB 2015

3. History 26 years old Chinese lady G2P1 at 34 weeks POA Headache for 3 days – Throbbing – Fronto-parietal area Fever for 3 days with myalgia ID HSB 2015

4. Examination Afebrile ( taken PCM) BP 120/80 mmHg, PR 90/min Weight 79kg, IBW 64kg Abdomen – soft, non tender – Uterus : 34 weeks Examination of CVS/Lungs/CNS – normal ID HSB 2015

5. Would you admit this patient? Possible diagnosis : Pre-eclampsia Subarachnoid hemorrhage Dengue fever/ Viral fever Tension headache ID HSB 2015 Alas ! FBC was not done !

6. Probable dengue Live in/travel to dengue endemic area. Fever and 2 of the following criteria: Nausea, vomiting Rash Myalgia or arthralgia Thrombocytopenia Leucopenia Any warning signs ID HSB 2015 WHO 2009

7. Fever + Myalgia+Headache Must rule out Dengue Fever ID HSB 2015

8. Since patient was afebrile, she was discharged home with T. PCM The next day, she came to ED again, Complaining of worsening of headache and vomited x 3 times BP: 120/70mmHg, PR 100/min, good pulse volume SPO2 100% on RA Pink, not jaundice, afebrile GCS 15/15 but in pain( headache), no neck stiffness Lung Clear PA :no tenderness ID HSB 2015

9. What is your diagnosis ? FBC WBC : 4.,Hb 12.2, HCT 36.3, Platelet 29 Dengue rapid test kit : not available ! G2P1, at POA 36/52 Dengue fever, day 4 of illness In defervescence phase With warning signs ( vomiting) ID HSB 2015

10. What would you do next ? Inform FMS immediately Transfer patient to Emergency room for close monitoring Hourly BP/PR monitoring Observe GCS Start IV drip Refer patient to the nearest hospital ID HSB 2015

12. Are you worried about “headache and vomiting” ? 1.Symptoms of Dengue fever 2.Need TRO meningitis / encephalitis 3.TRO pre-ecclampsia, BUT BP : not high 4.Intracranial bleeding secondary to thrombocytopenia ID HSB 2015

13. Atypical presentations of Dengue Diarrhoea Myocarditis Encephalitis Myositis Hepatitis Acute abdomen Severe bleeding without plasma leakage Haemophagocytic syndrome ID HSB 2015

14. Dengue with warning signs Contacted Physician and ED Physician Oncall Hospital AA, accepted the case Ambulance not available at that point in time! Observe patient at Emergency room Start fluid regime : Dengue with warning signs Observe “headache” and GCS Hourly BP/PR ID HSB 2015

15. How much fluid to give? Fluid management in dengue with warning signs – Obtain baseline HCt – IVD 5-7mls/kg/hr for 1 to 2 hours, then – Reduce to 3-5mls/kg/hr for 2 to 4 hours, and then – Reduce to 2-3mls/kg/hr or less according to clinical response If clinical parameters worsened, and Hct is rising, increase the infusion rate ID HSB 2015

16. Investigations D4 9am D4 11am D5 1pm Hb12.512.213.2 Hct36.236.339.7 Wbc4.03.63.2 platelet522925 BP PR 120/80 90, good volume 124/80 88, good volume 130/84 94, good volume Any other information ? Antenatal booking : Baseline platelet 245,000 Baseline Hct : not stated D4 ID HSB 2015

17. What is your diagnosis at this juncture ? G2P1 at POA 27/52 Day 4 illness( D1 defervescence), with warning signs ( HCT, Platelet ) hemodynamically stable ID HSB 2015

18. What are the warning signs Listen : Mucosal bleed ( 4 symptoms) Abd pain Persistent vomiting Restless/lethargy Examine : Tender enlarged liver ( 2 signs) Third space loss Lab : ( 1 lab) increase in HCT accompanied by rapid decrease in Platelet count ID HSB 2015

19. Drip regime ? Dengue with warning signs hemodynamically stable Drip regime : should be 5/3/2 ID HSB 2015

20. What would you do? 1.Fluid resuscitation : 5ml/kg x 2 hours ( 5/3/2 regime) 2.Monitor vital signs hourly 3.Monitor urine output She was transferred to Hospital AA at 1.30PM, accompanied by a doctor and a nurse Continue IVD and BP/PR monitoring in ambulance Bring alone dengue clerking sheet and vital signs chart ID HSB 2015

23. What actually happened She was only started on IVD 3 pint 24 hours ( not based on body weight) throughout the journey to Hospital AA. BP/PR monitored in ambulance but not documented ID HSB 2015

24. Arrived at Hospital AA, 2.30pm D4 1pm D4 2.45pm Hb12.213.2 Hct36.339.7 Wbc3.63.2 platelet2925 BP PR 120/80 90 Vitals stable No vomiting, no abd pain Headache : reduced Lung : clear IVD reduced to 1x maintenance =104ml/H IVD 3 pints 24 hours ID HSB 2015 104ml/H

25. Admitted to Dengue ward at 4.30pm At 5pm HCT : 42.4% BP/PR stable Mild headache, no vomiting Lungs : clear ID HSB 2015 D4 1pm D4 2.45pm D5 5pm Hb12.213.214.4 Hct36.339.742.4 Wbc3.63.24.3 platelet292523 BP PR 120/80 90 110/80 90

26. What would you do ? Hct is in an upward trend, indicates ongoing plasma leakage ( with warning signs) IBW 64kg, 1x maintenance = 104ml/H Would you give bolus of fluid (10-20ml/kg/H) to bring down the HCT quickly ? NO ! ID HSB 2015

27. Rising HCT with warning signs, stable BP: Correct the rising HCT by increasing the maintenance drip ( 5/3/2 Regime) Fluid resuscitation : When patient is in shock / impending shock 10ml/kg  compensated Shock 20ml/kg  decompensated Shock Overzealous fluid resuscitation  promote 3 rd space loss  Pleural effusion  fluid overload ID HSB 2015

28. Fluid regime for patient with warning signs Fluid regime : Should be 5/3/2 regime Reassess patient at the end of each fluid regime, ect at second hours of 5ml/kg/H Increase fluid infusion rate if HCT is rising or patient is hemodynamically not stable ID HSB 2015

29. D5 of illness, day 2 critical phase D4 5pmD5 12amD5 6am Hb13.214.415.0 Hct39.742.443.8 Wbc3.24.36.7 platelet252314 Day 2 desfervescence, with warning signs ( epigastric pain), VS stable She complained of epigastric pain since 3 am BP 110/70 PR 80 good volume CRT<2s PA : Tender epigastric region Lung : Bilateral pleural effusion ID HSB 2015

30. Management – D5 Day 5, day 2 desfervescence : 1pm Patient became tachypnoeic Lung : Worsening pleural effusion Refer for ICU admission, reasons : – On-going leakage, need more fluid but this will tip the balance and plunge the patient into respiratory failure – VBG : HCO3 19.5 GSH sent ID HSB 2015

31. Fluid regime ? Dilemma : Respiratory failure secondary to Pleural effusion, Patient may become more tachypnoeic with rapid fluid resuscitation ID HSB 2015

32. Pleural effusion ID HSB 2015

33. Patient was transferred to ICU eventually Dengue IgM D5 – equivocal Dengue IgM D7 – positive She was discharged on D11 of of illness FBC upon discharge (D11) – Hb 10.4, Hct 30.1 – Wbc 7.1 – Plat 79 To review FBC in 1 weeks at clinic ID HSB 2015

34. Dengue serology test Dengue IgM is usually positive after day 5-7 of illness. Therefore a negative IgM taken before day 5-7 of illness does not exclude dengue infection. If dengue IgM is negative before day 7, a repeat sample must be taken in recovery phase. ID HSB 2015

35. Practical issues in management of dengue during pregnancy Physiological changes in pregnancy complicate diagnosis and assessment of plasma leakage Elevation of Hct in dengue is masked by the hemodilution of pregnancy – Look for evidence of plasma leakage Haemodynamic instability Third space fluid accumulation (difficult to recognise) – Serial Hct is more useful than a single value Hct is lowest in the 3 rd trimester. Baseline blood pressure may be lower. Heart rate may be higher. Pulse pressure wider. ID HSB 2015

36. Hematologic changes at term: Blood volume increased by 45%. RBC volume increased by 15%. Hct falls  blood viscosity falls Pregnant woman may tolerate hemorrhage better than non-pregnant woman, before demonstrating a fall in blood pressure. ID HSB 2014

37. Take Home Message Admit all pregnant mothers with possible dengue regardless of the stage of infection. Careful in interpreting hematocrit in pregnancy Baseline Hct will be helpful if available The period of plasma leakage may be more prolonged especially if complicated by intrauterine LSCS or delivery during plasma leakage phase if possible. ID HSB 2015

38. Blood/blood products must be on standby if delivery can not be avoided. Baby needs to be observed for possible congenital dengue. ID HSB 2015 Take home message

39. If a dengue patient presented with headache and vomiting, must watch out for encephalitis Close monitoring and adequate fluid resuscitation is the key to successful outcome ID HSB 2015

40. THANK YOU ID HSB 2015