Management
of
dengue
hemorrhagic
fever
in
a
secondary
level
hospital
in
Bangladesh:
A
case
report
Yasmin
Jahan
a,*,
Atiqur
Rahman
ba
GraduateSchoolofBiomedical&HealthSciences,HiroshimaUniversity,Japan
b
DivisionAgeingandSocialChange(ASC),ISV,LinköpingUniversity,Sweden
ARTICLE INFO Articlehistory: Received8June2020
Receivedinrevisedform18June2020 Accepted18June2020
Keywords:
Denguehemorrhagicfever Management
Secondaryhospital Bangladesh
ABSTRACT
Dengueisanimportanttropicalinfectioncausedbyanarbovirus.Asamosquitoborneinfection,this diseaseiswidelyspreadinseveraltropicalendemiccountriesandthisimpliestheglobalimportanceof this infection. In this specific case report, the author discussedthe case management of dengue hemorrhagicfever(DHF).A42-year-oldpatientcametoasecondarylevelhospitalwithcomplaintsof diffuseabdominalpain(moreincentralregion)continuallyfor3days.Basedonhisclinicalinvestigations thepatientwasdiagnosedbyDHFandmanagedwithintravenouslyadministeredfluidresuscitationas hehadahistoryofvomiting,closemonitoringofvitalstatus,andgaveconservativetreatment.Although, theplasmaleakagehadconcernedthedoctorsaboutdevelopingDSS.Butafterseeinghisbloodreport, whenthedoctorsfoundthatthepatient’splateletcountwasraisedgraduallyandnootherassociated signsthentheydecidedtogivehimdischargefromthehospital.Preventionandcontrolofdengueand DHF hasbecome more urgent and the available vaccine is still limited. Hence, effective disease prevention programs, education of themedical communityto ensure effective casemanagement, community-basedintegratedmosquitocontrolarenecessary.
©2020PublishedbyElsevierLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Dengue fever (DF) is a mosquito borne (family Flaviviridae, genus Flavivirus) disease of humans considered as a temporal worldwide public health concern [1]. The disease is now hyperendemicbothintropicalandsubtropicalregionscirculating all four serotypes (DENV-1 to DENV-4) [2]. Globally, almost 4 billionpeoplefromatleast128countriesareundertherisk[3]and estimated50milliondengueinfectionsareoccurringeachyear[4]. TheWorldHealthOrganizationdeclaredSouthAsiaasanendemic areaforthediseaseduetofavorabledisseminationenvironmentof Aedesaegypti,themaindenguevector[5].
Theclinicalspectrumofdenguediseasemanifestationsranges fromasymptomatic to symptomatic forms like dengue hemor-rhagicfever(DHF)anddengueshocksyndrome(DSS)[6]. Most commonlydeterminedsignsandsymptomsofDFincludeshigh fever,myalgia,arthralgia,severeheadache,retroorbitalpainand maculopapular rash. In exception, dengue patientsmight have nonspecific symptoms like nausea, vomiting, cough, dizziness,
diarrhea[7].Sometimes,itcanbeasymptomaticorself-limitingDF toseveredenguecharacterizedbyplasmaleakage(DHF),(grades1 and2)thatcanleadtoalife-threateningsyndrome(DSS),(grades3 and4)[5].Furthermore,subjectswhodevelopDHFaccompanied byDSShave3–5%higherchanceofdeath[8].Wepresentacase reportofapatientwithDHFattemptingtodiscloserelatedsigns, symptomsandtreatments.
Casereport
A42-year-oldpatientcametoasecondarylevelhospitalwith complaints of diffuse abdominal pain (more in central region) continuallyfor3days.Onadmissiontothemedicalward,hewas afebrile(37.4degreecentigrade),withapulserateof92beatsper minute anda bloodpressureof105/65mmHg.Hedidnothave history of fever at thetime of admission. On inspectionof his abdomen,reddishdiscolorationwasfound(Fig.1)and noother localizedcomplaintswerereportedexceptanabdominal tender-nessjustupperabdomenonpalpation.
Aftertakingapropernarrativehistory,thepatientletinform abouthis3dayscontinualfever.Firstdayitwashighgrade(39.5 degreecentigrade);andlowgrade(38.3degreecentigrade)inthe next two days. Initially, he had visited to a local primary care hospitalduetosymptomslikevomiting,losemotionanddiffuse
* Correspondingauthorat:GraduateSchoolofBiomedicalandHealthSciences, HiroshimaUniversity,Kasumi1-2-3Minami-ku,Hiroshima,734-8553,Japan.
E-mailaddress:d160207@hiroshima-u.ac.jp(Y.Jahan).
https://doi.org/10.1016/j.idcr.2020.e00880
2214-2509/©2020PublishedbyElsevierLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
IDCases21(2020)e00880
ContentslistsavailableatScienceDirect
IDCases
abdominalpain,therefore,beenadvisedtodosomeinvestigations. Resultsof the investigationswere as follows:platelets 32,000/ mm3; white blood cell count 3400/mm3 (neutrophils 40 %;
lymphocyte43%);hematocrit36%;hemoglobin11.6g/dl;blood picture– leukopenia,lymphocytosis,andthrombocytopenia.No abnormalities were shown in his ultrasonogram of whole abdomen.But hisphysical conditionwas deteriorating, and he hadbeenreferredtoasecondaryhospital.
Theon-dutydoctorofsecondaryhospitalprimarilypredicted the patient might have acute hemorrhagic pancreatitis due to tendernessonpancreaticregionregardlessofhispreviousreports. Basedonthissymptom,thedoctorhadstartedmanagementand advisedforroutinebloodinvestigationssoonerafterthe admis-sion.Resultsoftheinvestigationswereasfollows:whitebloodcell count9700/mm3(neutrophils54%,lymphocytes40%);hematocrit
42.9 %; hemoglobin 11.7g/dl, platelet 22,000/mm3; peripheral
bloodpicture–thrombocytopenia;antidengueIgMwaspositive (done on 4th day of fever-on admission day); random blood glucosewas 5.8mmol/l,alaninetransaminase39 IU/mL; serum creatinine 1.3mg/dl; serum electrolytes: serum sodium (Na) 126.4mmol/l;serumpotassium(K)4.29mmol/l;serumchloride (Cl)93.2mmol/l;serumamylase82IU/L(normalupto95);urinary amylase650IU/L(normalupto490);bloodgroupwasABpositive; ultra-sonogram of whole abdomen showed moderate ascites, prominent pancreas, mild to moderate pleural effusion (as an
abnormalchestfinding)andhisurinaryoutputwasnormal.There wasnohistoryofbleedingmanifestations.Astheplateletcounts werebelowinrespecttonormalrange,doctorsmadetheclinical diagnosis of dengue hemorrhagic fever. Due to a history of vomiting,thepatientwasmanagedwithintravenously adminis-teredfluidresuscitation,closemonitoringofvitalstatus,andgave conservative treatment. Besides, the plasma leakage was a concernedofthedoctorsindevelopingDSS.
Onnextday,thereportsofrepeatbloodinvestigationsadvised by thedoctors were: platelet 20,000/mm3; serum electrolytes:
serumsodium(Na)130.1mmol/l;serumpotassium(K)4.30mmol/ l;serumchloride(Cl)91.3mmol/l.Hewasadvisedtoarrangeblood donors (for fresh frozen plasma) since his platelet count was deteriorating gradually even though the vital signs were completelynormal.
Similarly,theplateletcountwasdoneagainateveningresulted around 50,000/mm3. He had no fever and stomach pain was
likewisedieddownsteadily.Doctorscompletedanultra-sonogram ofwholeabdomenanditdemonstratednonoteworthyvariations from the norm. At that point they proceeded with similar treatmentlikeplateletcountonceaday,forthefollowing2days. Whentheyfoundthepatient’splateletcountwasraisinggradually (70,000/mm3and 110,000/mm3)and nootherassociated signs,
theydecidedtogivehimdischargefromthehospital(Table1). Discussion
OnlyacountablenumberofcasereportsinrespecttoDHFhave beendocumentedinmedicalliterature.Pathophysiologyofsevere clinicalmanifestationobservedinDHFremainspoorlyunderstood, sinceacommonbeliefissecondaryinfectionputthesubjectsat great risk of DHF [8]. Besides, vasculopathy, deficiency and dysfunction of platelets and defects in the blood coagulation pathwaysaretheattributedfactors[9].
The clinicalcourseof DHFischaracterized bythree phases: Febrile,leakage,andconvalescentphase.Theinitialfebrileillness ismarkedbyamorbilliformrashandhemorrhagictendencies[10]. Thefeverpersistsfor2daysto1weekandthendropstonormalor subnormallevelswhenthepatienteitherconvalescesoradvances totheplasmaleakagephase.Highplasmaescapecasesaremarked byfrankshockwithlowpulsepressure,cyanosis,hepatomegaly, pleuralandpericardialeffusions,andascites.Hence,highclinical
Fig.1.Bandshapedskinrashontheabdomen.
Table1
Investigationsreportandvitalsignsrecordedfromadmissiontodischargeday.
Investigations Day0 Day1 Day2 Day3
Whitebloodcellcount 9700/mm3 – – –
Hematocrit 42.9% 47% – –
Hemoglobin 11.7g/dl – 12.1g/dl –
Platelet 22,000/mm3 Atmorning-20,000/mm3
Atnight-50,000/mm3
70,000/mm3 110,000/mm3
Randombloodglucose 5.8mmol/l 4.8mmol/l – –
Anti-dengueIgM Positive – – –
Serumelectrolytes Na-126.4mmol/l K-4.29mmol/l Cl-93.2mmol/l Na-130.1mmol/l K-4.30mmol/l Cl-91.3mmol/l – –
Serumamylase 82IU/L 76IU/L – –
Alaninetransaminase 39IU/mL – – –
Serumcreatinine 1.3mg/dl – – –
urinaryamylase 650IU/L 530IU/L Ultra-sonogramofwhole
abdomen
moderateascites,prominentpancreas,mildtomoderate pleuraleffusion(asanabnormalchestfinding)
– nonoteworthyvariation wasfound
– Urinaryoutput normal normal normal normal VitalSigns
Temperature 37.4degreecentigrade 37.1degreecentigrade 36.7degreecentigrade 37.0degreecentigrade Pulserate 92beats/minute 84beats/minute 80beats/minute 82beats/minute Bloodpressure 105/65mmHg 110/70mmHg 110/65
mmHg
112/73 mmHg 2 Y.Jahan,A.Rahman/IDCases21(2020)e00880
suspicionandclosemonitoringofpatientareimportantforearly diagnosisandmanagementofsuchcases.Managementisusually conservative.
DHFisfrequentlyseenduringasecondarydengueinfection.An interviewwiththepatientdidnotrevealthatapreviousdengue viralinfectionhadoccurred.Aroundthattime,thefeverbeginsto subside(usually3–7daysaftersymptomonset),thepatienthad developedwarning signsofseverediseaselikeabdominalpain, persistent vomiting, change in temperature (from fever to afebrile).In ourcase report,the patientwas closely monitored withacautionofdevelopinghemorrhagicmanifestations,or/and changesinmentalstatus(irritability,confusion,orobtundation). Conclusion
The factors associated with dengue transmission include demographic and societalchangeslike uncontrolledpopulation growth,unplannedurbanization,substandardhousing,crowding, anddeteriorationinwater,sewer,andwastemanagementsystems. Alongwiththese,lackofpublichealthawareness,andappropriate diseasehavecreatedidealconditionsforincreasedtransmissionof mosquito-borne diseases especially in tropical and subtropical developing countries like Bangladesh. Nonetheless, prevention andcontrolofdengueandDHFhasbecomemoreurgentwiththe expanding geographic distribution and increased disease inci-denceinthepastdecades.Thereisaneedforunderstandingthe changingepidemiologythroughcontinuousmonitoring,including extendingthesurveillanceareasandaddressingthechallengesto reducetheimpactofthediseaseonpublichealth.Itmaybevery challengingtorootupthediseasefromthesupplysidedepending oneconomicconditionofthecountry.Along-terminvestmentis neededtoachievebehavioralchangesintheurbanpopulationto jointhefightagainsttheAedesmosquitoes.
Byfar,onedenguevaccine(Dengvaxia),developedbySanofi Pasteur,hasbeenapprovedbytheWorldHealthOrganizationand licensed in 20 countries[11]. The vaccineis only available for peoplelivinginsomedengueendemiccountriesyettobeavailable commerciallyfortravelers.Currently,theCDCandIndianresearch organizationsarecollaborating[12],tocomeforwardtoinitiate and coordinate a large-scale randomized clinical trial of the dengue vaccine in Bangladesh. Further studies are needed to explore. Finally, this case report urges a need for up taking awarenessonpossibleoccurrenceofserioussecondarybacterial infectionsrelatedtodengueviralinfection,especiallyinpatients with prolonged fever (more than 5 days) and highlights the likelihoodofshockoccurringcommonlyinDHF.
Fundingsource Nofundingsources.
Ethicalapproval
Informedconsentwasobtainedfromthepatienttopublishthe case.
Authorsstatement
The authorshave statedthat theyhave addressedallissues mentionedinthereviewers'commentsverycarefullyandmade the necessary corrections accordingly in the text with track changes.YJwrotethefirstdraftofthemanuscriptandARcritically reviewed andrevisedthe manuscript.Alltheauthors read and approvedthefinalpaper.
DeclarationofCompetingInterest
The authors declare that they have no known competing financial interests or personal relationships that could have appearedtoinfluencetheworkreportedinthispaper.
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