Fig. 58.1
Petechial rash (Courtesy of Dr. Jorge Hidalgo, from Karl Heusner Memorial Hospital Belize)
Question
What approach should guide this patient diagnosis?
Answer
The abrupt onset of fever with myalgias and arthralgias and rash is suggestive of a viral process.
In this case the epidemiological background, clinical symptoms, leucopenia and thrombocytopenia suggests a possible Arbovirus infection called Chikungunya, Hemorrhagic Fever Viral infections, Leptospirosis, Rickettsiosis, Yellow fever, or possibly Malaria.
The patient was initially managed with IV crystalloid administration, and having only a modest improvement in blood pressured was transferred to an isolation area in the intensive care unit. Cultures and serological test were drawn. ELISA IgM test for Chikungunya infection was reported as negative, ELISA test for Yellow fever was sent and pending, while an ELISA IgM test for Dengue was reported as positive. A Chest x ray demonstrated mild bilateral pleural effusions, and an abdominal ultrasound showed the presence of a small amount of intraabdominal fluid. Observation in the ICU continued with the monitoring of vital signs and levels of platelets along with the administration of intravenous fluid for the next 4 days. The patient improved symptomatically, the petechial rash vanished and the gum bleeding stopped. Bedside ultrasound confirmed disappearance of pleural and intra-abdominal fluid. Results for Yellow fever test were reported as negative and the patient was transferred out of ICU to the general medical ward the following day.
Principles of Management
Dengue is one of the most rapidly spreading mosquito borne viral diseases in the world. An estimated 50-million dengue infections occur annually in the world. Dengue is endemic in at least 100 Countries in Asia, the Pacific, the Americas, Africa and the Caribbean. This tropical disease is caused by the dengue virus, a single stranded, positive sense RNA virus, which has four different serotypes (DEN-1–4) that belong to genus Flavivirus, family Flaviviridae. Infection with one serotype does not protect against the others, and reinfection with a different serotype puts the patient at risk of severe disease. The disease is transmitted by the bite of infected mosquitoes of the genus Aedes, mostly A aegypti and A albopictus. Symptoms usually begin 4–7 days after the mosquito bite and last between 3 and 10 days [1–4].
According to WHO Dengue is classified as follows: Dengue Fever (DF), Dengue hemorrhagic fever (DHF) and Dengue Shock Syndrome (DSS).
Classification of Dengue (WHO)
Dengue Fever: Acute illness that manifests itself with fever and two or more of the following: retroorbital or ocular pain, headache, rash, myalgia, arthralgia, leucopenia or hemorrhagic manifestations (gum bleeding, epistaxis, blood in urine, vomitus or stool or vaginal bleeding).
Dengue Hemorrhagic Fever (DHF): Fever lasting 2–7 days with hemorrhagic manifestations, thrombocytopenia, evidence of plasma leakage, abnormal hematocrit (increased in >20 % above average for age), pleural effusion, ascites.Related posts:
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