The Summary of T. Mudwal Type III Hypersensitivity and

Its Application in Dengue Hemorrhagic Fever

  www.dhf-revolutionafankelijkheid.net

THE SUMMARY OF T.MUDWAL TYPE III HYPERSENSITIVITY

 

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plasma leakage

APPLICATION OF THE THEORY OF TYPE III HYPERSENSITIVITY T. MUDWAL

(The Ghostbuster Team)

APPLICATION OF THE THEORY OF TYPE III hypersensitivity T. MUDWAL

– the standards of dengue infection diagnosis
– Standard on Dengue infection therapy
– interesting cases:
I. Dengue infection with manifestations of repeated shock
II. Dengue infection with manifestations of acute myocardial infarction
III. Dengue infection with manifestations of cerebral disorder
IV. Dengue infection with manifestations of diarrhea
V. Dengue infection with dyspeptic syndrome manifestations
VI. Dengue infection with manifestations of multi-organ disorder, hemolytic anemia, severe MI-MS (cardiomegaly with severe dengue infection), and other interesting cases (following)

The standard in the diagnosis of dengue infection

2. When the tourniquet test (-), repeated tourniquet test every 8 hours for 2 days straight – participated in different hands. Or check again in the place where it had been donetourniquet test before and see wether it changes to positive or not.

3. If there is any laboratory abnormalities such as platelet count nearing 150,000 / mm3 (<170,000 mm3), a picture of pancytopenia, a significant decrease in platelets (> 50,000), lymphocyte differential count ≤ 20%, monocyte differential count ≤ 3%, Hb> 14 g% (In Indonesian <60 years), Ht> 42 (Indonesian <60 years), Hb> 15 g% and hematocrit> 45% (In Indonesia > 60 years), blue plasma lymphocyte (BPL)> 4%,, always ask the presence of fever even though patients present with the chief complaint not because of fever such as a sudden lightheadedness, decreased consciousness / stroke, severe dyspepsia syndrome, joint pain , sweat, sudden weakness, hematemesis melena, chest pain etc. If fever is not found, but laboratory abnormalities are present, even after repeated laboratory results, dengue infection is considered as the cause until proven otherwise.

4. Blue plasma Lymphocyte (BPL) will reach the highest value on the fourth day at the secondary dengue infection and the seventh day in primary dengue infection, and after that there is impairment of BPL. BPL that does not decrease in periodic examination, are not caused by Dengue virus infection.

5. WHO criteria of 2009 on how to diagnose dengue infection, is always used as a guideline.

Standard on Dengue infection therapy

When patients treated inpatient care

  1. Giving 125 mg methylprednisolone injection, accompanied by injection of proton pump inhibitors and anti-emetic injection should be given immediately if suspected dengue infection (Probable Dengue Infection) has been enforced. Even antibiotic injection can be given in cases – cases that are suspected co-infection with bacterial or in severe cases such as shock, hematemesis melena etc.
  2. Giving methylprednisolone injection can be increased according to clinical response and cost benefits. If the patient is admitted to hospital after 4 days of illness and clinical examination and laboratory re showing signs of improvement, delay the methylprednisolone (the patient has entered the recovery phase of dengue infection). If there is worsening of the symptoms such as sudden shortness of breath, the disturbance of consciousness, the decrease of platelets again, then the methylprednisolone injection can be given.
  3.  Contra- indication of methylprednisolone is only gastric ulcer which can clearly be proven by rectal toucher (positive melena), or a massive gastric bleeding in endoscopy foundings. On a mild gastric bleeding, methylprednisolone can still be given, because it benefits more than the losses. Concerns about the sudden occurrence of shock from kinin and the complement activation system is more precedence over the concerns of increased ulcers bleeding. Based on the experience of almost all patients who come with severe dyspepsia syndrome without melena caused by dengue infection, will increase in comfort after the administration of methylprednisolone injection, even though this patient was also given proton pump inhibitors and anti-emetic.
  4.  Check the blood pressure often as possible, because it was feared the occurrence of sudden hypovolemic shock.
  5. If the patient is not treated
    Give methylprednisolone tablets 1,5 mg / kg / day in divided doses 2-3 times.Give also proton pump inhibitors and anti-emesis.
  6. Whether the patient is treated inpatient or not, give methylprednisolone imunosupressif dose maximum of 7 days.

Interesting Cases:

I. Dengue infection and the repeated manifestation of shock

A Women (45 years) came to the emergency room at 02.00 PM, 24/02/11, with a chief complaint of fever  from last night (23/02/11). The fever is felt continuesly – never decreasing with drugs. History of prolonged fever, cold sweat denied. Nosebleeds, bleeding gums are denied. Nausea and vomiting (-). Diarrhea 2 times since last night without blood or mucus. Patient also denies joint pains, coughs, colds, sore throat, pain on urination.
Physical examination in the emergency room at 02.00 PM, 24/2/11
Blood Pressure: 110/70, pulse 102 x / min, respiration: 20 x / min,
Temp: 39.2 C. Rumple Leed is not done.
Other Physical examination: Within normal limits.
Laboratory: Hb 12.0, leukocytes: 10 300, Platelets:192 000, Erythrocytes: 3.9 million / mm 3, diff count: 0/0/1/93/5/2
Diagnosis is upheld in the ER: Observations one day fever
The therapy that is given in the ER: cefotaxim injection of 2 x 1 g, 2 x150 mg ranitidine injection, injection metamizol 3 x1 ampoules. Ringer lactate infusion of 500 cc / 8 hrs.

Visit 24/2/11 at 05.00 PM
Febrile one-day observation et causa Probable Dengue Infection?
Check Rumple Leed results +
re-checked laboratory-  Hb: 11.7, leukocytes: 10 200, platelets: 188,000, Ht: 33, erythrocytes: 3.2 jt / mm3, diff count: 0/0/1/94/4/1.
Diagnosis day one Probabale Dengue Infection
DD: Bacterial Infection
Therapy given:

Amoxycillin injection of 3 x 1 g, metamizole injection 3×1 ampoule, omeperazole injection of 1 x 40 mg, ondancentron injection 3 x 4 mg, Ringer’s lactate infusion 500 cc / 4 hours

Instructions:
Check the routine blood sample next 4 hours, when platelets <150.000/mm3, give 125 mg methylprednisolone injection (1 vial)
Check the blood pressure every 3 hours if the systolic <100 load Ringer lactate 500 cc, if the blood pressure does not rise, report to duty physician.
Results of monitoring blood pressure:

Time 02:00 AM, 25/2/11: BP: 80/60 loading RL 500cc ->BP 100/60
ECG: sinus tachycardia, HR: 120 x / min

At 06.00 AM, 25/2/11: blood pressure 80/palpable -> BP rose to 110/70 after loading 1000 cc RL.

Laboratory results 25/2/11:

Hb: 10.8 mg / dl, leukocyte count: 5300/mm3, Platelets: 160,000 / mm3, Erythrocytes: 3.4 million / mm3,
hematocrit: 30 gr%, Diff count 0/0/0/89/9/2

Sodium: 140 mg/dl, Potassium: 3.7 mg/dl, Chloride: 103 mg/dl, blood sugar: 97 mg/dl, Ureum: 18 mg/dl, creatinine: 0.67 mg/dl, AST: 17 U/I, SGPT: 5 U/I, total Bilirubin: 0.8 mg/dl.

Visit 25/2/11 05:00 PM

Patient asks to go home due to cost eventhough he was explained the danger that will happen. Before leaving the patient was given 500 cc RL because the blood pressure decreased 90/60  mm/Hg and rose to 110/70  mm/Hg, pulse 90 x/min, T: 37°C. The routine blood sample Hb: 10.9  mg/dl, Leukocytes: 7300 /mm3, Platelets: 158,000 /mm3, Erythrocytes: 3.6 jt million/ mm3, Hematrokrit: 30 gr%, Diff count: 0/0/0/89 / 6 / 5.

Therapy that given for outpatient care (Diagnosis: Severe Dengue)

Methylprednisolone 16 mg, 5 tablets -> 2-2 -1

For 5 days :
Omreprazol tablets 40 mg 1 x 1
Ondansentron 3 x 4 mg tablet

Discussion

This case shows that deaths due to dengue infection can occur very quickly (without having to be preceded thrombocytopenia /bleeding). Activation of the complement system of kinin and C3 A C5 A can cause severe vasodilation of blood vessels. This great vasodilatation sometimes cannot be overcome by giving crystalloid fluids, even colloid. Granting dopamine /dobutamine cannot give any effect at all. Therefore, in these patients, after diagnosis of probable dengue is upheld, we must dare to give immunosuppressive dose of methylprednisolone. Immunosuppressive methylprednisolone was not given at the time of visit 24/2/11 because there was uncertainty about the magnitude of the effects of kinin and the system was activated complement C3A and C5A. The existence of fever, a positive torniquete test, a low lymphocyte count and monocyte count, platelet counts that continues to fall, is sufficient proof, that the diagnosis in these patients are dengue virus infection, although Dengue Blot IgG, IgM and lymphocyte blue plasma have not been performed.

II. Dengue infection with manifestations of acute myocardial infarction

Mr. T (64 years), weight: 65 kg, height: 162 cm. Was consulted by the duty physician to physician in internal medicine (31/3/11 at 04.00 PM) because of cardiogenic shock (BP: 80/60, P: 88 x/min, RR: 24 x/min, T: 36°C). The Blood pressure rose after the loading Ringer lactate 300 cc to become 100/70. ECG: ST elevation V1 to V5.

thoracic photo:mild cardiomegali; negative pleural effusion, Rumple Leed: negative

laboratoruim: 31-3-11

Hb: 14.3, Leucocyte: 12 600 /mm3, E: 4.6 million /mm3, thrombocyte: 170.000 /mm3,
Ht: 41 g%. Diff count; 0/0/0/80/15/5.
CKMB: 121

In the history of patient’s illness it was found that 2 days earlier(29/3/11), the patient went to the emergency ward at 12.00 hours because pain in the right, left and back chest. But the pain was mainly felt on the back. Pain is felt continuously for 4 hours (since 8 am), there was a stabbing sensation which spread to the left arm. Pain was reduced when given a massage or with pain liniment. And the patient at date 29/3/11 complained of breathlessness.

But at the moment (31/3/11) breathless, chest pain and backpain reduced after taking the drug from the ER date 29/3/11. Patients come to the ER again because feeling numb, Nausea, vomiting -, cold sweat -, body heat -. The patient is a heavy smoker for more than 2 packs a day. In the last one week before admitted, patient is very busy. Hypertension history (+) 5 years, DM (-), hypercholesterolemia (+) 2 years.

Note physical examination 29/3/11 at 12:05 PM at emergency room by duty physician

BP: 150 / 90, Pulse: 80 / min, RR: 22 x / min, T: 37 C, ECG: in normal limit.
Laboratory:  Hb: 13.4 gr%, Leuc: 10 600/mm3, Platelets: 227 000/mm3, Ht: 42%, E: 4.7 million/ mm3. Total Chol.: 236 mg/dl, HDL: 33, LDL: 131 ; diff. count 0/0/0/45/51/4

Triglycerides: 238. SGOT/SGPT/total Bilirubin: 24/23/0, 4, albumin: 3.63,

Na: 142; K: 3.5; Cl: 104; Ca: 7.7; blood glucose: 167 mg%; CKMB : 13

The diagnose established at that time was (29/3/11)
Myalgia
Mild hypertension
hypercholesterolemia

Patients was discharged with a therapy
Ketorolac tablets: 3 x 30 mg, ranitidine tablets: 2 x 150 mg, ondancentrone tablets: 3 x 4 mg, amilodipin: 1 x 5 mg, aspirin: 2 x 80 mg.

Diagnosis date 31/3/11 (by Internist)
Acute anterior STEMI extensively caused by Dengue infection which is exacerbated by the presence of risk factors for hypertension, hypercholesterolemia, and cigarettes.
based on this a blue lymphocyte plasma and Dengue Blot examination was done. The results was positive BLP 14%, IgG -, IgM -,

the therapy given:

Methylprednisolone injection of 2 x 125 mg
Omeperazole injection of 1 x 40 mg
Ondansentrone injection of 3 x 4 mg
Metamizol injection of 3 x 1 ampoule
ISDN (Isosorbid Dinitrat) 2 x 2.5 mg tablets
Enoxaparine sodium (lovenox) injeksi 2×3000 anti (-) xa IU (2×0,3 ml)
Clopidogrel 1 x 1 tablet (75 mg)
Aspirin 1 x 80 mg tablets
Infusion 2 lines 1. Hemacel (Colloid)1 kolf / 24 hours
2. Ringer lactate (RL)1 kolf /6 hours
Instructions
Check the blood pressure every 3 hours if the systolic <100 load RL 500cc or 1000cc, if not increased than load colloid 250cc or 500cc, if the blood pressure still does not increase infuse into 3 lanes
1. Colloid 500 cc / 24 hours
2. Ringer lactate 500 cc / 6 hours
3. Ringer lactate 500 cc + dobutamin 1 ½ ampoule / 24 hours
During the monitoring, the systolic blood pressure from the patient ranged from 100 to 120
Date 4/4/11 patient asks to go home because he feels he is healthy.
ECG: ST elevation in V1 and V2 disappeared. ST elevation in V3 – V4 – V5 is still there. Hb: 12.4, Leuc: 14 900/mm3, Ht: 34, Tr: 209 000/mm3,
E: 4.0 million /mm3, diff 0/0/1/92/5/2 count. LPB: 11%, CKMB: 12.
T: 110 / 70, N: 80 x / min. RR: 20 x / min, t: 36° C

outpatient therapy:

Methylprednisolone tablet 16 mg, 7 tablets a day: 3 – 2 – 2 for 3 days.

For 5 days :

Omeperazoletablet 1 x 40 mg
aspirin tablet 1 x 80 mg
Clopidogrel tablet 1 x 75 mg
Gemfibrozil tablets 1x 1
ISDN (isosorbid dinitrat) 2 x 1 tablet
Ondansentrone tablet 3 x 4 mg

Discussion 

At the beginning of the ER 29/3/11 the pain is too long more than 2 hours, pain is reduced with liniment, picture a normal ECG and CKMB, then the doctor’s diagnosis is correct there is no heart disease  and only pain muscle. Maybe what should be done at that time was to repeated routine blood sample. because, there was a very high lymphocyte count (51%). May be this is a false laboratory result, because high lymphocyte count like that is common in malignant disease (acute lymphoblastic leukemia). If at that time routine blood sample was done and found lymphocyte count <20% ,on this basis a imunosupressif dose of methylprednisolone therapy given might  possibly prevent the occurrence of myocardial infarction.

With the enforcement of the diagnosis of dengue infection in these patients on 31/3/11 based on the existence of hypovolemic shock, a low lymphocyte count, the platelet counts decreased to 170,000 (from 227,000 at 29/3/11) and its positive blue plasma lymphocytes, the severe pain in the chest and back in this patient 29/3/11, is also caused by dengue infection (immune complex destruction which spread to the muscle by macrophages)

After the occurrence of myocardial infarct, the admistration of vasodilatation drug and antithrombotic drugs must be very carefull. Because the dengue infection always vasodilate  of capillary and there is a very high risk of bleeding. Therefore, in these patients, they are given only isosorbid dinitrat 2 x ½ tablet, and low moleculer weight heparin (LMVH) ½ dose (should its 2 x 0.6). Monitoring of platelet count and the bleeding should always be done. When platelets fall <150,000 and especially if there is  positive abnormal bleeding in the urine or a nosebleed, then ISDN, LMVH, Clopidogrel, and aspirin must be stopped. In these patients given high dose methylprednisolone (2 x 125 gr / day), because given the great immune complex had spreaded this patient.

 

III. Dengue infection with manifestations of cerebral disorder

  1. Mr. P 16 years, admitted to hospital at 07:30 PM with seizures-15x since 1 hour before entering the hospital. Seizures lasted for ± 5 minutes, with unconsciousness at the time of seizure. At 04.00 PMthe patient felt her body cold, stiff, constant headache, nausea and upper left abdominal pain, and shortness of breath. There is no history of inpatient care and no history of any previous illness. The day before the seizure the patient complained of dry cough. Denies fever, nosebleeded and gums bleedingPhysical examination date 28 November 2010Blood pressure: 100/palpable , Pulse: regular 100x/min equal, content enough,RR: 24x/min, S: 36.o C, Compos Mentis, Rumple Leed: (-)Laboratorium date 29 November 2010
    Hb: 9.8 gr/dl, Leukocytes: 900 /mm3, Platelets: 34,000 /mm3, Erythrocytes: 3.4 million/mm3, Ht: 32 %, Diff count: 0/0/0/75/18/7, SGOT: 23, SGPT: 9, Total Bilirubin: 1,2, Ureum: 22mg, creatinin: 0.5, NA: 142, K: 3.9, CL: 104, Ca: 8.2
    rechecked blood sample 12 hours later
    Hb: 12.5gr/dl, Leukocytes: 6800 /mm3, platelets: 204,000 /mm3, Erythrocytes: 3.9 million/mm3, Ht: 33 %, Diffcount: 0/0/0/69/26/5
    → ENCEPHALOPHATY DENGUE?
    IgM (+), IgG (+) day-to-2 of treatment
    CT shows scan cerebral edema
    During the 5-days care the patient never experience fever and the blood sample are always normal

Therapy given:
Methylprednisolone injection of 1 x 125 mg
Phenytoin 2 x 1 tablet
Manitol 3 x 100 cc
Ondansentrone injection of 3 x 1 ampoule
Omeprazole 1 x 1 tablet
Ringer Lactate infusion 500cc / 4 hours + Diazepam ampoule  every 4 ½ hours
Diazepam injection of 1 ampoule when seizures

the therapy when discharge from the hospital:
Methylprednisolone tablet 16 mg (weight: 50 kg) of 5 tablets:
2-2-1 per day for 2 days

Phenytoin tablets 2 x1 / 2 tablets for 3 days
Omeprazole tablets 1 x 40 mg for 3 days
Ondancentrone 3 x 4 mg tablets for 3 days

 

Discussion

It is interesting that this case was handled by a specialist in internal medicine. Incidentally at that time the neurologist was not present so that this case wasconsulted to internist. If the neurologist handled the case, it is certain that the possibility of dengue infection with manifestations of seizures will not be unthinkable.
It could happen after the results of CT – Scan obtained, the patient will be consulted to neurourgeon for infasive therapy. Even if the internist was consulted in the disease it is because of the possibility of pancytopenia at the time of initial entry.

The possibility of dengue infection in this patient, because:

a. 2 hours before the seizure, the patients complain of stiffness, cold body, head pain, left upper abdominal pain, shortness of breath and cough the day before.

b. A picture of pancytopenia, and eventhough the  patients say there is no disease whatsoever previously. The picture of pancytopenia shows that the immune complex spreads to the bone marrow and then destroyed by healthy macrophages. Peripheral blood picture in the evening which has become normal again shows that the process in the bone marrow has been finished.

c. Lymphocyte count ≤20% (Routine blood sample on the first / early morning)

Based on this, it was asked to do the Dengue Blot examination and the result is IgM (+), IgG (+). This shows that about 1-2 months before patients had experienced primary infection, and then exposed to Dengue virus re-infection from another type. The absence of fever is because of the destruction of immune complex in circulation are few, so that it does not stimulate the hypothalamus to release arachidonic acid. Immune complex directly spread to the brain and bone marrow.

II. Mr. A (50 years)

Patient admitted to the hospital 03/08/2011 at 08:57 AM, with a chief complaint of loss consciousness at 06.00 AM for 2 minutes. After that, the patient felt dizzy, he was taken to the hospital.

In 3 darys nausea (+), less intak food (+), vomiting (-) fever was denied, cold sweat (+) was experience before fainting. History of HT, DM and other diseases denied.

Physical examination 2011 in Emergency Room (ER) 8/3/11

Blood pressure: 130/90, pulse: 60 x/min
RR: 20 x/min, T: 36.7°C, consciousness: Compos Mentis, other sign are in the normal range.

ECG: within normal limits

Laboratory of 8/3/11:

Hb: 12.6 gr/dl, L; 13 400/mm3, E: 5.6 million/mm3, Ht 39, LED: 3, Diff count: 0/0/1/91/7/1
Blood Chemistry:
Ureum: 27, creatinine: 0.8, SGOT: 49, SGPT: 56, Bil Tot: 0.24, Na: 142, K: 3.9, Cl: 102, CKMB: 16; Blood Glucose 100 mg%

Thorax photo: Mild Cardiomegaly

ER Diagnosis: Vertigo ec, decrease in food Intake ec, Dyspepsia Syndrome

Visit 8/3/11 04:00 PM:

syncope ec Dengue Encephalopathy ?

Based on the low lymphocyte count (7) and a low monocyte count (1) the history of the illness was re-anamnesa and Rumple leed examination was checked again. The results of the Rumple Leed was positive and in fact the patient felt somewhat feverish this past seven days and athralgia. The results of Dengue blot examination was IgG (-), IgM (-).

Repeated routine blood examination at 04.00 pm  08/03/11

Hb: 12.6 gr/dl, L: 8300 /mm3, T: 233 000 /mm3, E: 5.7 million/mm3, Ht: 40 %,
Diff count: 0/0/0/77/18/5

Visit 8/3/11 in the ward at 05:00 PM

The patient complained of still dizzyness
BP: 110/70, T: 36.5°C, RR: 20 x/min, N: 80 x/min, other findings are within normal limits

Diagnosis is established:

Vertigo and history of syncope ec dengue infections, based on positive Rumple Leed, Ht / Hb> 3 x, a history of fever, low lymphocyte and monocyte count.
It was planned to examine the blue plasma lymphocyte and lipid profile. The  results was the blue plasma lymphocytes 6% (results obtained on 9/3/11). Total cholesterol: 225, HDL: 34, LDL: 164, TG: 125

Therapy given:

Ringer Lactate (RL) infusion 4 hours / kolf
betahistin mesilate tablet 3x 10 mg
Ondansentrone injection of 3 x 4 mg
Ranitidine injection of 2 x 150 mg
simvastatin tablet 1 x 10 mg

Instructions:

Check the blood pressure every 3 hours, if systolic <100 load RL 500 cc, if the blood pressure does not go up-call and report to the duty doctor.

10/3/11 at 04:00 PM, the patient asks to go home because he felt healthier. On the record status is obtained at 11:00 AM
(10/3/11), the blood pressure had fallen to 90/60 and only rose to 100/70 after the loading RL 1000 CC (2 kolf)

routine blood sample 10/3/11 at 04:00 PM:

Hb: 12.5 gr/dl, L: 6600 /mm3, T: 246 000 /mm3, Ht: 38%, Diff count: 0/0/0/82/14/4

Physical examination:

BP: 110/70, RR: 22 x/min, N: 92 x/min, S: 37°C

With the record that the patient had experienced shock the patient is discharged with methylprednisolone 1.5 mg/kg/day

The drug is given:

Methylprednisolone 16 mg 3 x 2 tablets for 3 days (weight: 60 kg)

For 5 days:

Omeprazole tablets 40 mg 1 x 1
Ondansentron tablets 4 mg 3 x 1
Simvastatin tablets 10 mg 1 x 1
Betahistin mesilate tablet 2 x 6 mg

Discussion:

In this patient, he was not given methylprednisolone injection because it considers that the patient has entered the healing phase. However based on the possibility of dengue infection in this patient, instruction were still given to the nurse to monitor blood pressure every 3 hours. Precautions against Dengue infection causes the shock which occurred on 10/3/11 to  be detected and quickly resolved. If no instruction was made,then the blood pressure would be checked at the end of every nurse shift (every 8 hours). With the phenomenon of shock, methylprednisolone should absolutly  be given at least 2 days and a maximum of 5 days (because of lack of clarity of fever in the patient’s history). It is possibile this patient experience day 3 of fever, although at the time of entry into the ER was not feverish. This is based on its high-BPL 6% on the date of 9/3/11 (possible fever day 4). Based on research, BPL will reach the highest number on day 4 when it is a secondary infection or day 7 when the infection is primary.

BPL is a cell – plasma that have not yet mature, but contribute to the formation of antibodies due to sensitivity of the individual. Because of this antibodies that are formed imperfect (IgG imperfect or IgM imperfect), which according to the theory of ADE /Secondary hetrologous infection is said to be non-neutralizing antibodies. Actually after BPL high results obtained, we can provide methylprednisolone (9/3/11), methylprednisolone administration even before the results can still be justified based on the BPL of the possibility of dengue infection (history of fever although only slightly and has last for 7 days, the positive tourniquet test, as well as low lymphocytes and monocytes and hematocrit / hemoglobin > 3 x). Giving a fast methylprednisolone can prevent a sudden occurance of  shock due to the activity of kinin system which can be accelerated by the small leakage of plasma alone, without significant intravascular dehydration. Activation of this kinin system can stimulate active complement C3 and C5 which then degrade Mast cells (release of histamine), or the occurrence of reaction anaphylaktoid.

IV. Dengue infection with manifestations of diarrhea

1. Mrs D 60 years
Patient enters Emergency Room (ER) 3/3/11 at 10:00 PM, with the chief complaint of diarrhea 4-5 times a day, since late afternoon, liquid form, blood (-), mucus (-), vomiting (+) 2 x, the patient still can eat and drink. The fever occur from around noon. There is a history of DM (+) 13 years, history of hypertension (+) 13 years.

Physical examination:

BP: 200/120, T: 39.6°C, P: 130 x /min, RR: 32 x /min
Compos mentis
other examination are within normal limits except that increased bowel sounds.

Laboratory in ER: Hb: 13.9, Leuc: 17 600 /mm3, platellets: 203 000 /mm3, E: 4.54 million/mm3,
Ht: 39.3, Diff count: 0/0/0/85/13/2. Blood Glucose: 360 mg%.

Dated 3/3/11 EKG: sinus tachycardia.

Laboratory ½ months before entering the emergency department (outpatient care)
Hb: 13.5 gr/dl, Leuc: 9600 /mm3, platellet: 369 000 /mm3, Ery: 4.3 million/ mm3, Ht: 38%, Diff count: 0/1/1/66/27/5. Total cholesterol: 365, HDL: 35, LDL: 161, Trigliceride: 237, urea/creatinine: 36/0.7, uric acid: 3.9, calcium: 9.1; blood glucose 200 mg%.

Diagnosis by ER doctor at 11.30 PM 3/3/11:

Acute Diarrhea + NIDDM type 2 + severe hypertension + hypercholesterolemia.

Therapy given:

Nacl: 0.9% 500 cc / 8jam, intravenous metronidazole 500 mg / 8 hours, ranitidine 150 mg injection of 2×1 amp, ondancentrone injection of 3 x 4 mg, amilodipin 1×10 mg, digoxin 2×0125 mg. Simvastatin tablet 1×10 mg.

Sliding scale Insulin/ 8 hours.
blood glucose:201-250 – insulin:5 units
blood glucose:301-350- insulin:10 units
blood glucose:301-350- insulin:15 units
blood glucose:> 350- insulin:20 units

duty physician Visit 4/3/11 (thus called by the duty nurse) at 5:30 AM, due to shock BP: 80/60, P: 104 x /min, R: 24 x /min, T: 37.5°C. blood glucose: 229 mg%.

the history of diarrhea from 10:00 PM until 05:30 AM only as much as 2 times consisting of  ± 100 cc each diarrhea, vomiting (-).
Therapy duty physician:

load Ringer Lactate until the systolic blood pressure 100 or a maximum of 4 kolf (2000 cc), if the blood pressure does not rise report to the duty physician. If the blood pressure rise, infuse RL 500 cc / 4 hours. check vital signs every hour when systolic <100 to report to the duty physician.
Having load 1000 cc of Ringer Lactate the blood pressure rose to 100/70

Results Thorax photos 4/3/11, 10:00 AM: mild cardiomegali, pleura effusion (-)
At 1.00 PM the duty physician -call the internist because the blood pressure fell to 70/palpable and did not rise eventhough after loading 1000 cc RL

Visit by the internist 01.00 PM

BP: 80 / palpation (post loading RL 1000 cc), P: 110 x /min, R: 28 x /min, T: 37.2°C. consciousness: Somnolent, pupil: isokhor (symetrical), heart sound: 1-2, fast regular, HR: 120 x /min. Extremitas

 

 

 

 

 

 

history from the patient’s family: diarrhea since 5:30 Am(-), vomiting (-)
01.00 PM. ECG: sinus tachycardia, inverted T V5 – V6, HR 120x /min

Latest Lab at 12.05 PM 4/3/11
Hb: 12.6 gr/dl, Leuc: 13 700 /mm3, platellet: 305 000 /mm3, E: 4.0 million/mm3, Ht: 36 %, Diff count: 0/0/1/92/6/1. Widal H: (+) 1 / 320. GOT / GPT: 41/23, tot Bil.: 0.9, CRP: (+)
Complete urine: normal, Na: 139, K: 2.9, Cl: 98, CKMB: 19, blood glucose: 163 mg%
Check Rumple Leed (+)

Diagnosis:
– Hypovolemic shock and encephalopathy ec dengue infection 1 day
– Type 2 NIDDM normo weight
– Hiperkolestrolemia
– History of hypertension 13 years
– Hypokalaemia ec diarrhea and vomiting

Therapy:

load RL again up to 1000 cc or until systolic BP 100, note whether the patient has an increased shortness of breath or pulmonary edema. If the blood pressure does not go up, load colloid (hemacel®) maximum of 2 kolf and report the results. Provide direct injection of methylprednisolone 250 mg iv.

Result of the loading: blood pressure rose 100/70 after loading RL 1000 cc and 500 cc colloid (1 kolf)

Subsequent therapy:

Infusion 2 lines:

1. Ringer Lactate 500 cc /6 h + KCl 25 meq /6 h
2. Colloid 12 hours / kolf

Methylprednisolone injection of 1 ampoule (125 mg) every 12 hours
Levofloxasin infusion 1 x 1g
Metamizol injection of 3 x 1 ampoule
Omeprazole injection of 2 x 40 mg
Piracetam injection of 4 x 3 gr
Put NGT
2100 cal diabetic diet, gastric diet I
Simvastatin tablets 1 x 10 mg in NGT
Sliding scale blood sugar every 4 hours
blood sugar 251-350: actrapid 5 units
blood sugar> 350: actrapid 10 units
digoxin (Fargoxin®) injection of 1cc every 6 hours, if HR> 100 x /in

Move ICU:

Visit 5/3/11 at 07:00PM

Awareness Compos Mentis, BP: 180/100, P: 80 x / min, RR: 20 x / min,

extremitas

 

 

 

 

 

diarrhea: (-), Dengue Blot: IgG (-), IgM (-), Na: 139, K: 3.2,
Hb: 12.6, Le: 22 200, rec: 223 000, E: 3.97 jt, Ht: 35, Diff count: 0/0/0/93/5/2,
For monitoring blood sugar ranging 200-400 mg%

Therapy:

Moving back to the ward
Infuse 2 lines: 1. Colloid 500 cc / 24 hours
2.Ringer Lactate 500 cc / 8 h + KCl 15 meq / 8 hours

Piracetam injection of 3 x 1 g
Methylprednisolone injection of 1 x 125 mg
Omeprazole injection of 1 x 40 mg
Levofloxasin infuse the 1 x 1 g
Metamizol injection of 3 x 1 ampoule

Sliding scale / 8 hours
blood sugar 201-250: actrapid 5 units
blood sugar 251-300: actrapid 10 units
blood sugar 301-350: actrapid 15 units
blood sugar > 351: actrapid 20 units

Visit 6/3/11

Compos Mentis awareness

Extremitas

BP: 140/80 mmHg, R: 22 x /min, T: 36, 5°C, P: 92 x /min.

Laboratory:
Na: 139, K: 3.2, Cl: 104, Hb: 12 gr/dl, Le: 18,000 /mm3, Tr: 180,000 /mm3, E: 4.0 million/mm3,
Ht: 35%, Diff count: 0/0/0/95/4/1

Patients wish to go home because of costs of inpatient care and he feels that he has recovered

discharge Therapy:

Methylprednisolone tablets 16 mg: 3 x 2 tablet pc for 2 days (weight: 60 kg)

5 days therapy :

Levofloxacin tablet 500 mg 1 x 1
Ondransentrone tablets 4 mg 3 x 1
Simvastatin1 x 10 mg        for 5 days
Metformin tablet 500 mg: 2 x 1 (morning – afternoon)
KSR 1 x 1 tablet

Delay medication for high blood pressure.
Control to the hospital after the drugs run out, before the control check routine blood sample, blood glucose, total cholesterol, LDL, HDL, triglycerides and potassium.

Discussion:

This patient suffered shock up to 2 times the date 4/3/11 at 05:30 AM (7.5 hours after entering the hospital) and 01:00 PM (7.5 hours from the first shock). Even at the second shock falls to the state of somnolent.

The rise in blood pressure after loading fluid, indicates that the shock is hypovolemic (non-cardiogenic shock, septic shock nor neurogenic shock). Diarrhea is only 2 times since entering the hospital 3/3/11 at 10:00 PM until 05:30 AM (4/3/11), and diarrhea that stopped since 05:30 AM until01.00 PM shows that it was not the diarrhea that cause the hypovolemic shock. Likewise the possibility of shock due to hyperglycemia or diabetic ketoacidosis cannot be said to be the cause of hypovolemic shock and the fall of the state of consciousness in this patient. This is because at that time the blood glucose is only 229 mg% and 163 mg%. The rappid occurance of shock in this patient is more correct to say are caused by kinin activation system, activation of complement C3 and C5 and possibility of anaphylactic reaction caused by degranulation of Mast cell (as has been described in cases of dengue infection with vertigo).

The existence of fever, a positive tourniquet test, low lymphocyte and monocyte count, shows that this patient suffer Dengue infection. Likewise, with a decrease in consciousness, which is caused by the spread of immune complex to the brain.

With this basis, high immunosuppressive dose of methylprednisolone 250 mg is given to this patient, eventhough we feared with the risk in the rises blood sugar and increased bacterial infection in this patient. It turned out that this high dose methylprednisolone gives good result, so in a very short time (1 day), the awareness becomes compos mentis and extremities movement become normal.

2. Mrs. D 80 years

Experience diarrhea for 2 days with a frequency of more than 10 times a day, the consistency is liquid, blood (-), mucus (-). Fever is present for 2 days and nights, nausea, vomiting (+) the patient  can still eat and drink although slightly, there is no other complaints.

Physical Examination Date February 17, 2011
BP: 110/70,T: 38 ˚ C, P: 100x/minute, RR: 20x/minute, Rumple Leed: (-)

Laboratory:

Hb: 12.3, Leuco: 4300, Trombo: 153 000, Erytrocyt: 3.8, Hematocryt 36,
Diff: 0/0/0/89/8/3, Glucose: 57, U: 71-creatinin: 1.2, SGOT: 29, SGPT: 18, Bilirubintotal: 0.8, sodium: 138, potassium: 2, 7, CL: 107,
Calcium: 8.4
Dangue blood: IgG (-), IgM (-)

Widal

S.Ty.O: 1 / 320, S.P.Ty.AO: 1 / 80
S.P.Ty.BO: (-), S.P.Ty.CO; (-)
S.Ty.H; (-), S.p.Ty.Ah: (-)
S.P.Ty.BH: 1 / 320, S.P.Ty.CH: (-)
VISIT Date February 18, 2011

Is Dengue infection STILL POSSIBLE?

Possible, because the lymphocyte count is low (8%) and monocyte count is low (3%).With that basis Rumple Leed was re-examination and the result found was positive. And routine blood sample re-examination found that there was thrombocytopenia (Hb: 11.3, Le: 4300, Tr: 129 000, E: 3.54, Ht: 33, Diff count: 0/0/1/90/7/2)

Diagnosis: Acute Diarrhea ec Dengue infection day 1

Therapy:

Injection of methylprednisolone 125 mg 1 x 1

Anti-diarrhea medicine
Corrections potassium
Ringer lactate 500 cc / 4 hours

Instructions:

Check the blood pressure  every 3 hours, if systolic <100 load a kolf RL. If the blood pressure does not go up report duty physician.

Patients was discharged on day 3 of treatments without complaint and normal laboratory.

Discharge Therapy:

Methylprednisolone 16 mg of 4 tablets: 2 x 2 tablets (morning – afternoon) for 1 day (weight: 40 kg)

During 3 days :

Omeprazole tablet 40 mg 1 x 1
Ondransentron tablets 4 mg 3 x 1

IV. Dengue infection with dyspepsia syndrome manifestations

1. Mr. R 64 years

Nausea and vomiting continuously since the day before entering hospital. Pains in joints, abdominal tenderness. There was no fever. The patient went to the doctor and he was recommended for inpatient care. There was no history of stomach ulcers.

Physical examination date February 8, 2011

Blood pressure: 110/70, Pulse: 100x/minute, RR: 22x/minute, T: 36.5 ˚ C
Tenderness in the epigastric region

Laboratory:
Hb: 15.6 mg /dl, Leukocytes: 7.300/mm ³, Platelets: 171.000/mm ³, Erythrocytes: 4.700/mm ³, Ht: 46gr%, Diff: 0/0/0/76/13/1, LED: 15 ; blood glucose 90 mg%

VISIT Date February 9, 2011
Is there STILL THE POSSIBILITY OF  DYSPEPSIA SYNDROME ec DENGUE INFECTION?

There is a posibility based on:

1. The low lymphocyte and monocyte count. Lymphocytes from the circulation are moving to thymus, to turn into cells B lymphocytes and T lymphocyte cells thereafter these cells enter into the reticuloendothelial system. Low monocytes, are because the monocytes are  infected then destroyed by the virus (the cells that are targetedby dengue virus).

2. The absence of fever is common in old age (> 60 years), a viral or bacterial infection.

3. Severe dyspepsia syndrome is a clinical symptom that often occurs in dengue infection.

4. For the Indonesian people> 60 years of Hb> 15 g%, Ht> 45 g% had suspected the existence of plasma leakage.

Based on these a re-examination of laboratory finding was done on 9/2/11 and found thrombocytopenia (Hb: 15.7, Le: 6500, tr: 124 000, E: 4.5 millions / mm3, Hct: 44 gr%, Diff count : 0/0/0/90/8/2).
Diagnosis: Dengue infection with a warning sign to 1 day

Therapy:
Methylprednisolone injection of 1 x 125 mg
Omeprazole injection of 1 x 40 mg
Ondancentron injection of 3 x 8 mg
Infuse 2 lines: 1. RL 500 cc / 6 hours
2. Nutrition infuse (Aminofluid) 500 cc /12 hours for patients with fussy eaters

Instructions:
Check the blood pressure every 3 hours, if systolic <100 load RL 500 cc and if the blood pressure does not increase report this to the duty physician.
the patient were discharge after 3 days treatment with no complaints and normal laboratory.

Therapy given when discharge from the hospital:
Methylprednisolone tablet 16 mg tablet of 5: 2-2-1 pc (weight: 50 kg) given for 1 day
omeprazole tablets 40 mg 1 x 1 tab —> for 3 days
Ondansentron tablets 4 mg 3 x 1     —> for  3 days

2. . Mr. B (80 years)
Came to the hospital on 3 March 2011. 11:00 pm, because of fever from the early morning (9:00 am).

From 27/2/11 until 28/2/11 the patient was recently treated in hospital because of dyspepsia syndrome and hypertension.

the drug given when discharge from the hospital: (28/2/2011)
Amlodipine tablets 1 x 5
Omeprazole capsul 1 x 40 mg
Ondansentron tablets 2 x 4 mg
Clobazam tablet 1 x 1 (night)

So this patient was at home for only 3 days and then came to the hospital for care again.

Physical examination date 03.03.2011 in the ER:

Blood pressure: 150/80, pulse: 100 x /min, RR: 22 x /min, T: 38.6° C, Rumple Leed (+)

Laboratory:

Hb: 14.4 mg / dl, leukocyte count: 13,200 / mm3, platelets: 136.000/mm3, Erythrocytes: 5.1 million / mm3, Hct: 43 gr%, diff count; 0/0/1/94/5/0

Dengue Blot: IgG (+)
IgM (-)
Diagnosis: Dengue infection with warning signs and fever day 0
Laboratory at the first time treated (Leed Rumple examination was not done)
Dated 27/2/11                                          Date 28/2/11
Hb: 11.8                                                    Hb: 12.9
L: 6800                                                      L: 8,000
E: 4 million                                               E: 4.4 million
Ht: 34                                                         Ht: 36
DFE: 0/0/0/70/22/8                                  DFE: 0/0/0/72/21/7

Dated 27/2/11 Date 28/2/11
Hb: 11.8 Hb 12.9
L: 6800 L: 8,000
E: 4 million E: 4.4 million
Ht: 34 Ht: 36
DFE: 0/0/0/70/22/8 DFE: 0/0/0/72/21/7
Platelet 164000 Platelet 152000

 

 

 

 

Discussion:
On 27/2/11 when the platelets 164,000 Rumple Leed (RL)examination should have been done. Moreover, when the platelets fell to 152,000 at the date of 28/2/11. However no examination RL or RL is considered (-), probable Dengue diagnosis with dyspeptic syndrome cannot be ruled out. This is based on the decrease in platelet counts approaching 150,000 and severe dyspepsia syndrome which is common in dengue virus infection. On the basis, patients are advised to not go home for at least 3 more days (until day 5 of illness) and imidiately give injection of methylprednisolone given 1 x 125 mg (although the patient complained of severe dyspepsia syndrome). The patient can be discharged when the platelets> 160,000 or near the platelet count 2 days when the patient first entered the hospital – in succession there is no fever. If patients still ask to go home, even though platelets does not go up until 160,000 given oral methylprednisolone 1.5 mg /kg /day divided into 2 -3 doses and also provide proton pump inhibitors and anti-emetics. In this patient, methylprednisolone was not given because the physician was focused on the dyspepsia syndrome and result of a low lymphocyte and monocyte was not found yet.

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