Think Possible Existence of Dengue Infection Before You Play the Surgery Knife

Case:

An Obess woman (weight 78, Height: 165) came to the poly surgery on 5/7/12 with complaints of a lump for the thumb on the left mammary since last 3 months and no pain. While the surgeon’s diagnosis: mammary fibro adenoma. Planned surgery with general anesthesia on 5/8/12 because the patient was uncooperative. there was no other complaint from the woman . A history of high blood pressure, heart disease, diabetes, lung, etc. denied.

Laboratory prior to surgery (05/07/12)

 Hb : 11,3  Ht : 35  Erythrocytes 4.8  Leukocytes: 6300  Diffcount: 0/0/0/52/42/6
 Platelets: 296 000  LED : 24  Clotting time : 7′ (3-11)  Bleeding time : 2′ (1-3)
 Blood Sugar: 101 mg%  Total cholesterol: 218  HDL :58  LDL :146  Triglycerides: 70
 Ureum / creatinine: 15/0
 GOT/GPT :16/17  Sodium: 138  Kalium : 4,3  Potassium: 4.3, Cl: 109

 

Operations performed on 5-8-12, 11:00 to 11:45 hours with the amount of incision made 4x5x4 cm . Vital signs before surgery compos mentis, tension: 130/80, Pulse 92x/minute, R: 24x/minute, t: 37 ° C

Post surgery (at 12.00) The patient went into the hospitalization with blood pressure 120/80, pulse: 92x/minute, R: 24x/minute, t: 36.5. Drugs given Vancep: 2×1 g, ketorolac injection: 3×30 mg, Vitamin K Injection: 3×1 ampoules, injection Transamin: 3×1 ampoules.

Date 5/9/12 (10 am) Patients in shock, tension: 80 / palpate, R: 28x/minute, pulse: 140x/minute, t: 38.9° C, compost mentis. Therapy of primary care physicians: a maximum of 5 flush lactate Ringer kolf if the blood pressure does not increased, flush the fluid colloidal widahess maximum of 2 kolf, if not it does not rise consul specialist in internal medicine.

14:00 hours: specialists in internal medicine 9/5/12 laboratory results obtained:

Hb: 9.0, leukocytes: 18 100, diff count: 0/0/0/95/2/3, platelets: 35,000, erythrocytes: 4.1 million, hematocrit: 29, Na: 146, K: 4.3, Cl: 110, complete urine: urinary erythrocyte full, Dengue blot: IgG (-), IgM (-).

Physical examination: T: 80/60, N: 120x / mins R: 24x / min, p: 38° C, CM, Rumple Leed test (+) Others within normal limits Diagnosis  established: Persistent Hypovolemic shock in patients due to Dengue Infection Fever  day zero and the possibility of secondary infection

Mammary FA postoperative day 1:

Hypercholesterolemia.

Therapy was given:

Extra methyl prednisolone 250 mg IV injection and continue with metlprednisolon injection 2×250 mg

Infusion of two paths: a. tetrahess 24 hours / kolf

b. RL 6 hours / kolf + 2 ampoules of calcium gluconate / 6 hours

Dobutamine 1 ½ hours in siringe pump ampul/24

Levofloxasin injection of 2×500 mg Intravenous

metronidazole infuse 3×500 mg Vit K 3×1 ampoules

Transamin 3×1 injection ampoules

Digoxin injection (fargoxin) 1 cc / 6 hours, if HR > 100x/minute

Omeprazole injection vial 2×1

Ondansentron injection of 3×8 mg

metamizol injection 3×1 ampoules

Check blood sugar as / 4 hours, if BLOOD SUGAR > 200 mg% insulin given 5 units

Move ICU

Visit dated 5/10/12

Complaints: Diarrhea 3 x. Blood pressure 110/70. 92x/minute Pulse. R: 24x/minute. t: 37° C. Blood pressure began to stabilize in the range of 110-120 systolic from 23:00 hours on 5/9/12.

laboratory: Hb: 8.9. Le: 30 300. Diff count: 0/0/1/87/4/8. Platelets: 37 000. Ht: 29. GOT / GPT: 117/81. Total bilirubin: 5.1. Calcium: 7.5 (N: 8.4 to 10.4).

Therapy

Stop Doubutamin, stop Ondansentron.

Add drug with B6 tablet 3×1, Lecithin (hepabalance) 2×1 tablet, Curcuma 2×1 tablet, diadium (loparamid HCL) 2×1 tablet, new diatab (activated actapulgist) 2×1 tablet, continue the other drug.

 

Visit 5/11/12 Complaints: Menstruation (+) the first day, diarrhea (-). Normal vital signs. laboratory: Hb: 9.2, Le: 28 500, Diff count: 0/0/0/95/3/2, platelet count: 38,000, E: 4.1 million, Ht: 29, Calcium: 9.6, PA Results: Fibrocystic. therapy: Diadium Stop, stop new diatab, add ondansentron injection 3×4 mg, raise methylprednisolone injection ampoule (2×500 mg), primolut 2×1 tablet, calcium gluconate stop. Other therapies continue. 4-hour infusion of RL / kolf

Visit on 12 & 13 are not carried out because Saturday and Sunday. 5/12/12 laboratory results: hemoglobin 9.7, Le 17 800, diffcount: 0/0/0/90/8/2, platelets 56 000, E: 4.1 million, Ht: 30. Laboratory 5/13/12: Hb 9.7, Le 10 600, diffcount 0/0/2/76/14/8, platelets 34 000, E 4.0, Ht 31. Therapies such as date of 5/11/12

Visit dated 5/14/12:

Complaints (-), normal normal vital signs, still menstruating but slightly. Laboratory: Hb 9.8, Le 7700, diff 0/0/1/58/29/12 count, platelets 27,000, E 4.5, Ht 32, GOT / GPT / Bil. Total: 34/36/0.9, Na 135, K: 2.7, Cl: 107, complete urine: full erythrocytes. Therapy: Primolut increase 3×1. Other drugs go, infusion: RL 4 hours / kolf, KCl 100 meq/24 hours in siringe pump.

Visit dated 05/15/12

Complaints (-), periods (+) slightly. Normal vital signs. Laboratory: Hb 9.6, Le 8800, diff count: 0/1/0/71/17/11, Tr: 63 000, E 4:29, complete urine full erythrocytes, Na: 137, K: 3.4, CI: 10, Ca: 5.4 .

Therapy: RL 4-hour infusion / kolf + 1 ampoule of calcium gluconate / 4 hours + 10 meq KCl / 8 hours. Stop injection of methyl prednisolone, methyl prednisolone replace with 16 mg tablets: 4 tablets in the morning, 3 tablet morning, 3 tablet evening after meals. Other drugs continue.

May move the room.

Visit 5/16/12

Complaints (-), periods (-), normal vital signs. Laboratory results: Hb 10.0, 13 300 Le, diff count: 0/0/1/76/15/8, Tr 91 000, E 4.3 million, Ht 31, Na 132, K 3.6, Cl 10.7, Ca 7.7.

Treatment: Stop methylprednisolone tablets, vitamin K stop, stop transamin, primoulut stop, stop KCl, others continue therapy, infusion: NaCl 0.9% 4 hours / kolf + calcium gluconate ½ ampule / 4 hours

Dated 5/17/12:

Do not visit because of Easter holiday _ _. Laboratory results: Hb 9.7, Le 8100, diff count: 0/0/0/2/3/66/11, Tr: 142 000, E 4.1 million, Ht 31.

nurses night report Intravenous on hand was swollen and the patient does not want an IV again, want to go home on 5/18/12.

Visit dated 5/18/12

Complaints (-), slightly longer period, normal vital signs. Laboratory results: Hb 9.6, Le 9000, diff count: 0/0/0/70/24/6, platelets 109,000, E 3.9 million, Ht 30. Dengue IgG blot (+), IgM (-), Na 133, K 3.3, 107 Br, Ca 6.5.

Home medications: primolut 2×1, calcium tablets 3×1, vitamin K tablet 3×1, transamin tablets 3×1, omeprazole tablet 1×1, ondansentron tablet 4 mg 2×1 Clobazam tablet of 1×1 (night), Sultanisilin 2×1 tablet.

 

 

Discussion

Diagnosis of infection or severe Dengue Hemorrhagic Fever at the date of 05/09/12 (1 day after surgery) in my opinion is clear. Founding because of fever, thrombocytopenia, RL test (+), and other lab results such as Ht / Hb> 3x, 2% lymphocyte count, monocyte count 3%, however Dengue IgG & IgM blot (-). Dengue IgG blot, based on new research (+) on day 2 of fever and IgM on day 5 of fever, while a new patient day-0 of fever. For that reason and the reason that the operation is performed only slightly, and performed by surgeons who are very senior (20 years has become a surgeon) I ignored the allegations of sepsis and DIC as a cause of fever and thrombocytopenia. Apparently at the time the patient was  going home (5/18/12) we found IgG Dengue blot positive. It means that my diagnosis is correct on the date 5/9/12. So, if we believe if the patients had Dengue infection is the main problem is the date of surgery performed 5/8/12 justified or not? I believe that all surgeons worldwide to allow such a small operation done. For laboratory abnormalities that is obtained is only hypercholesterolemia (while the LEDs are a bit high perhaps due to the presence of hypercholesterolemia) But if we hold on to my theory when I said that we can diagnose Dengue infection without fever, it means that we must be careful if we find laboratory abnormalities. Founding mainly in patients who will have surgery. In these patients obtained Ht / Hb> 3 times normal (laboratory 05/07/12), so it should first tested torniquet test examination (test rumple LEED). When the test RL (+), the probable diagnosis of Dengue can be established, according to my theory (see the prospect of are looming iceberg). And the patient consulted a specialist in internal medicine. When the test RL (-) then tested re-examination of Hb package. If abnormalities are found remains Ht / Hb> 3 times in the absence of laboratory abnormalities other then the patient should be discharged and advised to drink a lot and control the outpatient surgery care one week later for evaluation laboratory.

Courage to operate on patients suspected of dengue infection very dangerous. For dengue-infected patients, the platelet count may be normal, but platelet function is not necessarily better plug when done surgically. Immune complex attached to the platelets, not seen by the laboratory analyst, so he still expressed normal platelet counts. If we believe this statement or believe the theory that I said then, an action that is truly absurd if we keep doing the surgery in patient that clearly had thrombocytopenia (platelet count ≤ 150,000) however the patient was not febrile. I’ve got the case, an obstetrician did SC Cito in patient with after stimulated oxytocin but without success with platelets 128 000. Indeed, if we read in the libraries about the number of platelets prior to surgery, then all libraries agree, that the number of platelets in platelet count ≥ 100.000/mm3 is safe to do surgery. Platelet counts below 100.000/mm3 then we must believe first that platelet function completely normal (CT / BT normal, normal platelet aggregation, normal APTT). Even if thrombocytopenia was more 50.000/mm3 surgery may be performed when the normal platelet function (except) in the nervous system and eye surgery. I think it only applies when thrombocytopenia is not due to dengue infection such as aplastic anemia, spenomegali, DIC, etc.. Even in patient that clearly have  ITP operating may be performed as long as platelet function absolutely normal. Dengue infections platelet plug can not be done well because we do not know exactly how much is actually that potent platelet counts for platelet plug in these patients. so that the platelets plug on Dengue infection are either not identical to the normal value of CT / BT, APTT or platelet aggregation. Cases of the patient with FAM operation is clearly sufficient evidence where these patients CT / BT normal platelet count with the number 256.000/mm3(however the examination APTT and platelet aggregation is not performed). On that basis the courage to do the SC in patient with platelet counts 128 000 in Country of  Indonesia which is hiperendemis Dengue area, without trying to see if the thrombocytopenia is caused by infection with Dengue area or not, I think bravery is really ridiculous. Saving the mother’s life rather than saving the live of precedence the fetus. improvements of  The General state of the mother including immunosuppressive doses of steroids with the protection of powerful antibiotics and broad spectrum that should be performed on these patients (rather than directly do the SC Cito). However I can understand the actions of the obstetrician’s because of my theory of Dengue area infection is still unknown to many physicians. After the patient undergo cito SC, Hb dropped from 11.7 to 6.4, platelets dropped from 128 000 to 66 000 and the the patient falls into a coma. The patient died in the ICU 3 days later without ever waking from his coma (cerebral hemorrhage widely suspected as the COD / CT scan was not performed).

Back to the patient of  post op the FAM. The entire disorders became good again after getting an imunosupressif dose of methyl prednisolone injection. Shock resolved, impaired liver function returned to normal value, hematuria (which is probably originated from urinary tract bleeding) become lost and platelets had reached 142 000 in the 10th day of hospitalization (5/17/12). Without immunosuppressive doses of steroids maybe all that is  bad as our discussion of the relationship between dengue infection and SLE with autoimmune hepatitis can occur.

Regarding platelet drop another from 142 000 to 109 000 on 5/18/12 (at the time the patient was going home) due to another periods the patient had on that date. Normal menstruation still requires a number and function of  normal  platelet or quite as well as other clotting factors, either at the beginning of menses (bleeding) or at the end of menses (blood end). If there is platelet dysfunction or the low platelet amount in theory the discharge of blood will be more. Mens which is lot of blood will reduce the number of platelets, as used to reduce menstrual bleeding that much on it. Based on that I always give a drug to stop the menses (primolut) in DHF the patient with menses. And since I did Thank God, there is no mens patients with DHF who died. On that basis I have criticize a colleague from the big state hospitals that did not give drugs however menstrual stopper Hb and platelets the patient continues to decline and eventually the patient died (one thing that had happened to me before it invented the theory of type III hypersensitivity) .

In patients with post-operative FAM I gave primolut 2×1 at the time reported the existence of menstruate on day-4 treatment (5/11/12). I gave Methyl prednisolone _ increase the dose to 2×500  mg on the day. Even on day-7 care primolut 5/14/12 I raise again to 3×1 tablet because of drop platelets continue to be 27.000/mm3. My mistake is to stop primolut on day-9 treatment (5/16/12) when the patient says she did not again menstruating and the lab also showed improvement (Hb 10.0 g% and trrombosit 91 000). On the other hand there was also errors on the patient. Because on the night 5/17/12 the patient did not want to infused patients do not want again, though at the time the patients was  in the correction of hypocalcaemia. It also led to a decline from 142 000 to 109 000 platelets and Hb 9.6 from 10.0 at the time the patient was almost discharged and menstruating again. In the anamnesis it was discovered that the patient menstruate regularly but often quite long. 7-9 days and occasionally a lot. Perhaps this is due to an intrauterine device in her uterus. If caught early it should not be stopped by primolut on 5/16/12 but lowered the dose to a 1×1 or 2×1. On the other hand, the patient still want an IV on a date night 5/17/12 for the correction of hypocalcemia.

The conclusion of this case.

My theory about dengue infection (T.MUDWAL Theory) must always be taken into account before a surgical knife come into action.

On that basis do not hesitate to give immunosuppressive steroid dose as soon as possible if the suspicion of dengue infection has been established. Large doses of steroids is safe up to 1 week in literature. When fear arises infection also provide a powerful broad spectrum antibiotics. Fear to hit the iceberg is preferred rather than the costs incurred.

 

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