Each day we learn some thing new from ICU . Even when features are typical for an entity there ll be something unique in each case .
Few experiences about cases referred to us as dengue from Periphery
Common clinical features shared by all of them were fever more than one week , rash circulatory insufficiency and bit of ascitis and pleural effusion .
No doubt most of them turned out to be dengue ,few of them referred withNS1 positive or second week Dengue IgM positive.
Managed as usual .
Mortality in dengue is very unusual now with early detection and proper management according to guidelines. Cases missed if at all are due to major complications .
Out of this case one turned out to be NSI and IgM degue negative , weil felix positive . He responded to Doxicycline.
Here is another one Now under Treatment in PICU
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Five year old boy developed fever 10 days back . No running nose cough bowel ,urinary disturbances. Fever subsided with paracetamol . Fever recurred after a gap of two days . High grade fever associated with abdominal pain and vomiting. Vomiting non -bile stained. No bowel disturbances. He was hospitalized and was put on Inj Cefotaxime and IV fluids . As the complaints worsened he was referred to us .
There was no history of rashes. bleeds joint pains . Urine and stools normally colored .
Routine Investigations done from that hospital showed leucopenia thrombocytopenia . NS1 was done negative ( on the fourth day of fever )
No past history of significant illness. Immunized update. No visits outside . There is contact with a prolonged fever case in neighborhood.
On admission he was fully conscious ,dyspneic RR 80 per minute , no cyanosis. BP 70/40 Capillary refill time <3 second .No edema. No jaundice , No rash or bleeds, No significant lymph node enlargement .
No pallor , no congestion eyes. irritable child .
System Examination
Upper GI , tongue, lips , throat normal
Abdomen distended. Liver soft 4 cm non tender ,Spleen 3 cms soft
Free fluid present
Respiratory system . Trachea not shifted. Both side percussion dull infrascapular and axillary area . Scattered creps bilaterally .
CVS. JVP not raised. Heart sounds normal intensity , no third heart sound
CNS. no focal neurological deficit No signs of meningeal irriation
Provisional diagnosis of Dengue fever with warning signs was made and management accordingly done
Dengue igM negative
Case was managed as dengue with meticulous fluid management and other supportive measures.
He is recovering now
Message
Dont rely too much on the Lab tests when clinical features are typical . NS1 and Ig M sensitivity is not hundred percent even when both taken together .
ESr is 56 . Sir, in dengue shouldn't it be normal or low ?
ReplyDeleteAgree sreeram , ESR wont be that high usually less than thirty . Hemoconcentration may lead to low ESR but many other factors decide the net result. We did nt do CRP here in this case
DeleteSir, What is NS1? We don't use that abbreviation, that is why.
ReplyDeleteViral antigen , which ll be positive in the first five days of dengue. We used to do IgM but it ll take one week or more . So now what we do is If a patient comes early we ll send for antigen , if he comes after first five days we ll send for IgM. By that time NS1 ll be negative.
DeleteThere are kits which do both together , in fact not much logic in that
When we see many cases clinically resembling dengue in the first week we manage as dengue ,but when we send for Ig M next week we used to get IgM . So final diagnosis Dengue
Sensitivity around 80 percent. Specificity of NS1 above 95 percent i think , there were false positive NS1
Can it be scrub itself ...Or any other viral illness which can present like ....Dengue...We call dengue like illness...Actually the first albumin itself shows very low value...Whether the boy is undernourished....Pcv not showing hemoconcentration....Rather hemodilution....Lnpathy ?...TC from the start it is high....Sir...Repeated values high can it be due to the illness itself than the response to illness....Dropping of Hb is proportionate with the dropping hematocrit....That also points against the dengue typical presentation right?
ReplyDeleteYes we get many cases clinically resembling dengue but markers negative. Few turned out to be Ricketsiels ,Here in kerala we are more and more aware of this entity . Can present this way , dramatic response to doxicycline
DeleteAlbumin low in this case is more likely due to capillary leak . Here derangement of LFT is there , which we see in many cases ,but frank case of encephalopathy or true brain involvnemet are rare
PCV here showed an initial rise but the other values during fluid management .
Last point "Dropping of Hb is proportionate with the dropping hematocrit....That also points against the dengue typical presentation right? i am not sure