Clinical Case Study: Treating Dengue Fever
Dengue Fever can be a deadly disease but not often encountered by US physicians. The following scenario explores the topic, and shows how resources such as the Merck Manual and Johns Hopkins ABxGuide can aid in making diagnoses and treatment decisions.
The Scenario You are a Family Physician in the Midwest. Joel Bradman, a healthy 22 year old man, well known to you has asked for an urgent add-on visit. You note that Joel grew up as a youngster in Thailand and occasionally travels there for the family business. He has apparently become ill 5 days after returning from Thailand.
He complains are of 2 days of high fever, headaches, myalgia, arthralgia, anorexia, and severe malaise.
On presentation to your office, his vital signs are T 39°C (102°F), HR 65, RR 20, BP 110/70, SaO2 99% on Room Air. Your Nurse comments that she noted a rash appear under the site where she applied the blood pressure cuff on taking Joel's blood pressure. Finding this somewhat peculiar, blood pressure was taken on the other arm with an identical rash occurring on that arm also and only being located under where the cuff was applied.
Joel's worst symptoms are his retro-orbital headache, arthralgias and low energy. His physical examination otherwise is unremarkable, except for the almost petechial rash underlying where the blood pressure was taken. There is no neck rigidity or photophobia.
Given your non-existent tropical medicine experience, this case was a bit perplexing. There was no evidence of a typical flu-like illness. There was no rhinorrhea, no injected pharynx and no cough. There was no cyclical nature to the fevers to suggest malaria. You strongly suspect Joel's issue relates to his recent travel.
As Joel didn't appear that ill, you decide on some basic laboratory testing of a CBC (full blood count) and Comprehensive Panel (electrolytes, LFTs). While waiting for these results, you decide to review some of your Skyscape resources.
Merck Manual was your starting point. You recall that Dengue Fever might be an illness somewhat like what Joel is experiencing; but have never seen a case. So you take a look at that topic. On searching for Dengue, you also notice a subtopic called Dengue Hemorrhagic Fever - odd considering the rash with the blood pressure cuff.
You review the information section and note that Thailand is an endemic area and that serologic testing is available. Joel is within the incubation period. After reading the content, you have Joel back in your office and on re-examination, you now note a palpable spleen and some cervical and inguinal nodes.
The CBC returns with a hemoglobin of 19.8, hematocrit of 65%, WBC of 2,500 with 30% neutrophils, 60% lymphocytes. Platelets are low at 62. The comprehensive panel is relatively unremarkable except for mild transaminase elevations.
You go on to read the section on Dengue Hemorrhagic Fever and realize that Joel has likely had Dengue previously and is at serious risk given the hemoconcentration, positive tourniquet test and thrombocytopenia.
As you also have the Johns Hopkins POC-IT Abx Guide, you take a look at this resource also. They have a topic on Dengue Hemorrhagic Fever (DHF). You note that the differential may include malaria, leptospirosis, early pulmonary anthrax, typhoid fever. You note that your patient currently has just Grade I DHF. You note indications for hospitalization include hemoconcentration>10% and thrombocytopenia.
You arrange for Joel's admission having properly suspected Dengue and having initial laboratory results quite consistent with the diagnosis of DHF. You also realize that without properly investigating this case, you would not have appreciated how compromised Joel was and that he has substantial risk of morbidity and mortality without careful management.
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