Case report dengue with vasculopathy and the role of innate immunity

EMERGENCY ROOM NIGHT SHIFTCASE REPORT

Dengue with vasculopathy On Wednesday, 2ND SEPTEMBER 2015

GP on duty: dr. Wulan

dr. NitaSupervisior : dr Soroy Lardo SpPD FINASIM (Divisi Tropik dan Infeksi

Departemen Penyakit Dalam)Coass on duty:

Ardian Ajeng

Universitas Kristen Jakarta (UKRIDA)Indonesia Army Central Hospital Gatot Soebroto

PATIENT RECAPITULATION

Mr. B , 22 y.o , dengue hemorrhage feverMs. T , 24 y.o , dyspepsia Mrs. E , 45 y.o , GERDMr. P , 78 y.o , susp. Hepatitis BMrs. S , 57 y.o, ca mammaeMr. P, 67 y.o , GEA +low intakeMrs. V , 55 y.o, gastritisMrs W, 44 y.o, SIDA + low intake

Patient’s Identity

• Name : BP• MR no : 81 30 39• Sex : male• Age : 22 years old• Religion : Christian• Marital status : single• Ethnic : Javanese• Occupation : Army Soldier

History of Present IllnessPatient came to the ER with the complain of the fever he had since 2 days ago. Fever that he had occurred all day long, even with the anti fever medication. The complaint also came with the headache that occurred from behind his eye balls. He also had muscles and joints pain and loss of eating appetite. Patient often felt nausea, but never vomitted. Patient once came to the 24 hours clinic, but didn’t feel better and decided to go to the ER for a check up.

History of Past Illness

- Patient has never been hospitalized before- Patient has neither hypertention, diabetes,

nor heart disease history.

Family Illness

• Diabetes Mellitus (-)• Hypertension (-) • Heart disease (-)

HABITS AND LIFESTYLE

•Smoking (+)•Alcohol consumption (-)

History of Medication

• Patient is not on any medication at this moment

• Patient never have a routine drugs to take for a long time

PHYSICAL EXAMINATIONVITAL SIGNS• General State : Moderate Illness• Consciousness : Compos Mentis, E4M6V5 GCS 15• Blood Pressure : 120/80 mmHg• Heart rate : 90x/minute• Respiratory Rate : 22x/minute• Temperature : 38,8 oC• Body Weight : 75kg• Body Height : 170 cm• Habit : athletic

PHYSICAL EXAMINATION

General Examination•Head : Normal

–Eye : anemic conjunctiva (-/-), icteric sclera (-/-)–Ears : normal, discharge (-)–Nose : septum deviation (-), discharge (-)–Mouth : dry lips (-) ptechie (+)

•Neck : lymph nodes enlargement (-), JVP 5 – 2 cmH2o

COR• Inspection: Ictus cordis (-)• Palpation: ictus cordis palpable (+), thrill (-)• Percussion: normal impression• Auscultation : irregular 1st and 2nd heart

sound, murmur (-), gallop (-)

PULMOInspection : chest within normal shape, symmetries

on static and dynamic statePalpation : tactile vocal fremitus in both of lungs were symmetries.Percussion : sonor in both of lungsAuscultation : Vesicular Breath Sound +/+, rhonki -/-, wheezing -/-

Abdomen : convex (+), intestinal motility (n), tenderness on epigastric regio.Extremities: no edema , petechiae (+) rumple leed (+)

Laboratory Results

RESULT NORMAL RANGE

Hematologi rutin:Hb 14 13 - 18 g/dlHt 44 40 – 52 %

Erythrocyte 4,7 4.3 - 6.0 mil /ulLeukocyte 5.620** 4800 - 10800/ul

Thrombocyte 144.000** 150000 - 400000/ul

LABORATORIUM

RESUMEPatient came to the ER with the complain of the fever he had since 2 days ago. Fever that he had occurred all day long, even with the anti fever medication. The complaint also came with the headache that occurred from behind his eye balls. He also had muscles and joints pain and loss of eating appetite. Patient often felt nausea, but never vomitted. Patient once came to the 24 hours clinic, but didn’t feel better and decided to go to the ER for a check up. Blood pressure: 120/80 mmHg, Heart rate:90x/minute, Respiratory rate :22x/minute, Temperature:38,8 o C, petechiae (+), leukocyte : 5.620.

List of problems

• Dengue hemorrhage fever Grade 2

Problem Analysis

• 2 days fever with retroorbital pain, arthralgia, myalgia, tenderness in epigastric

• Petechiae (+), rumple leede (+) • Trombocyte: 144.000 /µl Therapy 1. IVFD 2500 ml/days 2. Paracetamol 3x 500 mg

Prognosis

Quo ad Vitam = bonamQuo ad functionam = bonamQuo ad sanationam = bonam

THANK YOU

Vasculopathy in DHF

Viral infection

Endotelial cell

CD4/8 ratio

inversion, IL-6 and

cytocine overproduction

Trombocyte

dysfunction and vascular damage

Innate immunity in DHF

Innate Imunity in DHF

• Interstitial dendritic cells (DCs) are believed to constitute the first line of the innate host defense against invading DV

• Early activation of natural killer (NK) cells and type-I interferon-dependent immunity may be also important in limiting viral replication at the early times of dengue infection

Innate imunity in DHF