CASE 2 : Dengue Fever in Late Febrile Phase With Warning Signs

Admission Day - Day 1 (12/3/14)

NCC, a 13 year old Chinese school-going boy with no known medical illnesses, presented to the hospital with fever for 4 days. A high grade fever that was continuous throughout the day and associated with chills, rigors, headache, dizziness, bilateral lower limb rash, vomiting and diarrhoea was noted. He also noticed a decrease in frequency of urination. However, there were no complains of myalgia, arthralgia, spontaneous bleeding episodes or abdominal pain. The patient reveals that a recent case of dengue fever was reported in his neighbourhood about 2 weeks prior to his illness.
Upon arrival at the ED, his BP was 109/65 mmHg and temperature was 38.3°C. He had clear consciousness and was haemodynamically stable (good pulse volume, warm and pink peripheries, and brisk capillary refill time). Physical examination of all systems was unremarkable. Dengue fever was suspected and blood investigations were ordered. Serial full blood count readings revealed a progressive decline in total white cell (ranging between 2.3 to 2.6 x 10^9/L) and platelet count (ranging between 107 to 123 x 10^9/L). Haematocrit levels were normal. Dengue NS1 antigen serology test was positive. There was no liver involvement or coagulation abnormalities. Malaria fever was excluded by obtaining a negative result on BFMP.

The patient was diagnosed to be in late febrile phase of dengue fever with warning signs.

His management included disease notification and fluid therapy. He was given IV fluids, 2 units of Normal saline in 24 hours and Paracetamol. Adequate oral fluid intake was encouraged. Strict input/output charting was noted with careful observation for bleeding tendencies.

Day 2 (13/3/14)

Patient complained of still being feverish with 2 episodes of vomiting and 3 episodes of diarrhoea (not blood stained). No other warning signs were observed. Patient is able to tolerate orally well with increase in appetite, but with minimal fluid intake. On examination, BP was noted to be on the low side of 81/47 mmHg with a temperature of 37.4°C. Other vital signs were within normal range. Urine output showed satisfactory diuresis. Flushing of the skin was evident on all 4 limbs, chest and back.
Total white cell count showed an increasing trend, although still on the low side, ranging between 2.9 to 3.4 x 10^9/L. Haematocrit levels were stable. Platelet showed a rise in counts, between 128 and 132 x 10^9/L. A repeat BFMP came back negative.
IV 2 units of normal saline in 24 hours was continued with the continuation of Paracetamol. Patient was advised to increase oral fluid intake for about 2L/day to help increase his BP.

Day 3 (14/3/14)

Patient was well looking with no active complains. He was afebrile and no longer had episodes of vomiting or diarrhoea. Urine output was good. No other warning signs were evident. He had regained his appetite. Vital signs were within normal range.
Total white cell count had normalised at 5.5 x 10^9/L. Haematocrit levels were normal. Platelet counts were showing a rising trend compared to the previous days although still on the lower side, at 140 x 10^9/L.
IV fluids were stopped and patient was allowed for discharge that evening. He was advised to continue his fluid intake. He was given a follow-up appointment upon discharge.