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Sinus Bradicardia on grade II dengue hemorragic fever.pptx
1. Sinus Bradicardia On Grade II Dengue Hemorragic Fever
1
By:
dr. Irfandy Chairi Sulaiman Lubis
NPM: 2107601020018
INTERNAL MEDICINE RECIDENCY PROGRAM
FACULTY OF MEDICINE UNIVERSITY OF SYIAH KUALA BANDA ACEH
2023
•
3rd Case Report
2. 2
• Dengue is one of the most common tropical diseases affecting humans
causing significant morbidity and mortality in tropical countries
• Human become infected with dengue through the bite of DENV-carrying
female Aedes mosquitoes, including Aedes albopictus and Aedes aegypti
• World Health Organization (WHO) estimates that around 2.5-3 billion people
are presently living in dengue transmitted zones.
• In Indonesia, the number of its cases have fluctuated anually, and it tends to
experience an increase and expansion in the distribution of the affected areas
• In 2019 morbidity rate (incidence rate) has increased in compared to 2018,
from 24.75 to 51.48 per 100,000 population.
INTRODUCTION
3. 3
• Dengue fever is now known to involve the heart by inducing myocardial
inflammation, arrhythmias, and, in rare cases, fulminant myocarditis, up to
13% in severe dengue
• Conduction abnormalities can range from benign sinus bradycardia to
fulminant tachyarrhythmias and atrioventricular blocks
• Bradycardia is the most common electrical disturbance seen in dengue
• This case report emphasize on the diagnostic and therapeutic aspects, and the
correlation of how dengue hemorrhagic fever can caused bradycardia
INTRODUCTION
4. CASE REPORT
Name : Mr. T.A.
Age : 37 years old
Occupation : Teacher
Marriage status : Married
Address : Banda Aceh
Last Education : Bachelor Deegre
Religion : Islam
No. MR : 1-33-12-29
Chief complaint:
Fever since 5 days before admission to the hospital
5. CASE REPORT
Anamnesis (Medical History)
• The patient complained of having a fever since 5 days before the admission to the
hospital.
• The fever goes up and down, and currently, patient have no fever.
• No complaints of maculopapular rash on the body
• Nosebleed (-)
• Bleeding gums (-)
• Black stool (-)
• Hematemesis (+) 2 times
• Diarrhea (+) since 2 days ago, but currently the patient haven't had a poop for 2 days.
• The patient didn’t complain of having a headaches, pain behind the eyeballs
(retrobulbar pain), and muscle pain.
6. CASE REPORT
Past Medical History:
• History of past illness in the form of dengue was denied.
• History of travelling to dengue endemic area was denied.
Family Medical History:
• There was no one in the family who suffers an illness like the patient.
7. CASE REPORT
Physical Examination
General Condition : Weak, nutritional status adequate
Consciousness : E4M6V5 (Compos mentis)
BP : 117/82 mmHg
HR : 80 x/min, regular
RR : 20 x/min
T : 36,7 °C
SpO2 : 98% room air
8. CASE REPORT
Physical Examination
Head and Neck
• CA (-/-), SI (-/-)
• No enlarged lymph nodes
Thoracal:
• Symmetrical, vesicular breath sounds, crackles (-/-), wheezing (-/-)
• S1-2 reguler, cardiomegaly (-)
Abdominal:
• Distention (-)
• Normal bowel sounds
• Hepatomegaly (-)
• Splenomegaly (-)
Extremities
• No edema, warm acral, CRT < 2 seconds
15. CASE REPORT
Diagnosis
1. Grade II dengue hemorrhagic
fever
2. Sinus bradycardia ec dd viral
infection or pericardial effusion
Treatment
• Bed rest
• IVFD RL 30 drops/min
• IV ondansetron 1 amp/8 h
• IV lansoprazole 30 mg/24 h
• Paracetamol tab 500 mg/8 h
• Salbutamol tab 2 mg/12 h
• N-acetylcystein tab 200 mg/8 h
• Curcuma 1 tablet/12 h.
16. DISCUSSION
• The classic clinical manifestations of a person with
dengue usually present with fever, arthralgia,
myalgias, retro-orbital pain, and a red rash.
• Clinical manifestations of dengue hemorrhagic
fever, include :
• Acute onset, high and continuous, lasting two
to seven days in most cases.
• Any of the following haemorrhagic
manifestations including a positive tourniquet
test (the most common), petechiae, purpura
(at venepuncture sites), ecchymosis,
epistaxis, gum bleeding, and haematemesis
and/or melena.
• Enlargement of the liver (hepatomegaly) is
observed at some stage of the illness
LITERATURE
• The patient came with a main complaint of fever
• No complaints of maculopapular rash on the body
• Nosebleed (-),
• Bleeding gums (-)
• Black stool (-)
• Hematemesis (+) 2 times, diarrhea (+) since 2
days ago, but currently the patient haven't had a
poop for 2 days.
• The patient didn’t complain of having a
headaches, pain behind the eyeballs (retrobulbar
pain), and muscle pain.
• Examination of the abdominal region revealed
liver and lien are not palpable (no hepatomegaly
or splenomegaly).
CASE
Clinical Manifestation and Physical Examination
17. DISCUSSION
Laboratory Examination
• The results of routine blood laboratory tests in
Malahayati Bireuen Hospital on February 6th
Hb 14,0 g/dL; Hct 38,4%; platelet 138.000/mm3;
leucocyte count 6.100/mm3; Lymphocyte 12%;
• The results of routine blood laboratory tests in dr.
Zainal Abidin Regional Hospital on February 10th
Hb 16,4 g/dL; Hct 41%; platelet 29.000/mm3;
leucocyte count 11.960/mm3; Lymphocyte 49%;
AST/SGOT 173 U/L; ALT/SGPT 103 U/L;
albumin 3,40 g/dL; Na 134 mmol/L
CASE
• The white blood cell (WBC) count may be normal
or with predominant neutrophils in the early
febrile phase.
• A relative lymphocytosis with increased atypical
lymphocytes is commonly observed by the end of
the febrile phase and into convalescence.
• A sudden drop in platelet count to below 100.000
occurs by the end of the febrile phase before the
onset of shock or subsidence of fever.
LITERATURE
18. DISCUSSION
Laboratory Examination
• The results of routine blood laboratory tests in
Malahayati Bireuen Hospital on February 6th Hb
14,0 g/dL; Hct 38,4%; platelet 138.000/mm3;
leucocyte count 6.100/mm3; Lymphocyte 12%;
• The results of routine blood laboratory tests in dr.
Zainal Abidin Regional Hospital on February 10th
Hb 16,4 g/dL; Hct 41%; platelet 29.000/mm3;
leucocyte count 11.960/mm3; Lymphocyte 49%;
AST/SGOT 173 U/L; ALT/SGPT 103 U/L; albumin
3,40 g/dL; Na 134 mmol/L
CASE
• Haemoconcentration or rising haematocrit by 20% from the
baseline
• Thrombocytopenia and haemoconcentration are constant
findings in DHF
• Other common findings are hypoproteinemia or
albuminaemia
• Hyponatremia, and mildly elevated serum aspartate
aminotransferase levels
• A transient mild albuminuria is sometimes observed.
• Occult blood is often found in the stool.
LITERATURE
19. DISCUSSION
Diagnosis Criteria
The first two clinical criteria, plus
thrombocytopenia and
haemoconcentration or a rising
haematocrit, are sufficient to
establish a clinical diagnosis of DHF
20. DISCUSSION
Radiology Examination
• Normal cor
• Pleural effusion of the left lung.
CASE
• The presence of pleural effusion (chest X-ray or
ultrasound) is the most objective evidence of plasma
leakage
LITERATURE
21. DISCUSSION
Serology Examination
• Immunoserology of anti-dengue IgG and IgM
showed positive results
CASE
LITERATURE
IgM IgG Interpretation
(+) (-) Primary infection
(+) (+) Secondary infection
(-) (+) Had been infected before
(-) (-) Never been infected
22. DISCUSSION
Treatment
• Bed rest
• IVFD RL 30 drops/min
• IV ondansetron 1 amp/8 h
• IV lansoprazole 30 mg/24 h
• Paracetamol tab 500 mg/8 h
• Salbutamol tab 2 mg/12 h
• N-acetylcystein tab 200 mg/8 h
• Curcuma 1 tablet/12 h.
CASE
• Those presenting early without any warning signs
can be treated on an outpatient basis with
acetaminophen and adequate oral fluids.
• Those with warning signs can be initiated on IV
crystalloids, and the fluid rate is titrated based on
the patient's response
• Patients with warning signs, severe dengue
(DHF/DSS) need to be admitted to the hospital,
and be treated with paracetamol and fluid therapy.
• Those with warning signs can be initiated on IV
crystalloids
• Blood transfusion is warranted in case of severe
bleeding or suspected bleeding when the patient
remains unstable, and hematocrit falls despite
adequate fluid resuscitation.
• No antiviral medications are recommended.
LITERATURE
24. CONCLUSION
Electrocardiography (ECG) and echocardiography abnormalities are common during dengue
infection. One of those abnormalities is bradycardia. Bradycardia is the most common
electrical disturbance seen in dengue.