Clinico-Pathologic Conference

Department of Pediatrics
Southwestern University
College of Medicine

Discussants:
Aude, Gezza Marivada, Haribabu
Bohol, Nikke Prajapati, Harsh
Christian, Neil Ramaraj, Raj Durai
Guantero, Mary Claire Shijagurumayum, Vivian
Infante, Anvil Basbakan, Akilan
Lunagariya, Sukhdev

GROUP 6 JUNIOR CLERKS - BATCH EMMETROPIA

PATIENT DATA
• 10 year old
• Male
• Filipino
• Born on June 06, 2008
• San Fernando, Cebu

CHIEF COMPLAINT/S
• Headache and Abdominal Pain

HISTORY OF PRESENT ILLNESS

• Two (2) days prior to admission PTA
– Intermittent fever by touch as claimed by the mother
• One (1) day PTA
– Intermittent fever with headache with a pain scale of 5 out of 10
– Not being relieved by rest and worsen even doing the ADL
– Diagnosed with urinary tract infection.
– Medications are unrecalled except paracetamol with dose unrecalled.
• Temporary relief noted.
• Few hours PTA
– Patient lost his appetite
– Vomitted once, non-projectile, red colored vomitus with ampule amount.
– Abdominal pain in the epigastric region, non radiating
– Fever spikes again
– Patient passed out black colored stool with watery consistency once
– Sensorium of the patient was altered, thus referred in SWUMC.

BIRTH HISTORY
• Born from a 45 year old mother, delivered full term via NVSD
• No morbid conditions all throughout the pregnancy
• Denies intake of alcoholic beverages and smoking
• Unremarkable use of illicit and teratogenic drugs

FEEDING HISTORY
• Patient refused to eat any kind of food when sick.

PAST MEDICAL HISTORY

• No history of hospitalization and no surgeries undergone yet.

IMMUNIZATION
• The mother claimed that the patient received complete immunization
FAMILY HISTORY
• Paternal and Maternal Side
– unremarkable disease state
ALLERGIES
• Unremarkable

ENVIRONMENT HISTORY
• Good waste disposal
• Visible containers with stagnant waters
• Good human excreta disposal

PHYSICAL EXAMINATION
VItal Signs Results Normal Values
Heart rate 72 bpm 60-95bpm
Respiratory rate 16 cpm 14-22 cpm
Temperature 36.1°C 35.5°C - 37.5°C
Blood pressure 90/60 mmHg 110-120/60-75 mmHg
SpO₂ 98% 98-100%

General Length -140cm

Skin absence of rash, scars, edema and jaundice

Head normocephalic, presence of dandruff and lice

Face symmetric, no deformities and lumps

Eyes positive visual reflex, EOM intact
Ears and no discharges
mastoid
Nose patent, no discharges, midline position
Mouth and dry lips, pink tonsils, absence of cyanosis and cleft
throat
Neck flexible, absence of mass and lymphadenopathy

Heart absence of murmur and cyanosis

 Abdomen few scars on the right lower quadrant, presence of bowel sounds

Extremities absence of clubbing, edema and cyanosis

ISSUES
History of Present Illness:
• Patient sought consult in nearby hospital
• labs not specified, especially about the platelets and liver function test
• Pulse
• Is it weak? Rapid?
• Is the patient having myalgia and arthralgia?
• Does the vomitus of the patient Bilious or non-bilious?
•
Social History
• Does the patient attended private or public school?
•
Environmental History
• Good waste disposal, containers with stagnant water
• Is dengue prevalent in the patient’s locality?
• Is there more mosquitoes in the area?
• Do they use mosquito nets/repellents?

SALIENT FEATURES

Intermittent Abdominal Maculopapular

Headache Hematemesis Melena
Fever Pain rash

DISCUSSION
 Differential Diagnosis

Typhoid Fever Ruled IN Ruled OUT

• Endemic in the • affects < 5 yo
developing countries • Rose spots
• Intermittent fever
• Headache
• Loss of appetite
• Vomiting
• Diarrhea
• Abdominal pain

Gastrointeritis Ruled IN Ruled OUT

• Headache • < 5 years old
• Fever • Epistaxis
• Loss of appetite • Generalized rash
• Vomiting
• Diarrhea
• Abdominal pain

Chikungunya Ruled IN Ruled OUT

• Endemic in • Affects >15yo
developing countries • Back and joint pain
• Sudden onset of • Myalgia
Fever • Arthralgia
• Headache • No altered sensorium
• Vomiting
Ruled IN Ruled OUT
•• Abdominal
Affects <15 pain
yo
• Endemic in CANNOT BE RULED OUT
Dengue Fever
developing countries
• Dengue outbreak in
the Philippines
• Fever
• Headache
• Severe abdominal
pain
• Vomiting blood
• Epistaxis
• Musculopapular rash
IMPRESSION
DENGUE FEVER

DENGUE
• Etiologic Agent
▪ causative agent is dengue virus with 4 serotypes. Aedes aegypti is the main
mosquito vector.
▪ Infected for the first time showed mild clinical signs and symptoms
▪ However, if he/she is reinfected, severe conditions such as bleeding or shock
occurred

• Epidemiology
▪ Trend in the Philippines
▪ A DOH- Dengue Surveillance Report showed a total of 138,444 case of
dengue fever from January 1 to October 6, 2018.

▪ 780 deaths due to dengue fever reported in 2018, compared to 581 in

2017.

▪ The Trend of Dengue in Cebu Province

▪ The Department of Health-Central Visayas (DoH-7) has noted an
increasing trend, mainly in the cities of cities of Cebu, Lapu-Lapu and
Mandaue as well as in Bohol province.

▪ From Jan. to Nov. 24 2018 dengue cases in the region grew by 20%
according to DOH-7 data.
CLINICAL MANIFESTATIONS IN CHILDREN
System Manifestation
Gastrointestinal Vomited With Red Colored Vomitus With
Ample Amount

Melena With Watery Consistency

Hematologic Epistaxis

Skeletal Negative Findings

Muscular Negative Findings
Neurologic Negative Findings

Dermatologic Maculopapular Rash

Respiratory Labored Breathing And Positive Cough With

Whitish Phlegm
PATHOPHYSIOLOGY

Dengue Infection Antibody formation Reinfection Augmentation of Virus

Multiplication

Viremia Enlarged Liver Decreased platelets Viral Multiplication

Fever Increased AST and Coagulopathy Ag/Ab complex

Lethary ALT Complement pathway
Vomiting Prolonged PT and T-cell Activated Apoptosis
Headache PTT DIC
Abdominal Pain
Vasculopathy
Increased vascular
Shock Severe permeability
bleeding

Plasma leakage

Death
PETECHIAE Increased hct
Ascited Pleural effusion

Hypovolemia and Shock

Acidosis Tissue Hypoxia DIC

FINAL DIAGNOSIS

Dengue Hemorrhagic Fever