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1

CHAPTER 1BACKGROUND

1.1 Background

Dengue virus infection is an acute fever caused by a virus of the genus

flavivirus, family Flaviviridae which has four serotypes are DEN-1, DEN-,

DEN-!, and DEN-", through the intermediary by Aedes aegypti or Aedes

albopictus. #ourth dengue serotypes are in $ndonesia. DEN-! is the

predominant serotype and is associated with severe cases, followed by DEN-.1

%t this time, the number of dengue cases is still high at around 1&-' per

1&&.&&& population. (he age at which most children affected by dengue are

aged "-1& years. (he death rate due to dengue fever from &&1 to &&) is 1**

people. $n $ndonesia reported as many as 11.!!" cases of dengue fever with a

mortality rate of +*+ cases.!

(he clinical spectrum of dengue can be divided

into silent dengue infection, dengue fever, dengue hemorrhagic fever and

dengue shock syndrome.1

1. bective

(his paper is one of the reuirements to fullfil in the senior clinical

assistance programs in /ediatric Department of 0ai %dam alik 2eneral

0ospital, 3niversity of 4umatera 3tara. $n addition, this paper can be used asreference to know and understanding a little about dengue infection.



2

CHAPTER 2

LITERATURE REVIEW

.1. Dengue 5irus $nfection

.1.1 Definition

Dengue 5irus $nfection is a disease that caused by mosuito6s bite, such

as Aedes Aegypty and Aedes Albopictus.1

Dengue hemorrhagic fever 7/hilippine, (hai, or 4ingapore hemorrhagic

fever8 hemorrhagic dengue8 acute infectious thrombocytopenic purpura9 is an

acute and severe, often fatal, febrile disease caused by the dengue viruses, a group of

four antigenically related flaviviruses designated serotypes 1 through ". $t is

characteri:ed by capillary permeability, abnormalities of hemostasis, and in severe

cases, a protein-losing shock syndrome (dengue shoc s!nd"o#e$% which is

thought to have an immunopathologic basis.

.1. Epidemiology

Dengue disease is endemic disease in many countries such as $ndonesia,

yamar, (hailand, (imor ;este, and others. $n $ndonesia, dengue disease is a

contagious disease and a freuent cause of outbreaks. (his disease is second rank

disease of the top ten diseases that hospitali:ed patients in $ndonesia in &&*.

Based on the data, the cases of dengue hemorrhagic fever as much as 11.!!"

with the death as many as +*+ cases.!," 4till high number of deaths due to dengue

fever can not be separated from risk factor of dengue shock syndrome. Based on

the results of research conducted 4ubahagio 7&&*9 that 1)< of patients with

dengue fever will develop into dengue shock syndrome.' eanwhile, according to

research conducted by %nders, et al., that children aged = to 1& years are at risk of

developing into dengue shock syndrome and girls are more likely to suffer from

dengue shock syndrome than boys.=



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.1.! Etiology

Dengue fever is the cause of dengue virus has four serotypes 7dengue-1,

dengue-, dengue-!, dengue-"9, which included in the %rbovirus group, genus

Flavivirus, family Flaviviridae. %rbovirus is a virus that is transmitted by

arthropods such as mosuitoes.1 Dengue virus entered to the human body through

the bite of aedes aegypti. $n general, these mosuitoes bite during the day 7*>&& to

1&>&& pm9 and afternoon 71=>&& to 1)>&&9. %edes aegypty lives in tropical to

subtropical lowland. %dult mosuitoes are medium-si:ed, dark brown body, and

the body and legs are covered with scales and silvery white stripes.

%edes aegypty likes the cool house, damp, dark, and alighted on clothing or

belongings hanging. % place to live in clear stagnant water such as a bath tub and

water reservoirs. %edes aegypti mosuito lifespan of about to ! weeks, laying

about && to "&& grains, and flew a distance of about 1&& meters.)

Aedes aegypti is a small, dark mosuito with white lyre shaped markings

and banded legs. (hey prefer to bite indoors and primarily bite humans. (hese

mosuitoes can use natural locations or habitats 7for e?ample treeholes and plant

a?ils9 and artificial containers with water to lay their eggs. (hey lay eggs during

the day in water containing organic material 7e.g., decaying leaves, algae, etc.9 in

containers with wide openings and prefer dark-colored containers located in the

shade. %bout three days after feeding on blood, the mosuito lays her eggs inside

a container ust above the water line. Eggs are laid over a period of several days,

are resistant to desiccation and can survive for periods of si? or more months.

@hen rain floods the eggs with water, the larvae hatch. 2enerally larvae feed

upon small auatic organisms, algae and particles of plant and animal material in

water-filled containers. (he entire immature or auatic cycle 7i.e., from egg to

adult9 can occur in as little as )-+ days. (he life span for adult mosuitoes is

around three weeks. Egg production sites are within or in close pro?imity to

households.

Aedes albopictus 74kuse9, also called the A%sian tiger mosuito6, is a

vector for a series of human arboviruses among which flaviviruses 7dengue virus,



4

yellow fever virus, apanese encephalitis virus, and @est Nile virus9 and

togaviruses 7Coss Civer virus and hikungunya virus9. (he species is known to be

an important vector of dengue, second only to Aedes aegypti, and is suspected to

be the only important vector of the hikungunya outbreak on the $ndian $slands

outbreak in &&=. (he %sian tiger mosuito is a highly invasive mosuito species

and is difficult to control. $t is an aggressive day biting mosuito whose bites can

cause dermatological and allergic reactions. $t is considered a container breeder,

preferring to oviposit in small uantities of water such as drums, tyres, buckets,

flower saucers, tarpaulins, and manholes.

.1." lassification

%ccording to the @0 in &11 that the dengue virus infections are

classified as follows> 1



5

/icture 1. lassification of Dengue $nfection

.1.' /athogenesis

/athogenesis of dengue hemorrhagic fever is still debated. Based on

available data, there is strong evidence that the mechanism of imunopatologis role

occurrence of dengue hemorrhagic fever and dengue shock syndrome.

(he immune response that is known to play a role in the pathogenesis of dengue

are>

a9 0umoral response in the form of antibodies that play a role in virus

neutrali:ation process. %ntibodies to dengue virus play a role in virus replication

accelerates in monocytes or macrophages. (his hypothesis is called antibody

dependent enhancement.

b9 ( lymphocytes both (-helper 7D"9 and ( cytoto?ic 7D+9 plays a role in

cellular immune response against dengue virus. (01 differentiation of ( helper

that will produce interferon gamma, $;- and lymphokine, while (h produces

$;-", $;-', $;-= and $;-1&8

c9 onocytes and makrolag role in phagocytosis by opsoni:ation virus

antibodies. 0owever, this causes increased phagocytosis process of viral

replication and secretion of cytokines by macrophages8

d9 $n addition, (he activation of complement by immune comple?es led to

the formation of !a and 'a.

0alstead in 1*)! filed a secondary heterologous infection hypothesis

which states that dengue fever occurs when a person is infected with the dengue

virus with different types. Ce-infection causes anamnestic antibody reaction

resulting in high concentrations of immune comple?es.

;ess and Ennis in 1**" summari:es the opinion 0alstead and other researchers8

states that dengue virus infection causes macrophage activation phagocyte virus-

antibody comple? non neutrali:ation so that the virus replicate in macrophages.

acrophage infection by dengue virus causes the activation of ( helper and

cytoto?ic ( thus produced lymphokines and interferon-gamma. $nterferon gamma

activates monocyte thus secreted a variety of inflammatory mediators such as



6

(N#-, $;-1, /%# 7platelet activating factor9, $;-= and histamine that causes

dysfunction of endothelial cells and plasma leakage. $ncreased !a and 'a

occurs through activation of the virus-antibody comple? that also resulted in the

leakage of plasma. (hrombocytopenia in dengue infections occur through the

mechanism of bone marrow suppression and destruction and shortening the life

span of platelets.+

/icture . /athogenesis of D0#

.1.=. (he ourse of Disease

(he course of disease in dengue hemorrhagic fever is divided into !

phases. (here are three phases of dengue hemorrhage fever such as>

1. #ever /hase

/hase fever lasts to ) days with a body temperature of about !* to "&

. $n the acute febrile phase usually accompanied by redness of the face,

erythema of the skin, pain in the whole body, and headache. 4ome patients



7

also complain of difficulty swallowing, pharyngeal pain, conunctival pain,

loss of appetite, nausea, and vomiting. During the initial phase of fever is

difficult to distinguish between dengue fever and dengue hemorrhagic

fever. n dengue fever, once free of fever for " hours without fever,

patients will enter a period of healing. 0owever, in patients with

hemorrhagic fever, after the febrile phase is completed it will go into a

critical phase.

. ritical /hase

Body temperature in the critical phase decreased by about !).' or down

below. (his phase generally occurs in the third to fifth day of fever. $n thecritical phase of increased capillary permeability causing leakage of

plasma. ritical phase lasts for " to "+ hours. $f there is no leakage of

plasma, the patientFs condition will improve but if there is leakage of

plasma, the patientFs condition will deteriorate. onditions of prolonged

plasma leakage and delays will cause shock.

!. Cecovery /hase

/atients who have passed the critical phase, there will be a process of re-

absorption of fluids within to ! days and gradually the patientFs condition

will improve. 0ealing phase lasts between to ) days. 2enerally dengue

fever patients who have successfully passed the critical phase will recover

without complications within " to "+ hours after the shock. (he healing

phase is characteri:ed by the condition of the patient began to improve,

appetite begins to increase, and vital signs were stable. $n this phase of

intravenous fluids is usually discontinued, replaced with nutrition orally.



8

/icture !. /hase of D0#

.1.) Diagnosis

a. Dengue fever 1

$s an acute febrile illness for -) days, characteri:ed by two or more of

the following clinical manifestations>

G 0eadache.

G /ain retro-oebital.

G yalgia H arthralgia.

G 4kin rash.

G Bleeding manifestations 7petechiae or positive bending test9.

G (orniuet test 7I9.



9

b. Dengue 0emorrhagic #ever 1

Based on the 1**) @0 criteria for D0# diagnosis is made when all of

these things below filled >

G #ever lasts -) days, occasionally biphasic

G 0emorrhagic tendencies

G thrombocytopenia 7J1&&,&&& H mm!9

G Evidence of plasma leakage, manifested

by> - Cise in hematocritK &<

- Drop in hematocrit following volume replacement

- 4igns of plasma leakage

/icture ". 2rade of D0#

c. Dengue 4hock 4yndrome1

• %ll four criteria of D0# must be present

• Evidence of circulatory failure

anifested by >

- Capid and weak pulse

- Narrow pulse pressure 7J & mm0g9 or

- 0ypotension for age, and

- old, clammy skin and restlessness



10

/icture '. Diagnosis of D0#

.1.+ Differential Diagnosis

- easles

- $(/

- hikungunya

- 4carlet #ever

.1.* anagement



11

/icture =. anagement of 4uspected Dengue $nfection



12

/icture ). anagement of 4uspected Dengue #ever 7$npatient9 or Dengue#ever



14

/icture *. anagement of D0# grade $$$ and $5.



15

CHAPTER III

CA&E REPORT

'1 O)*ec+,-e

(he obective of this paper is to report a case of a 1= years old and

months old girl with a diagnosis of Dengue 0emorrhagic #ever.

'2 C.se

% 1= years and months years old boy admitted to emergency room in

0ai %dam alik 2eneral 0ospital edan on = th anuary &1= at 1."& p.m with

the main complain of fever since several days ago.

'' H,s+o"! o/ D,se.se

/atients present with fever e?perienced appro?imately days before

entering %dam alik hospital. #ever with high temperature and goes down with

the consumption of fever medicine. (he patient also complain about headache and

vomiting for the last ! days. 0istory of spontaneous bleeding was not found.

0istory of nausea and vomiting was found since three days ago. 0eadache

encountered since days ago. %bdominal pain and oint pain was found. oughs

and colds was not found. Black colour stool was found. 3rination was within

normal range. 0istory of traveling out of town and to the malaria endemic area

was denied.

H,s+o"! o/ #ed,c.+,on0 -

H,s+o"! o/ /.#,!0 #amily history of the same disease was found.

H,s+o"! o/ ."en+s3 #ed,c.+,on> 3nclear

Ph!s,c. E4.#,n.+,on0



16

• P"esen+ &+.+us0 ;evel of consciousness> ompos mentis. Body

temperature> !),* L, B@> !' kg, B0> 1=& cm. anemic 7-H-9, ikteric 7-H-9,dyspnea 7-9, cyanosis7-9, edema 7-9.

• Loc.,5ed &+.+us

- 0ead> Eye> eye light reflect IHI, conunctiva palpebral inferior pale -H-,

EarHNoseHouth> within normal range.

- Neck>

ugular 5ein /ressure> CI cm 0o

- (hora?>

4ymetrical fusiformis, Cetractions 7-9, CC> &?HiHregular,

respiratory sound> vesicular, additional sound 7-9, 0C> *& ?Hi,

regular, murmur 7-9.

- %bdomen>

4oepel, /eristaltic 7I9 N, 0epar and ;ien> unpalpable, Epigastric

pain 7I9.

- E?tremities>

/etechial rash is found on the lower of left arm, pulse> *&?Hi,

regular, weak, cold acral, C( J !M, edema pretibial 7-9, blood

pressure> 11&H+& mm0g.

L.)o".+o"! 6,nd,ngs0

=rd an &1'

omplete Blood ount>

(est Cesult 3nit Ceferal

• Eye > light refle? IHI, isochoric pupil, conunctiva palpebra

inferior pale 7-H-9

• Ear > within normal range

• Nose > within normal range

• outh > within normal range



17

0emoglobin 1'.& g< 1!.-1).!

Erythrocyte '.1! 1&=

Hmm!

".&-".+)

;eucocyte .1* 1&!Hmm! ".'-11.&

(hrombocyte 11! 1&!Hmm! 1'&-"'&

0ematocrite ",+& < "!-"*

Eosinophil &.&& < 1-=

Basophil &.&& < &-1

Neutrophil ==.&& < !)-+&

;ymphocyte 1.)& < &-"&

onocyte 1.1& < -+

Neutrophil

absolute

!.*+ 1&!H; .)-=.'

;ymphocyte

absolute

1.!1 1&!H; 1.'-!.)

onocyte absolute &.)! 1&!H; &.-&."

Basophyl absolute &.&1 1&!H; &-&.1

5 )1.'& f; +'-*'

0 '.'& /g +-!

0 !'.)& g< !!-!'

Blood 2lucose *!.&& mgHd; J&&

4odium 1* mEH; 1!'-1''Oalium '.& mEH; !.=-'.'

hloride 1&1 mEH; *=-1&=

D,.gnos,s0 Dengue hemorrhagic fever without shock

The".!0

- $5#D D'< Nal &."'< "& dropsHminute macro

- $n. /aracetamol '&&mgH$5

- B Diet &&&kkal I *&gr protein



18

P"ognos.0

Dubia ad bonam

6oo7 U0

=th an &1= &).&&

& O A P

#ever 7I9 4ensorium> ompos

entis , (> !),+ o, B@> "'

kg, B0> 1=& cm.

0ead> Eye Ceflect IHI,

$sochoric /upil, on.

D0# - $5#D D'<

Nal &."'<

1& dropsHmin

micro

- $n.



19

/alpebral $nferior /ale -H-,

outhHNoseHEar> Normal.

Neck> 5/ CI 0

(hora?> 4ymetris

#usiformis, Cetraction 7-9

0C> +=?Hi, 4ystolic urmur

7-9, CC> "?Hi, Conchi -H-.

%bdomen> 4oepel, Normal

peristaltic, 0epar

unpalpable, ;ien>

unpalpable, Epigastric /ain

7I9.

E?tremities> /ulse> +=?Hi,

Cegular, @eak, @arm

%cral, C( J !M, Edema

/retibial 7-9, B/ > 11&H)&

mm0g.

Cumple leed (est 7I9

paracetamol

'&& mgH +

hoursH

intravenous.

- heck for $g2

anti dengue

- omplete

Blood test

6oo7 U0

=th an &1= 1).&&& O A P

#ever 7I9 4ensorium> ompos

entis , (> !),+ o, B@> "'

kg, B0> 1=& cm.





D0# - $5#D D'< Nal

&."'< 1&

dropsHmin micro

- $n. paracetamol

'&& mgH + hoursH

intravenous.

- heck for $g2 anti



20

Neck> 5/ CI 0

(hora?> 4ymetris

#usiformis, Cetraction 7-9

0C> *&?Hi, 4ystolic

urmur7-9, CC> ?Hi,

Conchi -H-.


peristaltic, 0epar

unpalpable, ;ien>

unpalpable, Epigastric /ain

7I9.

E?tremities> /ulse> *&?Hi,

Cegular, %deuate, @arm

acral, C( J !M, Edema

/retibial 7-9, B/ > 11&H)&

mm0g.


dengue

- omplete blood

test

6oo7 U0

)th an &1= &=.&&

& O A P

#ever 7I9 4ensorium> %lert, (> !*.1 o

,

B@> "' kg, B0> 1=& cm.


isochoric pupil, on.


NouthHnoseHEar> Normal.

Neck> 5/ CI 0

(hora?> 4ymetris #usiformis,

D0# - $5#D D'<

Nal &."'<

1& dropsHmin

micro

- $n.

paracetamol

'&& mgH +

hoursH



21

Cetraction 7-9 0C> 11&?Hi,

4ystolic urmur 7-9, CC>

"?Hi, Conchi -H-.


/eristaltic, 0epar unpalpable,

;ien> unpalpable. Epigastric

pain 7-9.

E?tremities> /ulse> 11&?Hi,

regular, %deuate, @arm


/retibial 7-9, B/ > 11&H=&

mm0g.


$g > -

$g2 > I

intravenous.

6oo7 U0

+th an &1= 1=.!&

& O A P

#ever 7-9 4ensorium> , (> !), o,

B@> "' kg, B0> 1=& cm.





Neck> 5/ CI 0

(hora?> 4ymetris #usiformis,

Cetraction 7-9 0C> *=?Hi,

D0# - $5#D D'<

Nal &."'<

1& dropsHmin

micro

- $n.

paracetamol

'&& mgH +

hoursH

intravenous.



22

4ystolic urmur 7-9, CC>

+?Hi, Conchi -H-.


/eristaltic, 0epar unpalpable,

;ien> unpalpable. Epigastric

pain 7-9.

E?tremities> /ulse> 11+?Hi,

regular, %deuate, @arm


/retibial 7-9, B/ > 11&H)&

mm0g.

- urola? supp

CHAPTER IV

DI&CU&&ION

ase (heory



23

% 1= years and months years old boy

admitted to emergency room in 0ai

%dam alik 2eneral 0ospital edan on

=th anuary &1= at 1."& p.m with the

main complain of fever since several

days ago and was diagnosed with

Dengeu hemorrhagic fever..

/atients has a history of fever, nausea

and vomiting, headache, abdominal and

oint pain, black colour stool, and

petechie rash.

Based on laboratory result, trombosit was

11!.&&&Hmm!

- %ccording to research that children

aged = to 1& years are at risk of

developing into dengue hemorrhagic

fever and girls are more likely to suffer

from dengue hemorrhagic fever than

boys.

(he clinical manifestation of D0# are>

G #ever lasts -) days with of the

following such as headache, retroorbital

pain, myalgia, athralgia, and rash.

G 0emorrhagic manifestation.

;aboratory criteria of D0# are >

G(hrombocytopenia 7J1&&,&&& H mm!9

G Evidence of plasma leakage,

manifested by >

- Cise in hematocritK &<

- Drop in hematocrit following

volume replacement

- 4igns of plasma leakage

/atient was classified into dengue

hemorrhagic fever as manifested >

- Cumple leed test I

- D0# is classified into grade $, $$, $$$

and $5. D0# is diagnosed with the help

of rumple leed test

/atient was treated with >

- $5#D D'< Nal &."'< 1&

dropsHmin micro

- $n. paracetamol '&& mgH + hoursH

- (he management of dengue

hemorrhagic fever grade $ is >

$5#D D'< Nal &,"'< =-)

mlHkgbwHhour within !-" hours,



24

intravenous.

- onitoring for shock sign

and then evaluation. 7if the vital

sign still abnormally, higher the

fluid to 1&-1' mlHkgbwHhour. $f

the vital sign turn normally,

lower the fluid to ' to !

mlHkgbwHhour and then we6ve to

evalution again9. $n this case the

patient also diagnose with mild-

moderate gastroenteritis, so we

give this patient initial therapy

with $5#D D'< Nal &,"'<

1&gttHmin micro

CHAPTER V

&U88AR9

% 1= years and months years old boy admitted to emergency room in

0ai %dam alik 2eneral 0ospital edan on = th anuary &1= at 1."& p.m with

the main complain of fever since several days ago.

/atients present with fever e?perienced appro?imately days before

entering %dam alik hospital. #ever with high temperature and goes down with



25

the consumption of fever medicine. (he patient also complain about headache and

vomiting for the last ! days. 0istory of spontaneous bleeding was not found.

0istory of nausea and vomiting was found since three days ago. 0eadache

encountered since days ago. %bdominal pain and oint pain was found. oughs

and colds was not found. Black colour stool was found. 3rination was within

normal range. 0istory of traveling out of town and to the malaria endemic area

was denied.

/atients was treated with $5#D D'< Nal&,"'< 1&gttHmin7mikro9 for

rehydration and was give paracetamol '&&mgH+hoursHoral for the fever.

RE6ERENCE&

1. %ntonius 0, Eva Devita, 4etio 0, Ellen /. &&*. /edoman /elayanan Olinis

$D%$ > $nfeksi 5irus Dengue. $katan Dokter %nak $ndonesia.



26

. @0. &&*. Dengue guidelines for diagnosis, treatment, prevention, and

control. @orld 0ealth rgani:ation.

!. Depkes C$. &&*. /rofil Oesehatan $ndonesia &&*. Diunduh >

www.depkes.go.id.

". Depkes C$. &&'. /encegahan dan /emberantasan Demam Berdarah di

$ndonesia. akarta > Direktorat enderal /engendalian /enyakit dan Oesehatan

;ingkungan.

'. 4ubahagio. &&*. enentukan #aktor Cesiko Dominan Oeadian Dengue 4yok

4indrome pada /enderita DBD. Diunduh > digilib.bmf.litbang.depkes.go.id.

=. %nders, O.;, et al. &11. Epidemiological factor associated with dengue shock

syndrome and mortality in hospitali:ed dengue patients.

AM.J.Trop.Med.Hyg,84(1).1!"1#4.

). 4aleha 4ungkar. &11. Buku %ar /arasitologi Oedokteran. akarta > #O3$.

+. @ichman, , et al., &1. /athogenesis of Dengue 0emmorhagic #ever. .

(ropical edicine and $nternational 0ealth. 1&-1&+.

http://www.depkes.go.id/

http://www.depkes.go.id/