CASE PRESENTATION

DENGUE HAEMORHAGIC FEVER

preceptor :
dr. Ulynar Marpaung, Sp. A

Written by :
Sony Novriandi 1102010271

Faculty of Medicine Yarsi

Pediatric Department

Rumah Sakit Bhayangkara tk.I R.S. Sukanto-Jakarta

Periode: 16 March 23 May 2015

Contents
PATIENT
IDENTITY............................................................................................................................................

PHYSICAL EXAMINATION (April 17th 2015)....................................................................................

General Status....................................................................................................................................

Antropometry Status..........................................................................................................................

Head to Toe Examination...................................................................................................................

Neurological Examination...............................................................................................................

Meningeal Sign............................................................................................................................

Motoric Examination...................................................................................................................

Autonom Examination.................................................................................................................

Laboratory Investigation..............................................................................................................

FOLLOW UP..................................................................................................................................

LITERATURE REVIEW.....................................................................................................................

DEFINITION..................................................................................................................................

ETIOLOGY...........................................................................................................
...............20

PATHOPHYSIOLOGY.........................................................................................
...............20

CLINICAL MANIFESTATIONS....................................................................................................

DIAGNOSIS....................................................................................................................................

TREATMENT.................................................................................................................................

PROGNOSIS...................................................................................................................................

REFERENCES....................................................................................................................................

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PATIENT IDENTITY

Patient
Name : ANS
Birth Date : November 24th 2010
Age : 4 years 5 months
Gender : Female
Address : Asmin street, Ciracas
Nationality : Indonesia
Religion : Moslem
Date of admission: April 17th 2015
Date of examination: April 24 th 2015

Father Mother
Name Mr. N Mrs. L
Age 34 years old 32 years old
Job Police Housewife
Nationality Javanese Javanese
Religion Moslem Moslem
Education Police Academy High School (graduated)s
Earning/month Approximately Rp.2.000.000,- -
Address Asmin street, Ciracas.

ANAMNESIS
The anamnesis was taken on April 17 2015, by alloanamnesis (from patients
mother).

Chief complain : High fever since two days before admission to the hospital.
Additional complains : Petechiae (+) on face, hands and legs.

History Of Present Ilness

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 A 4 years 5 months old child came to Raden Said Sukanto Police Center
Hospital emergency room suffering from fever since 2 days before admission the
hospital, fever felt along day with a phlegm and found petechiae on face, hands,
and legs.

2 days before hospital admission, the child got fever at morning with the
temperature (39oC) along with phlegm. Then her mother gave her medicine. After
receiving treatment, the temperature still high.

1 day before hospital admission, the child the temperature (40 oC) along with
phlegm.

On the Admission Hospital Day, the child was still in fever and there are
some petechiaes on face, hands, and legs.

History Of Past Illness

Pharyngitis/Tonsilitis -

Bronchitis -

Pneumonia -

Morbilli -

Pertussis -

Varicella -

Diphteria -

Malaria -

Polio -

Enteritis -

Bacillary Dysentry -

Amoeba Dysentry -

Diarrhea -

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 Thypoid -

Worms -

Surgery -

Brain Concussion -

Fracture -

Drug Reaction -

Birth History
Mothers Pregnancy History
The mother routinely checked her pregnancy to the doctor in the hospital. She
denied any problem noted during her pregnancy. She took vitamins routinely
given.

Childs Birth History

Labor : Hospital
Birth attendants : Doctor
Mode of delivery : pervaginam
Gestation : 38 weeks
Infant state : healthy
Birth weight : 3200 grams
Body length : 50 cm
According to the mother, the baby started to cry and the baby's skin is red,
no congenital defects were reported

Development History
First dentition: 6 months
Psychomotor development
Head Up : 1 month old
Smile : 1 month old

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 Laughing : 1- 2 month old
Slant : 2,5 months old
Speech Initation : 5 months old
Prone Position : 5 months old
Food Self : 5 6 months old
Sitting : 6 months old
Crawling : 8 months old
Standing : 1 years old
Walking : 1 years old

Mental Status: Normal

Conclusion: Growth and development status is still in the normal limits
and was appropriate according to the patients age

History of Eating
Breast Milk : Exclusively 6 month.
Formula milk : Bebelac since 1 month ago
Baby biscuits : Biscuits regal
Fruit and vegetables : Banana, Carrots
Solid foods and side dishes : rice, Carrots, Potatoes
Immunization History
Immunization Frequency Time

BCG 1 time 1 month old

Hepatitis B 3 times 0, 1, 6 months old

DPT 3 times 2, 4, 6 months old

Polio 4 times 0, 2, 4, 6 months old

Hib 4 times 2, 4, 6, 15 months old

MMR 1 time 15 months

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Tifoid 1 time 24 months

Hepatitis A 1 time 1 times

Family History
Patients both parents were married when they were 26 years old and 24
years old, and this is their first marriage.
There are not any significant illnesses or chronic illnesses in the family
declared.

History of her sister

Childbirth Gender Age Age Died Sumption Died

Girl - -
Spontan pervaginam, 4 years 5
gestation aterm months old

Born died : ( - )
Child dies : ( - )
Miscarriage : ( - )

History of Disease in Other Family Members / Around the House

There is no one living around their home known for having the same condition as
the patient.

Sosial and Economic History

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 The patient lived at the house with size 20m x 10 m together with father
and mother.
There are 1 door at the front side, 1 toilet near the kitchen and 3 rooms, in
which 1 room is the bedroom of three of them and 1 room is for guest.
There are 4 windows inside the house. The windows are ocassionaly
opened during the day.
Hygiene:
o The patient changes his clothes everyday with clean clothes.
o Bed sheets changed every two weeks.

PHYSICAL EXAMINATION (April 17th 2015)

General Status
- General condition : mild ill
- Awareness : Compos Mentis
- Pulse : 110 x/min, regular, full, strong.
- Breathing rate : 28x/min
- Temperature : 38,5oC (per axilla)

Antropometry Status
- Weight : 19 kilogram
- Height : 105 cm

Nutritional Status based NCHS (National Center for Health Statistics) year 2000:
WFA (Weight for Age): 19/17 x 100 % = 111 % ( good nutrition)
HFA (Height for Age): 105/103 x 100 % = 101 % (good nutrition)
WFH (Weight for Height): 19/18 x 100 % = 105 % (normal)

Conclusion: The patient has good nutritional status.

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 Head to Toe Examination

Head
Normocephaly, hair (black, normal distributon, not easily removed ) sign of
trauma (-), large fontanelle closed.
Eyes
Icteric sclera -/-, pale conjunctiva -/-, hyperaemia conjunctiva -/- ,
lacrimation -/-, sunken eyes -/-, pupils 3mm/3mm isokor, Direct and
indirect light response ++/++
Ears
Normal shape, no wound, no bleeding ,secretion or serumen
Nose
Normal shape, midline septum, secretion +/+
Mouth

Lips: moist
Teeth: no caries
Mucous: moist
Tongue: Normal
Tonsils: T1/T1, No hyperemia
Pharynx: hyperemia (+)

Neck
Lymph node enlargement (-),
Thorax :
i. Inspection : symmetric when breathing , no retraction
ii. Palpation : mass (-), tactile fremitus +/+
iii. Percussion : sonor on both lungs
iv. Auscultation :
1. Cor : regular S1-S2, murmur (-), gallop (-)
2. Pulmo : vesicular +/+, Wheezing -/- , Rhonchy -/-
Abdomen :
i. Inspection : Convex, epigastric retraction (-),
ii. Palpation : supple, liver and spleen not palpable, fluid wave
(-),abdominal mass (-)
iii. Percussion : The entire field of abdomen is tympanic, shifting dullness
(-)
iv. Auscultation : normal bowel sound, bruit (-)

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 Vertebra : There does not appear scoliosis, kyphosis, and lordosis, do
not look any mass along the line of the vertebral
Ekstremities : warm, capillary refill time < 2 second, edema(-)
Skin : Good turgor.

Neurological Examination

Meningeal Sign

Motoric Examination
Power
Hand 5 5 5 5/ 5 5 5 5
Feet 5 5 5 5/ 5 5 5 5
Tonus
Hand Normotonus / Normotonus
Feet Normotonus / Normotonus
Trophy
Hand Normotrophy / Normotrophy
Feet Normotrophy / Normotrophy
Physiologic Reflex
Upper extrimities
Biceps +/+
Triceps +/+

Lower extrimities
Patella +/+
Achilles +/+

Pathologic Reflex
Upper extrimities
Hoffman -/-
Trommer -/-
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 Lower extrimities
Babinsky -/-
Chaddock -/-
Oppenheim -/-
Gordon -/-
Schaeffer -/-

Clonus
Patella -/-
Achilles -/-

Autonom Examination

Defecation Abnormal ( defecation (-) 3 times)

Urination Normal ( 4-5 times daily )
Sweating Normal

Laboratory Investigation
Hematology April 17th 2015

Hematology Results Normal Value

Haemoglobin 11,7 g/dL 13-16 g/dL
Leukocytes 6.000/L 5,000 10,000/L
Hematocrits 24 % 40 48 %
Trombocytes 51.000/ L 150,000 400,000/L
Erythrocytes 3,9 million/L 4 5 million/L

DENGUE BLOOD TEST

IgG +
IgM +

RADIOLOGY (THORAX PHOTO)

conclusion: mild pleura effusion

WORKING DIAGNOSIS
Dengue Haemorrhagic Fever
DD/ Typhoid Fever
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MANAGEMENT

IVFD NaCl 0,9 % loading, micro drip, 100cc

Inj. Cefotaxime 2x700 mg IV
Paracetamol syrup 3x1 cth
Imboost Force 3x1 cth
Antasida syrup 3 x 1 cth

PROGNOSIS

Quo ad vitam : dubia ad bonam

Quo ad functionam : dubia ad bonam
Quo ad sanactionam : dubia ad bonam

FOLLOW UP April 18th 2015 - April 21th 2015.

April 18th 2015. Second day of hospitalization, 5th day of illness

S Fever (+)
Phlegm (+)
Defecation (-) 3 times

O General condition: Compos mentis.

Heart rate = 110 x/min
Respiratory rate = 24x/min
Temperature = 39C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/-

A DHF grade II
DD/ Typhoid Fever

P IVFD Kaen3B, micro drip, 22 dpm 1600cc / 24 Hours.

Inj. Cefotaxime 2x700 mg IV

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 PCT syrup 3x1 cth
Imboost Force 3x1 cth
Antasida syrup 3 x 1 cth
Check full blood test

Hematology April 18th 2015

Hematology Results Normal Value

Haemoglobin 12 g/dL 13-16 g/dL
Leukocytes 9.600/L 5,000 10,000/L
Hematocrits 30 % 40 48 %
Trombocytes 58.000/ L 150,000 400,000/L

April 19th 2015. Third day of hospitalization, 6th day of illness

S Fever (+)
Phlegm (+)
Defecation (-) 3 times

O General condition: Compos Mentis

Heart rate = 120 x/min
Respiratory rate = 24x/min
Temperature = 38.5C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/-

Skin: Inspection: Petechiae (+) hands and legs

A DHF Grade II
Dd Thyfoid Fever

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P IVFD Kaen3B, micro drip, 22 dpm 1600cc / 24 Hours.
Inj. Cefotaxime 2x700 mg IV
PCT syrup 3x1 cth
Imboost Force 3x1 cth
Antasida syrup 3 x 1 cth
Check full blood test

Hematology Results Normal Value

Haemoglobin 12 g/dL 13-16 g/dL
Leukocytes 9.600/L 5,000 10,000/L
Hematocrits 36 % 40 48 %
Trombocytes 72.000/ L 150,000 400,000/L

April 20th 2015, Fourth days of hospitalization, 7th day of illness

S Fever (+)
Phlegm (+)
O General condition: Compos mentis.
Heart rate = 110 x/min
Respiratory rate = 26x/min
Temperature = 37C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/-

Skin: Inspection: Petechiae (+) hands and legs

A DHF Grade II
P IVFD Kaen3B, micro drip, 22 dpm 1600cc / 24 Hours.
Inj. Cefotaxime 2x700 mg IV
PCT syrup 3x1 cth
Imboost Force 3x1 cth
Antasida syrup 3 x 1 cth
Check full blood test

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 Hematology Results Normal Value
Haemoglobin 12 g/dL 13-16 g/dL
Leukocytes 9.600/L 5,000 10,000/L
Hematocrits 36 % 40 48 %
Trombocytes 86.000/ L 150,000 400,000/L

April 21th 2015. Fifth of hospitalization, 8th day of illness

S Fever (-). Weakness (+)

O General condition: Compos mentis (+)
Heart rate = 100 x/min
Respiratory rate = 26x/min
Temperature = 36,2C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/-
Skin: Inspection: Petechiae (+) hands and legs

A DHF Grade II
P Patient going well
Aff IVFD Kaen3B, micro drip, 22 dpm 1600cc / 24 Hours.
PCT syrup 3x1 cth
Imboost Force 3x1 cth
Antasida syrup 3 x 1 cth

Hematology Results Normal Value

Haemoglobin 12 g/dL 13-16 g/dL
Leukocytes 9.600/L 5,000 10,000/L
Hematocrits 34 % 40 48 %
Trombocytes 111.000/ L 150,000 400,000/L

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LITERATURE REVIEW

DEFINITION
Dengue hemorrhagic fever is an infectious disease caused by the dengue virus and
its spread through the mosquito Aedes aegypti. Dengue viruses including
Flaviviridae family. Dengue virus is an RNA virus that has four serotypes are
DEN-1, DEN-2, DEN-3, DEN-4. Dengue virus serotypes respectively transmitted
through the bite of Aedes aegypti. Ae aegypti mosquito is the species that live in
tropical and subtropical climates.

There are three factors that play a role in the transmission of dengue infection,
namely human, virus, vector intermediaries. Dengue virus is transmitted to
humans through mosquito bites. Mosquitoes can transmit the dengue virus to
humans either directly that, after biting a human being viremia, or indirectly ie
after the incubation period in the mosquito's body for 8-10 days (extrinsic
incubation period). In humans it may take 4-6 days (instrinsic incubation period)
before becoming ill after the virus into the body. In mosquitoes, once the virus can
enter and multiply in the body, then the mosquito can transmit the virus will
during his lifetime (infective). Whereas in humans, infection can only occur when
the state of viremia is between 5-7 days.
VIRUS

VEKT
HOST
OR

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ETIOLOGY
Dengue fever and dengue hemorrhagic fever caused by dengue virus, which
belongs to the genus Flavivirus, family Flaviviridae. Flavivirus is a virus with a
diameter of 30 nm composed of a single chain of ribonucleic acid with a
molecular weight of 4x106. There are four serotypes DEN-1 virus which, DEN-2,
DEN-3, DEN-4 that all of his can cause dengue fever or dengue hemorrhagic
fever. Fourth serotypes found in Indonesia with serotype DEN-3 is the highest.

PATHOPHYSIOLOGY
Secondary dengue virus infections cause changes in homeostasis. Antigen-
antibody complex activates the coagulation system which starts from factor XII
(Hageman) become active factor XIIa. The next factor XIIa activates other
coagulation factors sequentially follow a cascade shingga formed fibrin. Besides
that, in addition to the coagulation system, factor XIIa activates fibrinolysis
system, kinin system and the complement system which is entirely give you an
idea how complex consequences caused by the dengue virus.

Generally clinical symptoms of bleeding can be found as a result of severe

thrombocytopenia, bleeding time and prothrombin time elongated, decreased
levels of clotting factors II, V, VII, VIII, IX and X together hipofibrinogenemia
and increased fibrin split products (FDP). While activation of kinin system will
lead to increased permeability of blood vessels with consequent leakage of plasma
which is characterized by an increase in hematocrit and effusion of serous fluid.
Bradykinin formation will lead to dilation of blood vessels which can progress to
hypotension. Various haematological disorders have been shown to accompany
the journey of DHF, this state is used as a support for the diagnosis and
appropriate treatment.
Hematocrit values typically begins to rise on the third day of the course of the

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disease. As already mentioned that peningkatana hemokonsentrasi hematocrit
values are manifestations that occur due to leakage of plasma into space
extravaskular with effusion of serous fluid, through the broken capillaries. Due to
this leakage, the volume of plasma to be reduced which may result in
hypovolemic shock and circulatory failure. Hemoglobin value on the first day will
be normal even slightly decreased but then increased following the increase in
hemoconcentration and an early abnormalities were found in DHF.

Leukopenia mild to moderate may occur between the first day and the third day
with a count that is still within normal limits. Will decrease the number of
granulocytes in the third to the eighth day. In shock severe leukocytosis with
absolute neuttropenia.
Thrombocytopenia is one simple criteria proposed by WHO as dengue diagnosis.
Platelet counts are usually still normal during the first 3 days. Thrombocytopenia
began to appear a few days after the heat, and reached its lowest point during the
shock.

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 CLINICAL MANIFESTATION

Dengue infection is systemic and dynamic. Diseases caused can be asymptomatic, dengue
fever, dengue hemorrhagic fever, dengue shock syndrome. Based on the WHO Guidelines
of 2009, dengue fever is divided into 3 phases.

Febrile Phase

In this phase, the patient experienced sudden high fever. This phase occurs about 2-7 days
without typical symptoms. Symptoms are visible facial redness, skin erythema, muscle
pain, joint pain, headaches in some cases were sore throat, conjunctival hyperemia. This
phase can not be distinguished from the other fevers, but positive torniquet test can rule
out the possibility of another fever. Petechiae or bleeding in other areas, hepatomegaly
can be found in this phase.

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Critical Phase

Tempratur going down 37.5oC - 38oC fever 3-7 day. In this phase, increased capillary
permeability, hematocrit levels can also be increased. Plasma leakage will occur in 24-48
hours. Progressive leukopenia was also obtained in this phase. Capillary permeability can
also be normal. Pleural effusion and ascites can be found in line with the volume of
plasma leakage. If the change of fluid at this stage is not adequate then the patient will
fall on the phases of shock and risk of progressive organ damage, metabolic acidosis,
DIC.

Recovery Phase

If the patient can last 24-48 hours after the critical phase, then gradual reabsorption of
extravascular interstitial to happen and the patient will begin to improve after 48-72
hours. General condition will improve, increased appetite, gastrointestinal symptoms
improved, and diuresis improved hemodynamic status. "Isles of white in the sea of red"
usually occur and patients experiencing pruritus.

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DIAGNOSIS

Four Grades of DHF

Grade 1
Fever and nonspecific constitutional symptoms
Positive tourniquet test is only hemorrhagic manifestation
Grade 2
Grade 1 manifestations + spontaneous bleeding
Grade 3
Signs of circulatory failure (rapid/weak pulse, narrow pulse pressure, hypotension,
cold/clammy skin)
Grade 4
Profound shock (undetectable pulse and BP)

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DIAGNOSTIC PROCEDURES:
Exams,Tests and Laboratory Test

A physical examination may reveal:

Enlarged liver (hepatomegaly)
Low blood pressure
Rash
Red eyes
Red throat
Swollen glands
Weak, rapid pulse
Tests may include:
Arterial blood gases
Coagulation studies
Electrolytes
Hematocrit
Liver enzymes
Platelet count
Serologic studies (demonstrate antibodies to Dengue viruses)
Serum studies from samples taken during acute illness and convalescence
(increase in titer to Dengue antigen)
Tourniquet test (causes petechiae to form below the tourniquet)
X-ray of the chest (may demonstrate pleural effusion)
nucleic acid detection by PCR,
viral antigen detection or specifica ntibodies (serology).

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TREATMENT
The clinical spectrum of dengue infection includes asymptomatic infection, DF
and DHF, which is characterized by plasma leakage and haemorrhagic
manifestations.
Dengue fever patients can be treated the way, do not need to be treated. In the
phase of fever patients is recommended
Bed rest, as long as the fever.
Drugs antipyretic or warm compresses given if necessary.
To lower the temperature to <39 C, recommended giving paracetamol.
Aspirin / salicylate is not recommended (indication counter) therefore can cause
gastritis, bleeding, or acidosis.
It is recommended elektrolit oral fluids, fruit juice, syrup,milk, besides water, is
recommended at least given for 2 days.
Monitor the temperature, the number of platelets and hematokrit until
convalescent phase.

In patients with DF, when the temperature drops is generally a sign of healing.
Nevertheless all patients should be observed for complications that can occur
during 2 days after the temperature dropped. This is caused by the possibility it is
difficult to distinguish between DF and dengue fever phase. Differences will be
evident when the temperature drops, ie the healing whereas DF will occur in DHF
are early signs of circulatory failure (shock). Bleeding complications may occur in
DF without symptoms of shock. Therefore, parents or patients advised if severe
abdominal pain, bowel movements black, or there is a skin and mucosal bleeding
such as nosebleeds, bleeding gums, especially when accompanied by cold sweats,
it is a sign of the gravity, so it should be taken immediately to hospital. In patients
who did not experience complications after the temperature dropped 2-3 days, no
longer need to be observed.
Plasma Volume Replacement

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Basic pathogenesis of DHF is plasma leakage, which occurs at a temperature
decline phase (a-febrile phase, the phase of the crisis, the shock phase), the basic
treatment is the replacement of lost plasma volume. However, replacement fluids
should be administered with a wise and careful. Initial fluid requirements are
calculated for the first 2-3 hours, while in the case of shock may be more frequent
(every 30-60 minutes). Droplets within the next 24-28 hours should always be
matched with vital signs, hematocrit, danjumlah urine volume. Fluid volume
replacement should be adequate, sufficient minimum plasma leakage. In general,
the volume required is the amount of maintenance fluids plus 5-8%.
Intravenous fluids are required, if
(1) The child is vomiting continuously, do not drink, high fever that does not
rnungkin given drink by mouth, fear of dehydration that accelerates shock.
(2) The value of hematocrit tend to increase the periodic inspection. The amount
of fluid given depends on the degree of dehydration and loss of electrolytes, fluids
recommended 5% glucose in 0.45% NaCl solution. If there is acidosis, given
sodium bicarbonate 7.46% 1-2 ml / kg intravenous bolus slowly. If there
hemokonsentrasi 20% or more, the composition of the fluid given should be equal
to the plasma. The volume and composition of the fluid needed appropriate fluid
for dehydration in diarrhea, mild to moderate, namely maintenance fluid deficit +
6% (5 to 8%).

COMPLICATION
The emergency of Dengue Hemorrhagic Fever

The main clinical manifestations of dengue hemorrhagic fever (DHF) is a high

fever (> 39oC until hyper- pireksi 40-41oC), bleeding and circulatory failure.
Often there are complaints epigastric, tenderness at the right costal edge,
abdominal pain may be accompanied by a thorough and seizures. DBD urgency is

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particularly acute medical urgency involving hematological and cardiovascular
systems.

The phenomenon of bleeding in DHF associated with vascular changes, decreased

platelet count (<100,000 / l) and coagulopathy. Bleeding tendency seen in a
positive tourniquet test, petechiae, purpura, ecchymosis, and gastrointestinal
bleeding such as hematemesis and melena.

Circulatory dysfunction or shock in DHF (dengue shock syndrome = SSD), which

usually occurs between 2-7 days to the sick, caused by increased vascular
permeability, causing plasma leakage, fluid serous effusion into the pleural and
peritoneal cavity, hypo- proteinemia, hemokonsentrasi and hypovolemia, resulting
in reduced venous return, preload infarction, stroke volume and cardiac output,
resulting in circulatory dysfunction and decreased organ perfusion. Renal
perfusion disorder characterized by oliguria or anuria, whereas perfusion of the
central nervous system disorder characterized by loss of consciousness.

In the initial phase SSD vital organ function of hypovolemia maintained by

homeostatic system in the form of tachycardia, vasoconstriction, strengthening
myocardial contractility, tachypnea, hyperpnea, and hyperventilation. Peripheral
vasoconstriction reducing non-essential perfusion in the skin that cause cyanosis,
a decrease in the body's surface temperature and elongation of capillary refill time
(> 5 seconds). Differences in skin temperature and body temperature of more than
2oC shows homeostatic mechanism is still intact. At this stage of compensation
SSD cardiac output and blood pressure back to normal. Decrease in blood
pressure is a late manifestation on SSD, which means the system is disturbed
homeostasis, severe hemodynamic abnormalities, and there has been a
decompensation. At first pulse pressure fell less than 20mmHg for example
100/90, therefore systolic pressure fell in line with decreased venous return and
stroke volume, whereas diastolic pressure rises in accordance with an increase in
vascular tone. Dengue shock syndrome continues with the failure mechanism of
homeostasis. Effectiveness and integrity of the cardiovascular system is damaged,
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myocardial perfusion and cardiac output decreased, macro and micro circulation is
interrupted, tissue ischemia, damage cell function progressively and irreversibly,
resulting in damage to cells and organs, and patients will die within 12-24 hours.

Prognosis depends on the introduction of the gravity of DHF, appropriate

treatment, immediate and strict monitoring of shock. Once the SSD is resolved
though heavy, healing will occur within 2-3 days. A sign of good prognosis is
improving tachycardia, tachypnea and awareness, sufficient diuresis and appetite
arise. Long trips severe dengue is 7- 10 days. In the convalescent period DHF
usually found bradycardia or arrhythmias.

PROGNOSIS
DBD prognosis based on the success in but and penetalaksanaan done. Proper and
prompt treatment will provide optimal results. Management of late will lead to
complications and management are not adequately tapat and will worsen the
situation. Deaths due to dengue fever is almost non-existent. In DHF / SSD
mortality is quite high. Research on adults in Surabaya, Semarang, and Jakarta
indicate that the prognosis and course of the disease is generally milder in adults
than in children.
DHF Grade I and II will give a good prognosis, management of rapid, precise will
determine the prognosis. Generally DHF Grade I and II did not cause
complications that can recover completely.
DBD degrees III and IV are degrees of dengue shock syndrome in which patients
fall into a state of shock with or without loss of consciousness.
Prognosis given appropriate management, Dubia at bonam

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REFERENCES

IDAI. 2000. Demam Berdarah Dengue. Jakarta. Balai Penerbit Fakultas

Kedokteran Universitas Indonesia
Murray Natasha. Quam B Mikel. Wilder-Smith Annelies. 2013. Epidemiology of
dengue: past, present, future prospect. Jerman. Institute of Public Health.
Dovepress Clinical Epidemiology.
Novie Homenta Rampengan. Mulya Rahma Karyanti. Sri Rezeki Hadinegoro.
2011 Ensefalopati Dengue pada Anak. Jakarta. Departemen Ilmu Kesehatan Anak
FK UI/RS Dr. Cipto Mangunkusumo.
Seok Mui Wang. Shamala Devi Sekaran. 2010. Early Diagnosis of Dengue
Infection Using Commercial Dengue Duo Rapid Test Kit for the Detection of
NS1, IGM and IGG. Malaysia. Departement of Medical Microbiology.
Vijayalakshmi. Jayavardhana. 2013. Febrile Rash and Convalescent Rash of
Dengue Fever. India. Departement of Pediatric.
WHO. 2009. Dengue Guidelines For Diagnosis, Treatment, Prevention And
Control. Perancis. WHO

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