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Dengue Fever case study

Nursing (Capitol University)

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DENGUE FEVER: A CASE OF 9-YEAR OLD FEMALE CHILD FROM SILAO, POBLACION 1,

VILLANUEVA, MISAMIS ORIENTAL

A Case Study presented to

The Faculty of the College of Midwifery

Tagoloan Community College

In Full Fulfilment

of the Requirements for the Degree

Bachelor of Science in Midwifery

JULIE ANN G. ABAO

MARL FRANCIS C. ABAO

GAVILYN L. CASIPLE

MARIA FE T. CASTILLO

MELIZA O. MASKARINO

MAE ANNE JOY T. ORGANIZA

RUTH I. SALMASAN

MAY 2022

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ABSTRACT

Dengue is the major cause of arthropod-borne viral disease in the world. It presents
with high fever, headache, rash, myalgia, and arthralgia and it is a self-limiting illness.
Severe dengue can occur in some cases resulting in dengue hemorrhagic fever (DHF) and
dengue shock syndrome (DSS). We present a case of a 9-year-old female patient of high-
grade fever, bilateral subconjunctival hemorrhages, abdominal pain, headache and body
malaise. After investigations, he was diagnosed with dengue fever with possible signs of
hemorrhagic dengue fever. Upon assessment by hospital physician, the patient was known
to be malnourished as manifested by low weight according to her age. Her family was also
on the poverty line which leads to poor environmental sanitation and other factors which
may lead to poor persona hygiene. The surrounding neighbors had stagnant water canals
over the area which could be a possible breeding site for mosquitos. Upon further
investigation, there is evidence of variable presentations of dengue fever after the disease
burden is increased, and thus, diagnosing with such manifestations can be very
challenging.

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ACKNOWLEDGEMENT

With the great honor, pride and respect, the proponents would like to personally

convey their gratitude to the following individuals who are in one way or another, had

contributed in the success of this academic endeavor.

Our Professors and instructors for their valuable suggestions, recommendations and

guidance on the refinement of this case study.

Michael Vincent M. Gadiane, RN, MAN, MPA for his expertise, insightful comments,

worthy suggestions, and recommendations for the improvement of this study.

Parents and family members who are very supportive to the quest of knowledge of

the case study, for understanding and showing their unconditional love.

Friends who have shared ideas and other sources of information related to our study,

their presence motivates the researcher to take more proactive leap to finish this academic

pursuit.

Above all, to the ALMIGHTY FATHER from whom the researchers have borrowed

their lives and who has given the strength and wisdom, this piece of work is humbly

dedicated.

THE RESEARCHER

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INTRODUCTION

Dengue is the foremost cause of arthropod-borne viral disease in the world and due to
severe muscle aches. It is transmitted through Aedes mosquito and commonly found in
tropical and subtropical parts of the world. The incidence of dengue has substantially
increased over the past few decades. It was estimated in a study that 3.9 billion people are
at risk of infection with dengue viruses in the world and Asia is the most affected part. A
seasonal pattern of dengue linked to climate. In Pakistan, the highest dengue cases are
reported during July-September due to more rainfall, optimum temperature, and humid
environment which are ideal for breeding of Aedes mosquitoes. Last year, the outbreak was
first reported on 8 July 2019 in Peshawar city. A total of 47,120 confirmed cases of dengue
fever, including 75 deaths, were reported during the outbreak period in the entire country.

Dengue fever is caused by one of the four distinct serotypes (DENV 1-4) of single-stranded
RNA Flavivirus genus. Infection caused by one serotype results in lifelong immunity to that
serotype, but not to others. Dengue fever (DF) presents with high fever, headache, rash,
myalgia, and arthralgia, and case fatality is less than 1%. Severe dengue, dengue
hemorrhagic fever (DHF), and dengue shock syndrome (DSS) are accompanied by
thrombocytopenia, vascular leakage, and hypotension. DSS is characterized by systemic
shock, which can be fatal with case fatality high as 12% to 44%.

There are few atypical manifestations of dengue fever growing with rising disease burden,
often missed and sometimes difficult to comprehend the case collectively. In this case
report, we will discuss atypical manifestations observed in dengue fever patients.

In the Philippines, there were reported cases of Dengue Fever which may lead to severe
cases like hemorrhagic fever and even death after the onset of the signs and symptoms.
Dengue fever in the Philippines are seasonal through the manifestation of climate change,
in the middle of the year, case of dengue fever is increasing and most vulnerable clients are

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children. Due to poor environmental sanitation as manifested by our client for this study, the
Purok Silao in Poblacion 1, Villanueva, Misamis Oriental has the most cases of dengue
fever in the Municipality

Findings from dengue studies could provide policy-makers with information needed for
rational decision-making regarding dengue preventive and control efforts. The focus of
dengue research may vary widely. This could include basic laboratory research, the
estimation of dengue seroprevalence and incidence; the assessment of risk factors for
severe disease; the quantification of its economic burden; the elucidation of local
transmission and epidemiology; the development of improved diagnostic tests or the
evaluation of interventions.

We reviewed published studies on dengue research in the Philippines during the past 60
years. The objective of the review is to better understand the trends in dengue research
and the findings from these studies. The results of the review could provide an impression
of local capacity and infrastructure for dengue research and help determine important
knowledge gaps. These gaps need to be identified since research interest and support for
funding can only be achieved if scientists, decision makers and other stakeholders are able
to understand developments related to the disease and recognize areas where more
information is needed.

SIGNIFICANCE OF THE STUDY

Midwifery Education

On the aspect of Midwifery Education, the main significance of the study if to build
and standardized researchers and case study towards Dengue Fever. Midwifery students
should learn the comprehensive way of assessing clients from physical, mental, emotional
and social aspects to properly understand the study. The tool mechanism of the study
should be based on the patient’s holistic experience about the disease and how these
disease affects the life of an individual. As primary health care providers of health services
in the community and even in the hospital setting, Midwives should understand that this
disease exist and we should learn how to address them accordingly to save patient’s lives.

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Midwifery Practice

In the practice of Midwives especially on the community and hospitals, we this study
will promote optimism and broad understanding about the disease itself. Dengue fever is a
disease that need immediate attention and intervention, and as health care providers, we
should learn when, how and where to refer these kind of health problems. Thus, prior to the
referral approach, Midwives should also know how to intervene this disease like primary
health care intervention relative to hydration, pharmaceutical management and other way to
prevent severe complications about this disease.

Midwifery Research

On the approach of Midwifery research, we need further and continuous research

regarding this disease especially on the surveillance and management approach. We have
series and tons of researches regarding dengue fever and yet, there are still increasing
number of case worldwide. Through this study, we may be helpful in standardizing the
approach on research to full eradicate this disease in our country.

OBJECTIVES OF THE STUDY

General Objectives

At the end of this study, the Midwifery students of Tagoloan Community College will
be able to identify the signs and symptoms of Dengue Fever and be able to understand it’s
disease process and manage their patient’s accordingly.

Specific Objectives

At the end of this case study, the Midwifery students of Tagoloan Communtiy College
will be able to:

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a. Endorse to the Local Government Units the importance of creating a Dengue

Technical Working Group for easy surveillance of the disease,

b. Endorse this case study for possible development of integrated vector control
approach on government institution and other concern government and non-
government agencies in the country,

c. Properly develop comprehensive diagnosis and management about this disease,

d. Able to refer the patient to tertiary hospitals and other health facility which can
manage the case of the patient immediately,

e. Intensify Information and Education Campaign (IEC) not only the in community
but even in hospital settings,

f. And lastly, operationalize and effective surveillance system to develop a dengue

epidemic contingency plan for health care workers.

PATIENT’S PROFILE

Below are the data gathered by on the assessment made by the students from a 9-
year old clients from Silao, Poblacion 1, Villanueva, Misamis Oriental.

PARENT’S
Mother: High School Graduate
NAME X EDUATIONAL
Father: Elementary Graduate
ATTAINMENT
GROSS
AGE 9 years old MONTHLY Php 10,000 – Php 15,000.00
INCOME
GENDER Female BIRTHDAY February 5, 2013
Newborn
Silao, Poblacion 1,
ADDRESS Screening NORMAL
Villanueva, Misamis Oriental
Result:
BP: 80/60 mmHg, RR: 22,
Laboratories CBC, Urinalysis, Dengue NS1
VITAL SIGNS Temp: 37.9 Celsius, PR: 92
Taken Antigen
bpm
Signs Fever, Petechiae, vomiting, Primary RURAL HEALTH UNIT OF

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Health Care
Manifested nausea VILLANUEVA
Facility
First Consulting Date of
Rural Health Midwife March 30, 2022
Professional: Consultation
Paracetamol 250/5mg syrup, 8ml
Headache, Abdominal Pain, every 4 hours for fever
Symptoms Medications
Body Malaise, Muscle Pain, ORESOL Hydration sachet, 1
Manifested Taken
Conjuctivitis, Skin Rashes sachet in a glass water to
consumed for 1 hour
Date referred
Referral Northern Mindanao Medical
to Tertiary March 30, 2022
Hospital Center
Hospital:

Patient’s Medical History: No medical History of Diseases.

Physician’s Assessment: A day PTC, patient was manifesting signs and symptoms of
headache and on and off fever with minimal temperature of 37.6 Celsius as verbalized by
the mother through home assessment. Paracetamol was given by the mother with 8ml
every 4 hours, there is a remission in fever but back by 2-hours post medication.

Management Prior to transport to tertiary hospital:

a. Intravenous Fluid started with PNSS 1L then regulated by 20 drops/minute.
b. Paracetamol given same with 8ml
c. Fluid intake and output strictly monitored
d. Referred by the Municipal Health Officer to NMMC Emergency Pediatric
Department

ANATOMY AND PHYSIOLOGY

Classic dengue fever mainly affects the adults and older children, characterized by
the rapid onset of fever and a variety of symptoms, including retro-orbital pain, frontal
headache, nausea and vomiting, body aches, joint pains, weakness and maculopapular
rashes. Anorexia, altered taste sensation, sore throat, diarrhea, constipation and respiratory
symptoms are reported infrequently in classic dengue patients. Dengue fever starts with
headache, chills, pain upon moving the eyes, low backache, painful aching in the legs and
joints with abrupt rise in temperature upto 104 °F (40 °C), bradycardia and hypotension.

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Usually the rash appears on trunk spreading to the extremities and face with an average
duration of 2 to 3 days. The end of the febrile phase leads to fall in temperature,
appearance of petechiae, intense pruritus following desquamation on palms of the hands
and soles of the feet. The most common symptoms are the petechiae and purpura with
bleeding gums, menorrhagia, gastrointestinal (GI) hemorrhage and epistaxis.

Dengue hemorrhagic Fever (DHF) mainly affects the children under 15 years of age and is
characterized by rapid onset of fever and headache usually lasts for 2 to 7 days causing
hemorrhage (bleeding), abdominal pain, and circulatory collapse (shock). Respiratory and
intestinal symptoms may appear along with sore throat, nausea, vomiting, cough, and
abdominal pain. After DHF symptoms appear, shock occurs 2 to 6 days with sudden
collapse, weak pulse, clammy extremities and circumoral cyanosis (blueness around the
mouth). In DHF, there is bleeding with easy bruising, petechiae (blood spots in the skin),
hematemesis (spitting up blood), melena (blood in the stool), gum bleeding, and epistaxis.
Vascular leakage in DHF results in serous effusions and hemoconcentration leading to
circulatory collapse.

It is very difficult to differentiate between DHF from classical dengue fever during acute
phase of illness, in which the differential diagnosis should include measles, influenza,
rubella, leptospirosis, typhoid, malaria and other viral fevers. During acute stage no
pathognomic symptoms and signs of DHF appears while in the critical stage sign of
circulatory failure may occur within 24 hours before or after the temperature falls to normal
or below. The plasma leakage in dengue fever patients leads to dengue shock syndrome
resulting in severe hypotension and undetectable pulse rate. The patients in dengue shock
syndrome may die within 8 to 24 h while antishock therapy may lead to rapid recovery
usually 2 to 3 days.

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Image 1: Signs and Symptoms associated with Dengue Fever

Pathogenesis of Dengue:

 Dengue virus after entering in the body invades the local macrophages and multiply
there.
 Infected local cells then migrate from site of infection to lymph nodes, where
monocytes and macrophages are recruited, which become targets of infection.
 Consequently, infection is amplified and virus is disseminated through the lymphatic
system. As a result of this primary viremia, several cells of the mononuclear lineage,
including blood-derived monocytes
 Viremia develops within 24 hours. During this period, virus travels throughout the
body.
 Bone marrow cells have also been shown to be susceptible to infection with DENV
 In severe case, viral load is very high and many vital organs are affected.
 Virus infected macrophages produces a number of signaling proteins such as
interferons, cytokines, chemokines, TNF, other mediators which are responsible for
many symptoms such as flue like syndrome and pain.
 These mediators affects hemostatic system of body.
 Fluid from blood vessels starts to leak out so that the blood volume decreases
resulting in low blood pressure.
 Decrease in blood pressure causes insufficient supply of blood and Oxygen to vital
organs such as brains.
 Dengue also infects bone marrow, so that bone marrow cannot produces sufficient
platelets.
 Since platelets are needed for blood clotting, dengue infection causes blood clotting
defect and increase the risk of bleeding.

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Image 2: Dengue Pathogenesis and disease process of Dengue Fever

PATHOPHYSIOLOGY

The pathophysiology of DENV and the immune response of the host are not fully
understood. Primary manifestations of disease include capillary leak syndrome (plasma
leakage due to DHF-specific endothelial cell dysfunction), thrombocytopenia (seen in all
types of DENV infection, but extreme in DHF), hemorrhagic tendencies, and leukopenia. It
is known that the major viral envelope (E) of glycoprotein in the virus helps to bind the host
cells, followed by viral replication. Data suggest that monocytes are the primary target.
Infected monocytes induce the production of interferon-a (IFN-a) and IFN-b. Envelope (E),
precursor membrane protein (pre-M), and nonstructural protein 1 (NS1) are the major
DENV proteins targeted by antibodies as part of the host immune response. Studies have
shown that DENV-specific CD4+ and CD8+ T lymphocytes attack infected cells and release
IFN-g, tumor necrosis factor-a (TNF-a), and lymphotoxin. Primary infection induces a
lifetime immunity of the individual to that particular serotype, but not to secondary infection
by another serotype.

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Figure 1: Pathophysiology of Dengue Fever associated with Hemorrhagic Problems

DIAGNOSTIC TEST

To ensure patient’s clinical assessment, a diagnostic test was done upon the
Physician’s Order;

COMPLETE BLOOD COUNT

Date taken: March 30, 2022

EXAMINATION RESULT NORMAL RANGE

Female: 11.7 – 14.5 g/dl
Hemoglobin 11.9
Male: 13.7 – 16.7 g/dl
Female: 34.1 – 44.3 vol%
Hematocrit 46.7
Male: 40.5 – 49.7 vol%
WBC Count 3,200 5,000 – 10,000/mm3

Platelet Count 109,000 150,000 – 400,000/mm3

Segmenters 68% 45% - 65%

Lymphocyte 22% 20% – 45%

Monocyte 7% 4% - 8%

Eosinophils 2% 1% - 3%

Basophils 1% 0% - 1%

TOTAL 100%

URINALYSIS
Date taken: March 30, 2022

SEDIMENTS: RESULT

Pus Cells 0-1

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Red Blood Cells 0-1

Epithelial Cells Rare

DENGUE NS1 ANTIGEN TEST:

Date taken: March 30, 2022
“POSITIVE” NS1 TEST
DEFINITION OF TERMS:

These are the terms used to define the medical aspect of this study:

DENGUE FEVER. A viral disease that is cause by mosquito bites and thus fatal
among children as manifested by increasing number of mortality and morbidity rates
reported by the Department of Health.

COMPLETE BLOOD COUNT. A clinical laboratory test which is primary needed to

determine the platelet count and hematocrit count of patient’s that is suspected to have
Dengue Fever.

DENGUE NS1 ANTIGEN. A laboratory antigen that identifies the level of antigen in
the body which is related to dengue fever disease. Thus, this laboratory result is not 100%
accurate for the detection of positive result may be associated with other diseases related
to Dengue Fever.

REFERRAL SYSTEM. Referral system is needed to immediately respond to the

need of the patient towards medical management. For Dengue Fever, patient’s need
tertiary hospital to properly monitor the prognosis of Dengue Fever.

NOTHERN MINDANAO MEDICAL CENTER. An apex hospital for the Province of

Misamis Oriental which is a level 3 health facility that caters emergency cases including
Dengue Fever.

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RURAL HEALTH UNIT OF VILLANUEVA. A level health care facility in the

Municipality of Villanueva which accommodates patients with primary health care. This is
also the center for referral system in the Municipality.

BIBLIOGRAPY

International Network (Internet) Site as reference

Nature Reviews Microbiology. BARRIERS TO PRECLINICAL INVESTIGATIONS OF ANTI-

DENGUE IMMUNITY AND DENGUE PATHOGENESIS. Ashley L. St. John, Et. Al.,. May 8,
2013.

Hindawi Journals. A CURIOUS CASE OF DENGUE FEVER: A CASE REPORT OR

UNORTHODOX MANIFESTATIONS. Raja Shakeel Mushtaque. July 20, 2020.

Cereus Journals. A CASE OF DENGUE FEVER WITH HEMORRHAGIC

MANIFESTATIONS. Muhammad Ali Raza. June 12, 2020

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