Monday, September 14, 2009

What could be her diagnosis? Part 2

She was 24 years old, mother of a 2-year-old child. She developed high-grade fever and was admitted in another small hospital nearby 4 days ago. She was discharged yesterday as she was apparently all right. Early this morning she developed tummy pain, vomiting and drowsiness and was admitted to my hospital.

She was really sick. Though drowsy she answered my questions. During her previous admission she only had fever and headache. No cough or breathlessness or loose stools. There were no joint pains too. Now from last night she is having vomiting, extreme tiredness and tummy pain.
On examination there was no fever. She seemed to have distension of her tummy more than that is expected of her 3 months of pregnancy. Her chest [lung] expansion was also less and the oxygenation low. Blood pressure was only 70/50 with almost no urine output for last 4 hours though her urinary bladder was catheterized.

By the time I saw her 3 pints of intravenous fluids had been transfused with no increase in blood pressure.

Is it a ruptured ectopic pregnancy?

A patient in early pregnancy coming with tummy pain and very low blood pressure should be considered as a ruptured ectopic unless proved otherwise.

I know the Gynaecologist must have ruled it out already before referring to me.

Yes she has by an ultra sonogram, which showed normal uterine pregnancy with a live foetus.

Ultra sonogram also showed moderate amount of free fluid in the peritoneal cavity and also in both sides of the chest inside the pleural space. That explains her abdominal distension and reduced lung expansion.

Now I looked at the lab results. Total WBC count is 3400 with 80% neutrophils while the Platelet count was 90 thousand. Both low. The Packed Cell Volume was 39% with a normal ESR. The liver enzyme SGPT [ALT] was high at 1050 with SGOT [AST] at 350. Rest of the lab values were normal. ECG was normal too.

What could be her diagnosis?

This was my post last week.

What did I do? I began to go thru the data again in my mind.

After 5 days of fever she developed shock. So an infection must be the cause.

Bacterial or Viral or Malaria?

Low WBC count usually rules out Bacterial infection. The pattern of fever and lack of history of travel to Malaria prone areas should rule it out. [Mercifully Kerala has almost zero cases of indigenous Malaria. All our Malarial fevers are imported from neighboring States].

So it must be a viral infection. Many viral infections cause low WBC count and low Platelet count. But only a few can cause Shock. In this rainy season such a viral infection producing shock can only be Dengue Shock Syndrome.

Any other clue that suggests Dengue infection?

Yes the moderate amount of free fluid in the peritoneal and pleural cavity. [Abdomen and chest]. This is classically seen in DSS due to increased capillary permeability causing plasma leak in to those spaces.

The low platelet count can cause bleeding if it falls below 20000.Then it is called Dengue Hemorrhagic fever.

The diagnosis is by detection of the virus by RT-PCR, which is very costly and the result may reach my place only after a week or by detection of antibody against the virus, which may become positive only after 7-10 days.

As the treatment is symptomatic with pumping in of large amount of fluids and if needed platelets and plasma, I did not send a blood sample for antibody detection at that time.

I started the treatment earnestly. Fortunately the relatives had confidence in my institution and me. Her urine output improved in a day and after about 3 days of pumping in of so many bottles of fluids and plasma her blood pressure started coming up.

Initially her PCV [packed cell volume] was high due to plasma leakage and blood concentration. Later it began to fall showing the treatment is effective. Rarely fall in PCV may also be due to bleeding. So a careful watch for bleeding is required.

I send the blood sample for diagnosis only on the 3rd day of admission. By that time she was shifted out of ICU. When the result came as positive for Dengue infection she was well in to the road of recovery.

When she was discharged on the 9 Th day of admission her Ultra sonogram showed a normal live foetus and no free fluid in the peritoneal and pleural cavities.

I have seen several patients with features of Dengue fever this season. All most all of them recovered without going in to shock as I pushed lot of intravenous fluids suspecting Dengue in all patients with high fever, headache, no joint pain, low WBC and low platelet.

There is a significant increase in Dengue fever cases this year in South India as evidenced by news reports. Large number of cases has also been reported from Sri Lanka.

I am hoping that all my patients with Dengue fever will recover fully like the patient in the story.


Anonymous said...

A relative of ours had Dengue last year, and for a long time it wasn't diagnosed, and she kept getting weaker! Similar symptoms I remember, but I am so glad you started intravenous fluids without wasting any time!!

Bindhu Unny said...

Wish all the cases get the right treatment.

Seema said...

Never knew about DSS before. Good piece on Information. Wish you the best for always overcoming diagnosis dilemmas

Charakan said...

IHM, In a patient with high grade fever without cough or cold,but only headache and severe muscle and bodyaches during and immediately after rainy season in India, Dengue is very probable diagnosis. The rule is to start symptomatic treatment without waiting for diagnosis.
I was right here and the Patient went home all right. Some times it is not that smooth.Will post about some wrong/delayed diagnosis soon.

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