50 F altered sensorium secondary to ?dengue encephalitis? Hepatic encephalopathy ? Uremic encephalopathy? Which form a part of expanded dengue syndrome.

 December 31, 2022

 I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan

50yr old female came to casualty with complaints of fever since 7days 

C/o dry cough since 7days 

C/o breathlessness since 4days 

C/o abdominal distension since 4days 

C/o decreased urine output since 4days 

History of present illness

  she was apparently alright 7days ago then she developed fever associated with chills insidious in onset, not associated with myalgia or arthralgia 

H/o dry cough since 7days , no seasonal variation or diurnal variation , not associated with blood, fever associated with decrease in appetite 

On day 1 of illness she sought for consultation at RMP, and was taking treatment at home

On day 3 of illness, she was having c/o breathlessness gradually progressive from grade 1 to 5 HYHA

H/o abdominal distension since 4days gradually progressive to present size associated with abdominal pain 

No sob or no c/o PND / Orthopnea 

H/o decreased urinary output since 4days 

No hematuria, blood in stools or other bleeding manifestations complaints 

C/o giddiness since 4days 

No c/o hematuria/ear ache /vertigo

K/c/o type 2DM since 1 year 

Surger referral notes:

Nephrology referral notes:

Personal history :

Appetite: decreased

Diet: mixed

Bowel and bladder: regular

Sleep: adequate

Addictions: occasional alcoholic and toddy drinker

Menstrual history:

Age of menarch: 12 years

Cycles regular

Attained menopause

Obstretric history: nulliparous

Family history: insignificant

General examination :

Patient was conscious coherent and cooperative at the time of admission

Pallor: present

Icterus: present

Cyanosis

Clubbing

Lymphadenopathy

Edema

Local examination

Petechiae seen on arm and fore arm

Bedsores and anal tags

Vitals:

GCS: E2V5M3 improved to E4V5M4 on31/12/22

E4V5M6 on1/1/23

Temp:

Vitals:

GCS: E2V5M3 improved to E4V5M4 on31/12/22

E4V5M6 on1/1/23

Temp:

Q

Bp: 130/80 mmHg

HR: 82 bpm

Spo2: 98%on ra

Grbs:

Apraxia chart:

4/1/23

8pm: 415 mg/dl insulin@ 6ml/hr(31/12/22)

10pm:573 mg/dlinsulin@8ml/hr

2am: 339mg/dl@4ml/hr

7am:276mg/dl@3ml/hr

9am:312mg/dl@3ml/hr

I/O: 2750/900ml

5/1/23

8am: 312 mg/dl (1/1/23)

1pm:246 mg/dl 8u Hai given

3pm:232mg/dl

5pm:180mg/dl

7pm: 179 mg)dl

9pm:212mg/dl :8uHai given

12am: 297mg/dl

6am:214mg/dl 4u hai given

I/O: 1900/1050ml

Systemic examination:

CNS:

Level of consciousness: conscious and slightly irritable

Patient was conscious coherent cooperative on1/1/23

Speech; not able to speak

Normal on1/1/23

Nomeningeal signs

Cranial nerves ;

1) olfactory nerve ; percieves smell on both sides

2) optic nerve : normal visual acuity

3) occlomotor nerve ; normal

4) trochlear nerve ;  normal

6) abducens nerve ; normal

(3,4,6 cranial nerves) ; ptosis,squint, nystagmus - absent.

* Ocular movements- present in upward,downward,temporal,nasal gaze

* Pupil- size- normal,shape- central

* Visual reflexes- direct, indirect- reacting to light

5) Trigeminal nerve ; cutaneous sensibility over skin and mucous membranes - present

✓ corneal reflex- present on both sides

✓ deviation of jaw on opening mouth- absent

7) facial nerve; normal

8) vestibuli cochlear nerve; normal

9) glossopharyngeal nerve; Taste sensation on posterior 1/3rd of tongue - present on both sides

✓palatal reflex- present on both sides

10)vagus nerve ; no history of regurgitation of fluids through nose

Palatal reflex- present

11) spinal accessory nerve ; normal

12) hypoglossal nerve ; normal

Motor system

Gait: not able to walk

Power  U/L         L/L

   Right   2/5         restrained

    Left      2/5        restrained

Tone        U/L                    L/L

Right       Normal        Normal

Left          Normal             Normal 

Reflexes   Biceps triceps supinator knee ankle 

Right             +             +            -            +.         -

Left                  +             +.          -         +.         -

On1/1/23

Tone: normal in all limbs

Power: U/L.  L/L

RT.     4/5      3/5

LT.      4/5     3/5

Reflexes: B  T  S   K   A.  P

RT.         : +. +  +    +.  -.  Flexion

LT.          : +  +  +   +.  -  flexion

Cerebellar signs : no

No meningeal signs

2/1/23

GCS: E4V5M6

Tone: normal in all limbs

Power: U/L.  L/L

RT.     4/5      4/5

LT.      5/5     5/5

Reflexes: B   T  S   K   A.  P

RT.         : ++ +  -   +.  -.  Flexion

LT.          : +  +  -  +.  -  flexion

Cerebellar signs : no

No meningeal signs

3/1/23:

GCS: E4V5M6

Tone: normal in all limbs

Power: U/L.  L/L

RT.     4/5      4/5

LT.      4/5     4/5

Reflexes: B   T  S   K   A.  P

RT.         : ++ ++ +  ++  + Flexion

LT.          : ++  +  +  ++ + flexion

Cerebellar signs : no

No meningeal signs

Pupil : reacting to light

Conjunctival reflex +

Corneal reflex+

Sensory system ; normal

No cerebellar signs

No meningeal signs

CVS:

Inspection;

Position of trachea ;midline

No visible pulsations,no raised jvp

Precordial bulge : absent

Shape of chest; bilaterally symmetrical

Apex beat ; left 5th inter costal space1cm medial to mid clavicular line

Palpation; no palpable thrills,parasternal heaves are palpable

Percussion ; 

Auscultation; S1,S2 heart sounds are heared , no added murmurs,

RS:

Inspection of upper respiratory tract;

Oral cavity ; normal

Nose; no DNS,polyp

Pharynx ; normal

Lower respiratory tract;

Position of trachea; midline

Position of Apex beat; left5ics 1cm medial to mid clavicular line

Symmetry of chest : symmetrical and elliptical

Movement of chest ; normal

 

Palpation ;

Position of trachea,apical pulse is confirmed

No tenderness over chest wall,no crepitation s,no palpable added sounds,no palpable pleural rub

Percussion;

Resonant note heared,no obliteration on traubes space

Auscultation;  Inspiratory crepts in bilateral IAA,ISA

Per abdomen:

Inspection;

Shape; distended due to fluid

Umbilicus; slightly retracted and inverted

Movements ; normal

No visible pulsations or engorged veins,no visible peristalsis

Skin over abdomen ;normal

✓Palpation;

Soft,non tender

No organomegaly

✓Percussion ;

Liver; dullnote heared,

shifting dullness+

No fluid thrills,

✓Auscultation;

Bowel sounds are heared

Provisional diagnosis:

 1. Dengue hemorrhagic fever or expanded dengue fever with polyserositis ( resolved)

2. Altered sensorium (resolved) secondary to?dengue encephalitis/hepatic/ uremic encephalopathy 

3. With prerenal acute kidney injury 

4. Acute liver injury 

6.Grade-1 bed sores

5. Known case of type 2 DM

Investigations:

Hemogram

Day-1. Day -2. Day-3. Day-4. Day-5

HB: 11.2g/dl. - 10.6 g/dl. 10.7 g/dl. 10.9. 9.4

D-6:8.6 Day 7: 8.2 d-8: 8.4 d-9:9.6

Plt c: 20,000. 30,000. 64,000. 1.55 lakh. 1.5 lakh d-6: 80,000 Day7:90,000 d-8: 1.3 lakhs d-9: 90,000

TLC:13.300. -. 12,600 12,500. 15,300. 16,000 d-6: 13,200 day7: 13,000 d-8: 9,200 d-9:8200

Lymphocytes: 30. 30. 30. . 14. 08

Monocytes:10. 10. 13. 10. 19

Neutrophils:60. 60. 60. 75. 82

Eosinophils:00. 00. 01 01. 00

Impression : Normocytic normochromic anemiawith leukocytosis and thrombocytopenia

Day-3 microcytic hypochromic Anemia with leukocytosis and thrombocytopenia

Day-4: Normocytic normochromic blood picture with leukocytosis

Day-5: Normocytic normochromic Anemia with neutrophilic leukocytosis

Day-6: Normocytic normochromic Anemia with neutrophilic leukocytosis and thrombocytopenia

Day7: Normocytic normochromic Anemia with thrombocytopenia

Blood group and typing: o positive

28/12/22 Day-1 Day-2. Day-3. Day-4

PT:. 22secs. 25secs. 27 secs

INR:. 1.62. 1.8. 2

Aptt:. 44secs 47 secs. 49secs

Day-5:

PT: 25 secs,Aptt: 48secs. , INR: 1.8

D6-pT: 20 secs,Aptt:44sec,INR: 1.4

D7-PT: 29secs,Aptt:41secs,INR:1.4

Reticulocyte count

Esr: 30

CUE:

Appearance: clear

Albumin: +

Sugars: nil

Pus cells: 3-6

Epithelial cells: 2-4

Rbcs: nil

Urine for ketone bodies: negative

31/12/22:

Appearance: clear

Albumin: +

Sugars: nil

Pus cells: loaded

Epithelial cells: 4-5

Rbcs: 4-5

Epithelial casts:4-5

Others: candida budding yeast hyphae

RBS: 76

FBS: 199

Plbs:

Hba1c: 7.5%

Thyroid profile:

T3: 0.58

T4: 7.60

TSH:0.40

Serology: negative

LFT: d -1 D-2. D-3 D-4. D-5

TB: 5.67. 6.25. 9.23 10.9. 8.34

DB:5.52. 6.15. 5.13 8.03. 6.37

AST:115. 485. 65 609. 1213

ALT:180. 189. 676 739. 531

ALP:500. 485. 547 392. 431

Total proteins:4.9. 4.9. 5.1 5.9. 6

Albumin:2.2. 2.6. 2.84 2.9. 2.94

RFT:

Day-1. Day-2. Day-3.

Blood urea: 105mg/dl. 124mg/dl 122mg/dl,118 mg,/dl (2pm) d-4 :

Serum creatinine: 3.1mg/dl. 3.5mg/dl. 3.6mg/dl ,2.7 m g/dl

Serum electrolytes:

Sodium:133. 124. 130. 137

Potassium:3.9. 3.5. 3.0. 3.0

Chloride:103. 101. 101. 104

Ionized calcium:0.86. 0.86. 0.85. 0.88

Phosphorus:5.6

Calcium: 9.8

Uric acid: 7.1

On1/1/23

S.urea:139

S,cr: 2.4

Electrolytes:

Na:140

K: 4.3

Cl:102

I ca:0.84

LFT:

TB:9.22

DB: 5.23

AST: 559

Alt: 390

ALP: 269

Tp:6.2

Alb: 3.07

A/G ratio: 0.98

2/1/23

.urea:139-128-55

S,cr: 2.4-1.9-1.2

Electrolytes:

Na:140-134-133-134

K: 4.3-3.2-2.9-3.1

Cl:102-104-99-98

I ca:0.84-0.88

Ca 9.3-10

P; 3.9-2.8

Uric acid: 5.1-3.3

LFT:

TB:9.22-11.64- 16.06

DB: 5.23-10.14- 14.20

AST: 559-369-138

Alt: 390-346-126

ALP: 269-297-292

Tp:6.2-5.6-5.6

Alb: 3.07-2.9 -2.6

A/G ratio: 0.98-1.0-0.90

Urinary electrolytes:28/12/22

Na:133

K:11.7

Cl:198

Serum osmolality: 271 mosm/kg

Urine for ketone bodies : negative

Abg:

Ph:. 7.321. 7.408

Po2:. 101. 110

Pco2:. 16.4. 17.6

Hco3:. 12.4. 14.9

Na:. 127. 113

K:. 3.6. 3.5

Ca:. 0.57. 0.30

Cl:. 102. 88

Anion gap

29/12/22

USG abdomen:

Grade-1 fatty liver

Edematous gallbladder wall

Moderate ascites

B/l mild pleural effusion

Chest x ray:

Xray erect abdomen:

31/12/22

ECG:

2d echo

https://youtu.be/IG_jZweKd8I

No RWMA

TrivialTr/Mr: no mr

Sclerotic Av, no As/ms

EF 60,RVSP:35mmhg

Good lv systolic function

No diastolic dysfunction, no pAH/PE

Icc size: 1.10 cms

Review 2d echo( 2/1/23)

Treatment:

1.  Iv fluids @ 100ml/hr

2. Inj piptaz 2.25 gm/iv/Tid- d3

3. Inj vit k 1 ampoule in 100 ml NS iv/ od

4. Inj optineuron 1 ampoule in 100ml nd iv /od

5. T.doxy 100mg/RT/BD converted to oral on 1/1/23

6. Syp lactulose 30 ml RT/Hs converted to oral on1/1/23

7. RT feeds milk 100 ml 4th hrly stopped on 1/1/23

Fluids 50 ml hrly

Inj N acetyl cysteine (1ml=200mg)

100mg/hr(continuous iv infusion)

Zinc oxide cream for local application

Position change every 20 minutes

Daily bed sore dressing

8. 3Hemodialysis sessions done

9. 1sdp+ 2 FFP transfusions done out side

10. 1 sdp+ 3ffp transfusions done

11. 5 ffp transfusion done on 31/12/22

    
    

Summary:

This is a case of A 50 year old female came to the casuality on 27/12/23 with Dengue fever, with thrombocytopenia in a Tachyponeic state and  petechiae in bilateral lower limbsand upper limbs, she had intact sensorium on day-1 on further evaluation she was found to have pre renal acute kidney injury along with liver injury.

On day-2

She went into a altered sensorium with hyponatremia of around 122 mg/dl of serum sodium,3%Nacl was given,even after post sodium correction her altered sensorium hasn't improved.cT brain was done to rule out bleeding and it was absent.fundoscopy was done to rule out raised ict

On day 3:

Her altered sensorium was secondary to ? Dengue encephalitis? Hepatic encephalopathy/ uremic encephalopathy inj dexa 8 mg was given

I/v/o inj ARTESUNATE was started on 3rd day and continued for 3 days

Grade1 bed sores were developed surgery opinion was taken and regular dressings were done.

Her uremia,hepatic enzymes are constantly raising and we took her to 2 sessions of Hemodialysis done on 29th and 30th December

On29th 1 Sdp transfusion was done

N acetyl cysteine was started  for 3 days i/v/o acute liver injury with persistentlyhighbilirubin levels.

On day 4 : 2 ffps were transfused

On31st : 2 ffps were transfused

2 nd january: 2 ffps were transfused 

Patients altered sensorium was improved on 1 st january

3rd session of Hemodialysis done on 3rd January

.

Gastropinion was taken he advised a tests for antibodies hepatitis A and E and asked to come with review lft report

On9 January  her hemogram was showing HB:10g/dl,TLC: 8,900,pc:1.6 lakh,pt:20secs

INR:1.4,Aptt: 39secs

Conclusion:

The reported women  with Dengue hemorrhagic fever developed several unusual manifestations such as acute kidney ( pre renal ) injury, acute liver injury, altered sensorium secondary to ?dengue encephalitis? Hepatic encephalopathy ? Uremic encephalopathy? Which form a part of expanded dengue syndrome.