SCHOOL OF MEDICAL SCIENCES

PHASE II
PAEDIATRIC POSTING
CLINICAL CASE WRITE-UP

NAME : MOHD YUSRI BIN JACIS

MATRIC NUMBER : 128223
COURSE/ YEAR : MEDIC 3RD YEAR
ACADEMIC SESSION : 2017/2018

POSTING : PAEDIATRICS
SUPERVISOR : AP DR. SALMI ABD RAZAK
 A. HISTORY TAKING
Name : Nur Farah Ilyana Binti Ahmad
Registration no. : HRPZ252877
Age : 11 years old
Gender : Female
Race : Malay
Address : Melor, Kelantan
Informants : Mother
Diagnosis : Dengue Fever Without Warning Signs
Underlying illness : Asthma
Date of Admission : 1/1/2018
Date of Clerking : 2/1/2018

Chief Complaint
The patient presented with persistent high-grade fever for 4 days of duration prior to admission.
History Of Presenting Illness
She was previously well and active before until 5 days prior to the admission, she complained of
having recurrent painful headache which was pulsating in nature spreading all over her head
associated with retro – orbital pain. She often cries due to the throbbing pain and her activity was
limited for each episode. The following day, she developed a persistent high-grade fever for 4
days before the admission, associated with chills but no rigors. The patient also noted
erythematous, raised and itchy rash formed on her right upper limb and only lasted during the
first 2 days of its presentation. Moreover, there had been reduced in her appetite and daily oral
intake ever since her illness.
During the 2nd day of fever, she was brought to KK and was discharged with syrup paracetamol,
however, the symptoms persists.
On further questioning, she also had been vomiting only for one day, more than 5 times in
frequency containing food and fluid. It was non-bilious with no presence of blood. There’s also
presentation of loose stool for one episode which was large in amount, also no blood nor mucus
noted.
Besides that, the patient also complaint of having muscle aches and joint pain especially at the
lower limbs and on her back that she had been feeling of uneasiness and been unable to move
freely.
On the 4th day of fever, the patient was brought again to KK, there, blood sample was taken and
tested, and the mother claimed that the GP told her that Farah was having very a low platelet
count. Hence, she was then referred to HRPZ and admitted due to suspect for dengue.
There was a positive history of recent travelling to dengue area where patient had been staying in
her grandmothers’ house during the holiday season for 3 weeks and claimed that there was a
recent fogging activity in early December in that area.
Otherwise, there were no abdominal pain, no conjunctivitis, no persistent vomiting, no mucosal
bleeding, no recent jungle – trekking or water activity and no family members presented with the
same symptoms.

Systemic Review

Cardiovascular system No ankle edema

No orthopnea
No chest pain
Respiratory system No shortness of breath
No coughing
No runny nose
Genitourinary system No haematuria
No changes in urinary frequency
No dysuria
Central nervous system No visual or hearing problems
No blurring vision

Past Medical History

Farah has an underlying illness of partially controlled asthma and was on MDI Salbutamol and
MDI Budesonide. She was unsure the number of current admission because there had been
numerous hospitalization before which mostly due to acute exacerbation of bronchial asthma.
However, the first hospitalization was during postnatal period due to neonatal jaundice while the
second hospitalization due to bronchopneumonia and she had been warded in NICU of HRPZ for
a week. Apart from that, it was unremarkable. There were no known food or drug allergy so far.
Paediatric History
Farah was born full term via spontaneous vaginal delivery in HRPZ with the birth weight of
3.6kg without any complications. Antenatally, it was uneventful while postnatally, as mentioned
above. She was on exclusive breastfeeding until 6 months of age and was introduced with semi
solid foods ever since. She started formula milk when she was 2 years old. Meanwhile, the
immunization was completed up to age with the last dose received at 7th years of age.

Developmental Milestone
The developmental milestone is currently normal according to her age. She started to roll prone
to supine at the age of 7 months, crawling at 8 months, stand with support at 9 months, walking
with support at 11 months and without support at 12 months of age. As for fine motor, she able
to self – feed at 8 months of age, pincer grasp at 9 months and scribble at 12 months. For
language, she started to babble at 8 months, able to speak one word with meaning at 11 months,
and able to speak 2 to 3 words in a sentence at 2 years of age. Lastly, she had stranger anxiety
during 12 months of age. Currently, she is appropriately active at home and in school and able to
maintain a very good relationship with her family and fellow colleagues. There is no
developmental delay so far and she claimed to be very active in school sports especially in
athletics. Futhermore, she is also good academically in every subject in class.

Family History

45 40
y/o y/o

20 19 15 11 10 8 y/o 6 y/o
y/o y/o y/o y/o y/o
Farah is the 4th child out of 7 siblings of a non – consanguineous marriage. Her father is a
businessman who has no known medical illness while her mother is a housewife who also has
underlying asthma. She has strong family history of asthma which including all her siblings have
asthma except the youngest child. Otherwise, there is no family history frequent miscarriage or
neonatal death, no known other chronic illness runs in the family such as diabetes, hypertension
and tuberous sclerosis.

Social History
Farah lived with her family in a house with adequate basic amenities such as electricity, well-
water supply and food. The mother claimed to have no any financial problems in the family.

Diet History
Farah is currently on adult diet consumption and she has loss of appetite since sickness. She has
no known food allergy so far.

SUMMARY OF HISTORY
Farah, 11 years old Malay girl presented with persistent high-grade fever for 4 days of duration
with presence of severe headache, retro – orbital pain, muscle ache and joint pain. She also had
history of vomiting and loose stools for one day that subsided spontaneously. Moreover, she had
been staying in her grandmother’s house during this recent school holiday season for 3 weeks
and claimed that there was a recent fogging that was held during early December in that area.
Otherwise, there is no abdominal pain, no persistent vomiting, no mucosal bleeding, no
conjunctivitis, no recent jungle – trekking or water activity and no other family members
presented with the same symptoms.

B. PHYSICAL EXAMINATION

General Examination
On inspection, Farah was lying supine, alert, conscious and ill – looking. She was not in
respiratory distress and noted breathing rate were 30 breaths per minute. There were no gross
deformity, no dysmorphism noted. Her hydrational and nutritional were clinically adequate.
There was a branula attached on the dorsum of left hand.
Vital sign :
Pulse rate : 98 beats/min, regular rhythm, good volume.
Respiratory rate : 30 breaths/min
Blood pressure : 112/68 mmHg
Temperature : 38.5 ̊ C

Anthropometry
Age : 11 years old
Height : 142 cm (on 25th percentile)
Weight : 31.4 kg (on 10th percentile)

Upper limbs
a. Palms were warm, dry and pink.
b. No finger clubbing
c. No peripheral cyanosis
d. Capillary refill was good, < 2 seconds
e. No palmar erythema
f. No thenar or hypothenar muscle wasting

Head and face

Examination of the eyes:
a. Conjunctiva was pink
b. No jaundice
c. No nasal discharge
d. No ear discharges
Examination of the mouth:
a. Tongue was moist and non-coated.
b. No central cyanosis.
c. No enlarged tonsils
Examination of the neck:
a. No tracheal deviation
b. No palpable lymph nodes.
c. No neck stiffness

Lower limbs
a. No pitting edema
b. Posterior tibial & dorsalis pedis pulses were palpable
Specific Examination
NEUROLOGICAL EXAMINATION

A. Motor system Examination

On inspection, both upper and lower limb were symmetrical, there was no abnormal posture, no
abnormal movement, no muscle wasting, no muscle hypertrophy, no muscle fasciculation, no
neurocutaneous sign and no scars.

Upper limb Lower limb

Right Left Right Left
Tone normal normal normal normal
Power 5/5 5/5 5/5 5/5
Reflex Bicep, tricep Bicep, tricep Patella and Patella and
and and ankle reflexes ankle reflexes
brachioradialis brachioradialis were normal were normal
reflexes were reflexes were
normal normal

Clonus No clonus No clonus

Babinski’s sign Down going Down going
plantar plantar

B. Cranial Nerves Examination

Cranial nerve:
I Normal
II Normal pupillary light reflex

III, IV and VI No ptosis, strabismus, nystagmus

Normal ocular movement and accommodation.
Pupils size and shape are normal and equal bilaterally

V Sensory and motor function of trigeminal nerve were intact.

VII No facial asymmetry. Facial expression muscles were normal.
VIII Able to locate source of sound. Whisper test normal.
IX and X Uvula was not deviated.
 XI Shoulder elevated symmetrically.
XII No deviation seen from the protrudes tongue

C. Sensory system Examination

a. Vibration sense, temperature sensation and were not done in this patient.
b. Proprioception was intact.
c. Light touch sensation was normal in all dermatomes.
d. Crude touch sensation was normal in all dermatomes.
e. No sensory inattention

D. Cerebellar Examination
a. No dysarthria
b. No dysmetria
c. Pendular knee jerk was normal
d. No cerebellar ataxia
e. Normal gait
f. Negative Romberg’s sign

RESPIRATORY EXAMINATION
Inspection:
a. Chest wall was rising symmetrically with each respiration
b. Chest wall expansion was symmetrical in all lung zones
c. No intercostals recessions
d. No use of accessory muscles during breathing
e. No surgical scars
f. No skin discoloration
g. No dilated veins
Palpation:
a. Chest expansion is symmetrically normal
b. No thrills upon breathing
c. Tactile fremitus was resonance.

Percussion:
a. Percussion note was resonance at both upper and middle zones of lungs.
b. Liver and spleen dullness present

Auscultation:
 a. Normal and equal air entry was heard over the upper, middle and lower zones
both lungs and no additional sounds heard.
b. Vocal fremitus was resonance in all lung zones

CARDIOVASCULAR EXAMINATION
Inspection:
No precordial bulge, no pectus carinatum, no pectus excavatum
Palpation:
a. Apex beat was palpable at left fifth intercostal space, at medial to mid-clavicular
line.
b. No parasternal heave
c. No thrill
Auscultation:
a. S1, S2 with normal intensity, no murmur was heard over mitral, tricuspid,
pulmonary and aortic areas. There was no murmur heard at apex beat and
subclavian areas as well.

ABDOMINAL EXAMINATION
Inspection:
a. Abdomen moved symmetrically with each respiration
b. It was non-distended.
c. The umbilicus was centrally located and inverted.
d. There was a well healed scar at the right inguinal region
e. No dilated veins, no visible pulsation and no skin discoloration.

Palpation:
a. Superficial palpation:
 Abdomen was soft and non-tender.
b. Deep palpation:
 No mass could be felt over all the nine quadrants.
 Liver was not palpable.
 Spleen was not palpable
 Kidneys were not ballotable.
Percussion:
a. Liver span was measured 10cm.

Auscultation:
a. Bowel sound was present with normal intensity.
 b. No renal bruit.

SUMMARY OF EXAMINATIONS
Examination of this patient revealed that she was still febrile. Otherwise, other neurological,
respiratory, cardiovascular and abdominal examinations were normal.

C. PROVISIONAL DIAGNOSIS

1. Dengue Fever Without Warning Signs

Positive Findings Negative Findings
 Persistent high grade fever with  Shortness of breath
transient rash  Abdominal pain
 Headache  Persistent vomiting
 Retro – orbital pain  Mucosal bleeding
 Arthralgia  Lethargy
 Myalgia
 Vomiting
 Poor oral intake
 Recent fogging at grandmother’s
house

D. DIFFERENTIAL DIAGNOSIS

1. Leptospirosis

Positive Findings Negative Findings

 High grade fever  No rigors
 Loose stool  No conjunctival suffusion
 Reduced Oral Intake  No dry cough
 Vomiting  No jaundice
 Myalgia  No reduced urine output
 Headache
 Retro – orbital pain

2. Typhoid fever
 Positive Findings Negative Findings
 Fever with chills  No progressive fever
 Vomiting  No constipation
 Loose stool  No abdominal pain
 No rose spots
 No hepatosplenomegaly
 No intestinal bleeding

3. Malaria

Positive Findings Negative Findings

 Fever with chills  No shaking chills
 Myalgia  No sweating
 Arthralgia  No fatigue
 Vomiting  No malaise
 Loose stool  No coughing
 Lethargy  No jaundice

4. Chikungunya

Positive Findings Negative Findings

 High grade fever  No sore throat
 Arthralgia  No abdominal pain
 Myalgia  No constipation
 Rash  No conjunctival
 Headcahe suffusion/conjunctivitis
 Retro – obital pain  No photophobia
 Recent fogging in Grandmother’s
house

E. INVESTIGATIONS

1. Dengue Rapid Test

 Rationale:
 To look for presence of IgM and IgG which highly suggestive for
occurrence of infection more than 5 days of duration. .
 The presence of IgG in the first few days of infection strongly suggests a
secondary infection
  Result : (1/1/2018)
 Negative IgM and IgG

 Interpretation :
 There might be no infection at all or the infection is still in its 1st week.
 Serology may be negative in the first 5 days of illness
 IgM and IgG often positive during the 2nd week of illness

2. Non – Structural Protein 1 (NS1) Test

 Rationale :
 To detect the availability of viral antigen nonstructural protein 1 in
plasma.

 Result : (1/1/2018)
 Positive

 Interpretation :
 There is presence of viral antigen hence, it may be dengue virus infection.

3. Full Blood Count

 Rationale:
 Look for leukocytosis as this may suggest bacterial infection or to look for
leukopenia as a sign of dengue infection.
 Look for thrombocytopenia that may suggest dengue infection.
 To detect the hematocrit value to identify presence of plasma leakage that
indicates increased vascular permeability in dengue and also dehydration.
 To examine the presence of anemia that may indicates bleeding tendency.

 Result : (3/1/2018)
 Hb : 130 (115 – 155 g/L)
 TWBC : 1.81 (4.5 – 13.0 X 10^9/L)
 RBC : 4.86 (4.0 – 5.2 X 10^12/L)
 MCV : 83.1 (77 – 95 fl)
 MCH : 26.7 (25 – 33pg)
 MCHC : 32.2 (31 – 37g/dL)
 HCT : 40.4 (35 – 45%)
 Platelet : 72 (150-450 X 10^9/L)
 Neutrophils : 0.87 (1.5 – 8.0 X 10^9/L)
  Lymphocytes : 0.65 (1.2 – 5.2 X 10^9/L)

 Interpretation :
 Hemoglobin level is normal.
 There is leukopenia which may indicates virus – induced destruction or
inhibition of myeloid line.
 Both neutrophils and lymphocytes are decreased.
 The platelet count is markedly low, bleeding tendency is likely, and this
might be due to destruction of peripheral platelet or bone marrow
megakaryocytes by viruses.
 Hematocrit level is normal, there is no dehydration or plasma leakage so
far.

4. Renal Function Test

 Reason:
 To check any electrolyte imbalance.

 Result in this patient : (1/1/2018)

 Na : 133 (135-145mmol/L)
 K : 3.4 (3.5-5.0mmol/L)
 Cl : 100 (98 – 106mmol/L)
 Urea : 6.0 (2.5-7.5mmol/L)
 Creatinine : 59 (35 - 62mmol/L)

 Interpretation :
 There is slightly reduced in serum Sodium and Potassium concetration.

5. Liver Function Test

 Reason :
 To identify elevation of ALT and AST as supportive diagnosis for Dengue
Hemorrhagic Fever or Shock Syndrome.

 Result in this patient : (1/1/2018)

 Albumin : 41 (3.5 – 5.0 g/dL)

 Total Protein : 68 (6.3 – 7.9 g/dL)

 Bilirubin : 0.9 (0.1 – 1.2 mg/dL)
 ALP : 185 (45 – 115 U/L)
 ALT : 25 (7 – 55 U/L)
  AST : 68 (8 – 48 U/L)

 Interpretation :
 There are increase in ALP and AST value yet normal ALT.

OTHER INVESTIGATIONS THAT I WILL ORDER

1. Coagulation Profile
 Reason : To look for haemorrhagic sign.

F. FINAL DIAGNOSIS : DENGUE FEVER WITHOUT WARNING SIGNS.

G. MANAGEMENT

 Goals:
 Treat fever
 Supportive management

Treatment that been done in this patient:

1. Monitor vital sign

 To monitor blood pressure, heart rate, respiratory rate and temperature, as well
as observe temperature trend, and to keep temperature as normal as possible to
look for warning signs or shock syndrome.

2. IV Drip full maintenance 75cc/hr Normal Saline

3. Strict I/O Chart

4. Encourage orally as tolerated

5. Anti-pyretic
 Syrup paracetamol 500g PRN to relieve fever
 H. DISCUSSION

1. Summary of clinical features, laboratory changes and frequency of monitoring during

different phases in dengue illness.

After the incubation period, the illness begins abruptly and will be followed by three phases:
febrile, critical and recovery phase.
Day of illness 3 to 7 days 3 to 7 days 1 to 5 days
Phase Febrile Critical Convalescence

High grade fever Fever subsides Vital signs stabilize

Rash Organ dysfunction Rashes
Myalgia (encephalitis, Plasma leakage and
myocarditis, hepatitis) haemorrhage resolve
Arthralgia
Warning signs: Accumulated fluid
Vomiting
resorbed
Persistent vomiting
Headache
Organ dysfunction may
Persistent diarrhea
Retro – orbital pain worsen.
Abdominal pain
Sore throat
Restlessness, lethargy
Clinical Pharynx injected
features Altered conscious level
Petechiae
Mucosal bleed
Mucosal membrane
bleed Hepatomegaly
Conjunctival injection Clinical fluid
accumulation
Pharyngeal erythema
Laboratory: increase in
Lymphadenopathy
HCT concurrent with
rapid decrease in
platelet count
 Leucopenia followed by Thrombocytopenia White blood cell
thrombocytopenia. normalized
HCT increase
Platelet normalized
Laboratory Leucopenia with
relative lymphocytosis HCT normalized and
changes
further reduce due to
Coagulation disturbance
haemodilution
AST/ ALT elevated
Hypoproteinemia
Hypoalbuminemia

-Monitor appetite, oral -Monitor appetite, oral -Monitor appetite, oral

intake and warning sign intake and warning sign intake and warning sign
daily. Do it frequently at least 2 times or daily.
at the late phase. frequent as indicated.

Monitoring -Monitor urine output 4 -Monitor urine output 2-

hourly 4 hourly. But if in
Frequency shock, 1 hourly. -Monitor urine output 4-
6 hourly.

-Monitor
-Monitor
haemodynamic status,
haemodynamic status,
respiratory status and
respiratory status and -Monitor
neurological status 2-4
neurological status 4-6 haemodynamic status,
hourly. If in shock, 15-
hourly. respiratory status and
30 minutes until
stable, then 1-2 hourly. neurological status 4-6
hourly.

Monitor FBC 4-12

hourly.
-Monitor FBC daily.
 -Monitor BUSE, LFT, -Monitor FBC daily.
RBS, Creatinine kinase
-Monitor BUSE, LFT,
at least daily.
RBS, Creatinine kinase
as clinical indicated.
-Monitor BUSE, LFT,
RBS, Creatinine kinase
as clinical indicated.

Monitor ABG, lactate, coagulation profile, CRP,

troponin/CKMB, fibrinogen, LDH, Ferritin, triglyceride,
ECG, Echo, Ultrasound as clinical indicated.

Criteria for severe Dengue:-

i. Severe plasma leakage leading to:
a. Shock
b. Fluid accumulation with respiratory distress
ii. Severe bleeding
iii. Severe organ involvement
a. Liver: AST or ALT ≥1000
b. CNS: impaired consciousness
c. Heart and other organ

2. Pathophysiological changes from normal circulation to compensated and

decompensated/hypotensive shock
Normal circulation Compensated shock Decompensated /
hypotensive shock
 Clear consciousness  Clear consciousness -  Change of mental state -
shock can be missed if restless, combative or
 Brisk capillary refill time you do not touch the lethargy
(<2 sec) patient
 Mottled skin, very
 Warm and pink  Prolonged capillary refill prolonged capillary refill
 peripheries time (>2 sec) time
 Good volume peripheral  Cool extremities  Cold, clammy extremities
pulses
 Weak peripheral pulses  Feeble or absent
 Normal heart rate for age peripheral pulses
 Tachycardia
 Normal blood pressure for  Severe tachycardia with
 Normal systolic pressure
age bradycardia in late shock
with raised diastolic
 Normal pulse pressure for pressure  Hypotension
age /unrecordable Bp
 Postural hypotension
 Normal respiratory rate  Narrowed pulse pressure
for age  Narrowing pulse pressure (<20 mmHg)
 Normal urine output  Tachypnoea  Metabolic acidosis/
 Reduced urine output hyperpnoea/ kussmaul’s
breathing
 Intense thirst
 Oliguria or anuria

3. Principles of Disease Monitoring

 During critical phase, monitoring of patients need to be intensified and frequent
adjustments in the fluid regime may be required.
 Recognition of onset of reabsorption phase is also important because intravenous fluid
regime needs to be progressively reduced/discontinued at this stage.

4. FLUID MANAGEMENT in Non-Shock Patients (DF with Warning Signs)

1. Increased oral fluid intake may be sufficient in those who are haemodynamically
stable and not vomiting.
2. Iv fluid (0.9% saline is recommended) is indicated in patients with increasing HCT
with evidence of ongoing plasma leakage, despite increased oral intake.

3. Iv fluid therapy should also be considered in patients who are vomiting, severe loose
stools and not tolerating orally.
4. The normal maintenance requirement for iv fluid therapy in such patients could be
calculated.
 5. Frequent adjustment of maintenance fluid regime is needed during the critical phase.
6. If the fluid infusion rate exceeds more than the maintenance requirement, the
infusion rate should be reviewed within 2-4 hours.
7. In patients with persistent warning signs with increasing or persistently high HCT,
the graded fluid bolus may be initiated with caution.
8. Frequent monitoring of clinical and laboratory parameters must be carried out every
2-4 hours until patients improve.
9. Aim for urine output of 0.5-1.0 ml/kg/hr.
10. A rising HCT indicates on-going plasma leakage and will require an increase in the
iv fluid infusion rate.
11. If patients deteriorate and progress to shock
a. Iv fluid therapy is the mainstay of treatment for dengue shock.
b. Colloid may be preferable as the fluid of choice in patients with intractable
shock in the initial resuscitation because seem to restore the cardiac index and
reduce the level of HCT faster
12. Reduce or consider discontinuation of iv fluid therapy when patients begin to show
signs of recovery usually after 24-48 hours of defervescence, or the HCT drops in a
stable patient.

I. PROGRESS REPORT

During her presentation at A&E at 6 pm, she was given tablet paracetamol to reduce the
temperature and the fever drops gradually. Later the next morning, the fever was spiking again
and persist until the next morning. Within that time interval, she was given tepid sponging and
tablet paracetamol and the fever subsided only slightly and temporarily. During the 3 rd day of
admission, the febrile phase ended where she no longer in feverish state and start to improve in
oral intake. There’s no vomiting, loose stools or abdominal pain so far. She finally discharged
from HRPZ during the 7th day of admission.

J. PROGNOSIS
Generally, the prognosis is favourable. She was discharged with no complications and recovered
fully.
 K. ETHICAL ISSUES
There are a few ethical issues surrounding the management of the patient. For example,
confidentiality of the child’s medical condition. As sometimes it is very important to promote
respect for the patient, but it is necessary to breach the confidentiality, where it is felt that the
child may be at risk if no one is alert and does not react accordingly in time. As such, the school
is usually informed so that a medical emergency can be adequately managed.
Moreover, the importance of empathy during communication even though some questions can be
very sensitive. Some patients’ families may be less likely to offer honest answers and may be
unreceptive to entertaining the possibility of an intervention. Knowing different ways of asking
about tobacco usage, for example, can help in getting the necessary information without
alienating the respondent. While sensitive, the information is needed for accurate diagnosis and
intervention. Adherence to interventions for sensitive topics (e.g., smoking cessation, alcohol
abuse) may present special challenges for the health care provider. A good communication plays
an important role in such conditions.

L. EVIDENCE BASED MEDICINE

Question:
What are the effects of corticosteroids in children with dengue-related shock?
Clinical Answer:
There is insufficient randomized controlled trial evidence to judge the effects of corticosteroids
in children with dengue-related shock.
Very low-quality evidence suggests that corticosteroids may have no benefit in terms of
mortality, need for blood transfusion, duration of hospital stay, pulmonary hemorrhage or
convulsions when compared with placebo/no steroids in children with dengue infection who had
been admitted to hospital suffering from dengue-related shock. Three small trials seemed to
report inconsistent results regarding the duration of shock, but data were sparse. All of the
analyses would have been too underpowered to detect differences between groups, even if these
were present.
Background
Dengue is a common and important mosquito-borne viral infection. In many low- and middle-
income countries it is endemic and is an important public health problem. Severe dengue is an
important cause of death in children. There is no specific treatment for dengue, but observational
studies suggest corticosteroids may have a benefit in dengue-related shock, and some people
believe corticosteroids may prevent the progression to severe illness if given early in the course
of the illness.
Objectives
To compare treatment of dengue with and without use of corticosteroids or placebo in relation to
preventing shock-related death and disease progression in children and adults.
Search methods
We searched the Cochrane Infectious Disease Group Centralized Register; CENTRAL;
MEDLINE; EMBASE; and LILACS, up to 6 January 2014. We screened reference lists and
contacted the relevant study authors for additional information where required.
Selection criteria
Randomized controlled trials or quasi-randomized controlled trials comparing corticosteroids
with placebo or no corticosteroids in patients diagnosed with dengue-related shock, or patients in
an early symptomatic state of dengue with positive serology.
Data collection and analysis
Two researchers independently screened eligibility of records, extracted data and assessed
quality of the studies. We presented findings in meta-analysis and summary of findings tables
and evaluated the quality of evidence using GRADE.
Main results
We included eight studies enrolling 948 participants in this review.
Paitents with dengue-related shock
Four studies enrolled children younger than 15 years with dengue-related shock at hospitals in
Southeast Asia and evaluated intravenous corticosteroids. The trials did not detect an effect on
death (four trials, 284 participants, very low quality evidence), the need for blood transfusion
(two trials, 89 participants, very low quality evidence), pulmonary haemorrhage (one trial, 63
participants, very low quality evidence), convulsions (one trial, 63 participants, very low quality
evidence), or duration of hospitalization (one trial, 63 participants, very low quality evidence).
The body of evidence is too small to confidently prove or exclude clinically important effects.
Furthermore, the trials are more than 20 years old with several methodological limitations.
Patients with dengue at an early stage
Four studies enrolled 664 children and adults with dengue at an early stage of infection (without
shock) in Columbia, India, Sri Lanka and Vietnam. In these participants there were no evidence
of effects of oral or intravenous corticosteroids on mortality (four trials, 664 participants, low
quality evidence), or on the development of complications of severe dengue such as shock (two
trials, 286 participants, very low quality evidence), severe bleeding (two trials, 425 participants,
very low quality evidence), severe thrombocytopaenia (one trial, 225 participants, very low
quality evidence), ascites (one trial, 178 participants, very low quality evidence) and intensive
care unit (ICU) admissions (two trials, 286 participants, very low quality evidence).
Authors' conclusions
The evidence from trials using corticosteroids in dengue is inconclusive and the quality of
evidence is low to very low. This applies to both the use of corticosteroids in dengue-related
shock and for dengue at an early stage. There is insufficient evidence to evaluate the effects of
corticosteroids in the treatment of early stage dengue fever and dengue-related shock outside of
the context of a randomized controlled trial.

M. REFERENCES

1. Paediatric Protocols, 3rd Edition

2. Dengue Fever, http://bestpractice.bmj.com/topics/en-gb/1197
3. Dengue Fever, https://www.uptodate.com/contents/dengue-virus-infection-pathogenesis?
search=dengue
%20fever&source=search_result&selectedTitle=2~87&usage_type=default&display_rank=2
4. http://cochraneclinicalanswers.com/doi/10.1002/cca.1012/full