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Title: dengue hemorrhagic fever

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A body of adult male with medium build that fits the descriptions of its appearance and age
presented with reddish, congested appearance and blood oozing from body cavities. Internal
examination revealed congested organ and multiple haemorrhages in the intestinal, 80% block of
the left coronary artery. Result of dengue Igm serology came out positive.
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a.c Éackground of case

Dengue, the most common arboviral illness transmitted worldwide, is caused by infection
with 1 of the 4 serotypes of dengue virus, family Flaviviridae, genus Flavivirus (single-
stranded nonsegmented RNA viruses). Dengue is transmitted by mosquitoes of the genus
`
 which are widely distributed in subtropical and tropical areas of the world, and is
classified as a major global health threat by the World Health Organization (WHO).

Initial dengue infection may be asymptomatic (50%-90%),1 may result in a nonspecific

febrile illness, or may produce the symptom complex of classic dengue fever (DF). A
small percentage of persons who have previously been infected by one dengue serotype
develop bleeding and endothelial leak upon infection with another dengue serotype. This
syndrome is termed dengue hemorrhagic fever (DHF), although dengue vasculopathy has
been proposed as a better term, as fluid loss into tissue spaces can lead to prolonged
shock and complications, including gastrointestinal bleeding, a greater fatality risk than
bleeding per se.2

b.c Rational and significance of choosing the case

Estimated 2.5-3 billion people in approximately 110 tropical and subtropical countries
worldwide are at risk for dengue infection. Yearly, approximately 50-100 million people
are infected with dengue, and 250,000 individuals develop dengue hemorrhagic fever.
Annually, approximately 500,000 individuals are hospitalized with the infection, and
24,000 deaths are attributed to dengue worldwide.

Currently, dengue hemorrhagic fever is one of the leading causes of hospitalization and
death in children in many Southeast Asian countries, with Indonesia reporting the
majority of dengue hemorrhagic fever cases. Of interest and significance in prevention
and control, 3 surveillance studies in Asia report an increasing age among infected
patients and increasing mortality rate.
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The event occurs at intensive care unit of Hospital Serdang


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a.c Ãatient biography

Name initials : Mr. ÉÃR

Age : 38 y/o
Sex : Male
Religion : Hindu
Civil status : Single
Race : Nepalese
Occupation : General worker

b.c History of event

The deceased was admitted into intensive care unit of emergency department for 3 days
before finally succumb to the disease. Ãatient was diagnosed for tetanus by the specialist
in-charge and was managed as what have been diagnosed for. However, it seems that the
deceased was not complying to the treatment and eventually died from shock.

Ãrior to the event, the deceased was living in a sharing house in Ãutra Ãermai ±a very
high risk area for dengue and crimes. According to the inspector, the area was known for
high prevalence of dengue cases in the area. In fact, two of the deceased housemates was
admitted for dengue fever before.

The deceased himself was having fever lasted for three days and this was confirmed by
his supervisor. He was taking a leave and rest at home. At the fourth day, the fever was
already subsided so he came to work. Suddenly during work, he fainted and immediately
being sent to Hospital Serdang by his colleagues ±to be admitted into intensive care unit
then.
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Upon examination, it reveals that the body was belongs to an adult male with medium
built, with complete rigor mortis and minimum post-mortem hypostasis. The deceased
was wrapped in hospital white bed sheet. The deceased was Nepalese with dark fair-
brown skin colour. His height was 164 cm with weight of 55 kg. His hair was black with
short haircut. There was a few facial hair. The eye was black, with dilated pupil. The
mouth was foamy, but the deceased was not on denture. The deceased had sign of
treatment on right neck, right and left brachial and right and left radial as well as left
femoral intravenous insertion.

The deceased face was congested and pale; the temperature of the body was following the
room temperature. The whole body appears congested especially at the area surrounding
the limbs and abdomen. The hypostasis was collected at lower part of the body mostly ±
as following the gravity and there was no definite contact pallor. There was blood oozing
from all over the body cavities.

Examination of the finger revealed that there is no change of coloration or disfigurement.

Examination of lower limbs also revealed the same thing and there was no evidence of
injury. Examination of the genital revealed there was no evidence of seminal discharge at
the glans-penis ±no evidence of myocardial infarction. The penis was not circumcised ±
the skin was retractable.

Not it is obvious, but the deceased skin is indeed appeared reddish and swollen.
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The internal examination starts with the opening of the thorax through a Y-incision
through the midclavicular line and down to the suprapubic fossa without cutting the
umbilical into two. The thoracic cavity is the opened by cutting through the ribs and the
heart was then revealed. Upon the incision, the bodily fluid came running through the
opening of the incision.

The head was opened through incisions that run through the vertex from mastoid to
mastoid. However, the brain was normal with no remarkable findings. The weight was
1240 gram.

Upon the bodily examination, it revealed that the patient¶s whole body was congested
with fluids ±pleural effusion was noted. The lung was congested and there was petechial
haemorrhage noted at the lung. Respectively, the weight of right and left lungs was 634
gram and 500 gram. There was in fact laryngeal oedema. Incision of the trachea revealed
normal trachea with blood staining. Examination of the heart revealed no pericardial
effusion. However, the coronary artery examination shows 80% blockage of left coronary
artery yet right coronary artery was still intact. The heart is weight 292 gram.

Incision of the abdomen and the intestinal has revealed ascites. There were indeed
multiple haemorrhages seen in the small intestines and colon in form of ecchymoses ±
findings very common in dengue haemorrhagic fever. Examination of liver revealed
multiple adhesions. The liver was normal, no nodule and fatty liver. The weight was 1916
kg. The spleen was congested with 242 gram. The kidneys appeared normal with 116
gram for right and 134 for left kidney respectively.

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Cerebrospinal fluid was taken for culture and biochemistry. Élood sample was taken for
dengue Igm serology test and the result came out as positive.

c

A body of adult male with medium build that fits the descriptions of its appearance and
age presented with reddish, congested appearance and blood oozing from body cavities.
Internal examination revealed congested organ and multiple haemorrhages in the
intestinal, 80% block of the left coronary artery. Result of dengue Igm serology came out
positive.


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The cause of death was dengue hemorrhagic fever

The deceased was presented with redness all over the body, congested body and limbs
and oozing of blood from body cavities.

Internal examination revealed that deceased have organ congestion ±lung, spleen,
pancreas, pleural effusion, laryngeal oedema, and ascites. There were multiple
haemorrhage noted in the intestinal especially colon. There was adhesion at the liver.
80% of the left coronary artery was blocked.

Dengue Igm serology test came out as positive.c c

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The deceased was died from dengue hemorrhagic shock after failed to be resuscitated.
The haemorrhage that occurs inside the body was not visible from the outside. The
haemorrhage cause the body to loss the blood volume resulted hypovoleumic shock.

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c Natural death


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Dengue has been called the most important mosquito-transmitted viral disease in terms of
morbidity and mortality. Dengue fever is a benign acute febrile syndrome occurring in
tropical regions. In a small proportion of cases, the virus causes increased vascular
permeability that leads to a bleeding diathesis or disseminated intravascular coagulation
(DIC) known as dengue hemorrhagic fever (DHF). Secondary infection by a different
dengue virus serotype has been confirmed as an important risk factor for the development
of DHF. In 20-30% of DHF cases, the patient develops shock, known as the dengue
shock syndrome (DSS). Worldwide, children younger than 15 years comprise 90% of
DHF subjects3c

Dengue hemorrhagic fever or dengue shock syndrome usually develops around the third
to seventh day of illness, approximately at the time of defervescence. The major
pathophysiological abnormalities caused by dengue hemorrhagic fever and dengue shock
syndrome include the rapid onset of plasma leakage, altered haemostasis, and damage to
the liver, resulting in severe fluid losses and bleeding. Ãlasma leakage is caused by
increased capillary permeability and may manifest as hemoconcentration, as well as
pleural effusion and ascites. Éleeding is caused by capillary fragility and
thrombocytopenia and may manifest in various forms, ranging from petechial skin
haemorrhages to life-threatening gastrointestinal bleeding.
 Similar to the deceased, it appears that dengue shock syndrome abruptly reflect itself
after 3 days of his medical leave. The shock is then resulted hyper permeability, and
bleeding inside the body ±presentation in the intestinal might be cause by disseminated
intravascular coagulation.

Factors believed to be responsible for the spread of dengue include explosive population
growth, unplanned urban overpopulation with inadequate public health systems, poor
standing water and vector control, viral evolution, and increased international
recreational, business, and military travel to endemic areas. All of these factors must be
addressed to control the spread of dengue and other mosquito-borne infections.1

Reflecting to the case, lack of hygiene in the share house ±usually involving working
immigrants cause the prevalence of hemorrhagic fever in the area. This unnecessary
death can be avoided if the area itself is cleaned and hygiene was one of the things that
deeply considered.

 
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Dengue fever is a benign acute febrile syndrome occurring in tropical regions. In a small
proportion of cases, the virus causes increased vascular permeability that leads to a
bleeding diathesis or disseminated intravascular coagulation (DIC) known as dengue
hemorrhagic fever (DHF). Incubation periods take place 3-4 days ±presented as fever
whereas patients usually fall into shock after the third day and died from dengue. 
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1.c ©yle JL, Harris E. Global spread and persistence of dengue. Annu Rev
Microbiol. 2008;62:71-92.Ross R. Atherosclerosis--an inflammatory disease. N Engl J
Med. Jan 14 1999;340(2):115-26.
2.c Statler J, Mammen M, Lyons A, Sun W. Sonographic findings of healthy volunteers
infected with dengue virus. J Clin Ultrasound. Sep 2008;36(7):413-7.
3.c Malavige GN, Fernando S, Fernando DJ, et al. Dengue viral infections. Ã 



. Oct 2004;80(948):588-601.