CASE MANAGEMENT CONFERENCE

General Objective
At the end of the conference, the participants will be able to diagnose and manage
patients with Dengue Fever

Specific Objective
● To obtain pertinent information from the clinical history and physical
examination of a patient with fever
● To formulate a diagnosis based from the information given
● To discuss the differential diagnoses of a patient with fever
● To discuss the diagnostic and therapeutic management of the
patient
● To critically appraise a journal on therapy in relation to the case
Chief complaint
“mainit ang katawan”
History of present illness
5 Days prior to admission:
- Patient is restless with undocumented fever, Patient given sponge bath, slight
relief was noted
- Mother gave 7.5 mL paracetamol with a preparation of 250/5mL (15 mkdose)
every 4 hours
- Patient w/ associated vomiting with loss of appetite
- Patient given hydrite (unrecalled measurement) and water alternately
- No rashes, bleeding, retro-orbital pain nor headaches were noted during this
time
History of present illness
4 days prior to admission:
- Patient experienced cramping pain in his abdomen specifically epigastric area
with persistent fever of 38.7deg celsius and 1 episode of vomiting after
breakfast
- Sough consult at a private clinic. CBC w/ PC, Urinalysis, Dengue NS1 and
Dengue Duo test has been done
- Given Omeprazole 20mg tab, 1 tab once a day every morning and hydroaid 1
liter to consume in 24 hours
History of present illness
5/30/2022
CBC w/ PC:
WBC: 3.5
Platelet: 157
Urinalysis: 2-4 pus cells
Dengue NS1: positive
Dengue IgG: positive
Dengue IgM: negative
History of present illness
3 days prior to admission
- Repeat CBC w/ pc was done and platelet started to decrease.
- Abdominal pain subsided few hours after taking Omeprazole but pain eventually came
back in the afternoon
- Temperature started to return to normal but another episode of vomiting occurred at night
2 days prior to admission
- Patient experienced muscle and joint pains in his lower extremities and no fever was
noted. Patient was noted to be anorexic
- Repeat CBC w/ PC showed a downward trend on patient’s platelet
- Advised for admission
- Mother refused admission, chose to observe first, was given referral for admission in case
another episode of vomiting occur.
History of present illness
1 day prior to admission:
- Patient was lethargic with sunken eyes, another episode of vomiting occured.
- Went to our institution for admission
- RTPCR was requested, patient on ER-PUI until no RTPCR result

Few hours prior to admission:

- RTPCR test came back negative
- Patient is febrile at 37.9 deg celsius
- Rash started to appear in patient’s lower extremities
History of present illness
5/31/2022
Platelet: 132

6/01/2022
Platelet: 109
Hematocrit: 0.38 (0.42 – 0.52)
WBC: 2.0 (5 – 10 x 10/L)

6/02/2022
Platelet: 83
RT-PCR: negative
 Review of systems
Constitutional: irritable, (+) loss of appetite, (-)weight loss, (-) chills
HEENT: (-) epistaxis, (-) headache, (-)blurring of vision, (-)hearing difficulty, (-)
nasal stuffiness, (-) discharge
Respiratory: (-) cough, (-) dyspnea
Cardiovascular: (-) palpitations
Gastrointestinal: (-) loose bowel movement, (-) constipation
Genitourinary: (-) difficulty or pain in urination
Extremities: (-) open wound, (-)abrasions, (-) hematoma
Musculoskeletal: (-)muscle weakness, (-)limitation of range of motion
Past Medical History
No known Allergies

(-) history of hospitalization

(-) Asthma

no known previous history of dengue

No previous surgical operations

No history of accidents and injuries

Family History
Mother side- CVD (“heart attack”)
Father side- Hypertension
No known history of diabetes,cancer, autoimmune disease on either side
No history of PTB
No family members with same signs and symptoms
 Personal and Social History
Home:
● 3 members of the family Activities:
● Only child Watch shows via internet
● Bungalow type, 1 room only Studies using module
● Good family relationship Plays with neighbors in their
● Always with her mother at work (teacher) community
● With empty cans of paint filled with
stagnant water at the back of their house
Spirituality:
● No known recent dengue case in their Born Again
community Attends church every sunday

Education:
Grade 1 via Online class module
Birth and Maternal History
Prenatal
● Born to G1P1(1001) mother
● Regula prenatal check-up at private clinic
● (-) maternal illness
● (-)exposure to radiation and teratogen
Birth and Maternal History
Perinatal:
● Born full term via NSD
● Cephalic in presentation with good cry, good suck and activity
● Attended by Ob GYNE
● (-)materno-fetal complications
Birth and Maternal History
Post-natal
● Essentially normal
● Good cry, suck, and activity
● BCG, Hep B, Vit K, erythromycin eye prophylaxis given at birth
● Normal NBS
● (-) complications
Nutritional history
Eats meal 3x a day
Present diet: rice, meat, vegetables and fruits
Seldom eats junk food and softdrinks
 IMMUNIZATION HISTORY

VACCINE At birth 6 wks 10 wks 14 wks 9 months 12 months

BCG ✓

Hep B ✓ ✓ ✓ ✓

DPT ✓ ✓ ✓

OPV ✓ ✓ ✓

HiB ✓ ✓ ✓

PCV ✓ ✓ ✓

Measles ✓

MMR ✓
Physical exam
General: well developed, awake, conscious, weak looking, not in cardiorespiratory distress
and looked appropriate at his chronological age of 7 years old

Vital Signs:
Blood pressure: 90/60
Pulse rate: 89
Respiratory rate: 24
Temperature: 36.7
O2 sat: 99%
Height: 124cm
Weight: 25cm
BMI: 16.2kg/m2
AGE: 7 YEARS
OLD HEIGHT:124
CM
WEIGHT:
25KG
AGE:
7
AGE:7 YEARS
OLD HEIGHT: 124
CM
WEIGHT:25KG
BMI:16.2KG/M2
Physical exam
Skin: (+) macular rashes on bilateral lower extremities, neither warm nor cold to
touch
Head: symmetrical facial features, no palpable mass, hair with normal texture and
equally distributed
Eyes: anicteric sclera, pink palpebral conjunctiva
Ears: mobile pinna without tenderness, (-) discharge
Nose: symmetrical nose, midline nasal septum, equal size and shape of the nares,
no discharge
Oral Cavity: Dry lips, (-) lesions, (-) mass, (-) tonsillo-pharyngeal congestions
Neck: (-)cervical lymphadenopathy, no palpable thyroid mass
Physical exam
RESPIRATORY:
Inspection- (-)mass, (-) lesions, (-) deformities or defects in chest wall,
symmetrical chest expansion, (-)retractions
Palpation- (-) tenderness, (-) mass, (-) lesions, equal tactile fremitus
Percussion- resonant on percussion
Auscultation- clear, equal lung sounds
CARDIOVASCULAR:
Inspection- no precordial bulging nor lesions on the chest
Palpation- no heave nor thrills, apex beat on 5th intercostal space of left
midclavicular line
Auscultation- no murmurs, regular rate and rhythm
Physical exam
GASTROINTESTINAL:
Inspection: flat, non-distended, (-) scars, (-) lesion, (-)discoloration
Auscultation: normoactive bowel sounds
Percussion: tympanitic all over
Palpation: (+)direct tenderness on epigastric area
GENITOURINARY: grossly male
EXTREMITIES: full equal pulse, capillary refill time <2 seconds
Physical exam
NEUROLOGIC EXAM:
Mental status- patient is conscious, coherent, and is aware of person and place
Motor Function- patient is ambulatory with a muscle strength of 5/5 on bilateral
upper and lower extremities
Sensory Exam- 100% on bilateral upper and lower extremities, perceives light,
touch pain, vibration and temperature
Salient features
(+)Filipino
(+)7 years old
(+) empty cans of paint filled with stagnant water seen at the back of their house
(+) intermittent fever
(+) vomiting
(+) lethargic
(+) sunken eyes
(+) abdominal pain and tenderness
(+) muscle and joint pain on lower extremities
(+) rashes on lower extremities
(-)jaundice
(-)icteric sclera
(-)dysuria
Admitting diagnosis
Dengue fever with warning signs
Differential diagnosis
1. Leptospirosis
2. Covid-19
3. Typhoid fever
Rule-in, Rule-out
Disease Rule In Rule Out

Dengue with warning signs (+) intermittent fever

(+) anorexia
(+) vomiting
(+) lethargic
(+) sunken eyes
(+) abdominal pain and
tenderness
(+) muscle pain on bilateral
lower extrtemities
(+) rashes on lower extremities
(+) Dengue NS1
(+)Leukopenia
(+) stagnant water at the back of
their house
(+)Thrombocytopenia
Rule-in, Rule-out
Disease Rule In Rule Out

Leptospirosis (+) fever no history of wading in flood

(+) vomiting no jaundice
(+) lethargic anicteric sclera
(+) abdominal pain and no difficulty or pain in
tenderness urination
(+) myalgia (-)leukocytosis
(+)thrombocytopenia (-)hematuria
Rule-in, Rule-out
Disease Rule In Rule Out

Influenza (+) fever (-) cough

(+) myalgia (-) colds
(+) anorexia (-) conjunctivitis
(-) pharyngitis
Rule-in, Rule-out
Disease Rule In Rule Out

Covid-19 (+) fever Negative RTPCR

(+) myalgia (-) cough
(+) body malaise (-) colds
(+) vomiting (-) crackles on both lung
fields
(-) O2 desaturation
(-) exposure to known
COVID-19 case
Rule-in, Rule-out
Disease Rule In Rule Out

Typhoid fever (+) fever (-)continuous stepladder

(+) myalgia fever
(+) abdominal pain (-)coated tongue
(+) vomiting (-)rose spots
(-)relative bradycardia
Course in the wards
6/03/2022

S (-) cough, (-) colds, (-)fever

O General: awake, conscious, coherent

Skin: (-) jaundice, (-) pallor
VS: BP- 90/60, RR- 23, PR- 90, Temp- 36.5 O2 sat- 98%
Respiratory: symmetrical chest expansion, clear breath sounds
Abdomen: (-) tenderness

A Dengue Fever w/ warning signs

P F:
IVF: 1 liter of D5 LR for 75cc per hour (3cc per kg) as fluid maintenance
I:
Paracetamol 250/5m x 5mL (10 mkdose) every 4 hours if temperature is greater than or equal to 37.8 per orem
H:
for CBC w/ PC monitoring once a day in the morning
For blood typing
O: Input- 2850 Output- 1400
D: Diet as tolerated
Course in the wards
6/03/2022
WBC: 6.14 (5-10)
RBC: 5.28 (4.7-6.1)
Hemoglobin: 137 (135-180)
Hematocrit: 43.8 (42-52)
Platelet: 54 (150-450)
Neutrophil 15.7 (50-70)
Lymphocyte 63.7 (25-40)
Monocyte 16.6 (3-11)
Eosinophil 2.9 (1-4)
Basophil 1.1 (0-1)
Blood typing: A Rh Positive
Course in the wards
6/04/2022

S (-) cough, (-) colds, (-)fever

O General: awake, conscious, coherent

Skin: (-) jaundice, (-) pallor
VS: BP- 90/60, RR- 24, PR- 87, Temp- 36.7 O2 sat- 99%
Respiratory: symmetrical chest expansion, clear breath sounds
Abdomen: (-) tenderness

A Dengue Fever w/ warning signs

P F:
IVF: 1 liter of D5 LR for 75cc per hour (3cc per kg) as fluid maintenance
I:
Paracetamol 250/5m x 5mL (10 mkdose) every 4 hours if temperature is greater than or equal to 37.8 per orem
H:
continue CBC w/ PC monitoring once a day in the morning
O: Input- 2850 Output- 1300
D: Diet as tolerated
If patient’s platelet is more than 150 tom(06/05) , for possible discharge
Course in the wards
6/03/2022
WBC: 6.14 (5-10)
RBC: 5.28 (4.7-6.1)
Hemoglobin: 137 (135-180)
Hematocrit: 43.8 (42-52)
Platelet: 54 (150-450)
Neutrophil 15.7 (50-70)
Lymphocyte 63.7 (25-40)
Monocyte 16.6 (3-11)
Eosinophil 2.9 (1-4)
Basophil 1.1 (0-1)

6/04/2022
7am:
WBC: 4.89
RBC: 5.42
Hemoglobin: 140
Hematocrit: 45.1
Platelet: 63
Neutrophil: 12.7
Lymphocyte: 63.6
Monocyte: 14.9
Eosinophil: 7.8
Basophil: 1
Course in the wards
6/05/2022

S (-) cough, (-) colds, (-)fever

O General: awake, conscious, coherent

Skin: (-) jaundice, (-) pallor, (+)itchiness on torso
VS: BP- 90/60, RR- 22, PR- 84, Temp- 36.5 O2 sat- 99%
Respiratory: symmetrical chest expansion, clear breath sounds
Abdomen: (-) tenderness

A Dengue Fever w/ warning signs

P F:
IVF: AS NEEDED
I:
Paracetamol 250/5m x 5mL (10 mkdose) every 4 hours if temperature is greater than or equal to 37.8 per orem
Cetirizine 5mg/5mL x 5mL (0.2 mkdose) once a day at bedtime per orem
H:
continue CBC w/ PC monitoring once a day in the morning
O: Input- 2450 Output- 1300
D: Diet as tolerated
For possible discharge
Course in the wards
6/04/2022
7am:
WBC: 4.89
RBC: 5.42
Hemoglobin: 140
Hematocrit: 45.1
Platelet: 63
Neutrophil: 12.7
Lymphocyte: 63.6
Monocyte: 14.9
Eosinophil: 7.8
Basophil: 1

6/05/2022
5am
WBC: 7.5
RBC: 5.17
Hemoglobin: 135
Hematocrit: 43.2
Platelet: 97
Neutrophil: 19.6
Lymphocyte: 60.8
Monocyte: 10.1
Eosinophil: 8.4
Basophil: 1.1
Course in the wards
6/06/2022

S (-) cough, (-) colds, (-)fever

O General: awake, conscious, coherent

Skin: (-) jaundice, (-) pallor, (+)itchiness on torso
VS: BP- 100/70, RR- 22, PR- 95, Temp- 36.4 O2 sat- 99%
Respiratory: symmetrical chest expansion, clear breath sounds
Abdomen: (-) tenderness

A Dengue Fever w/ warning signs

P IVF AS NEEDED
For discharge
Course in the wards
6/05/2022
5am
WBC: 7.5
RBC: 5.17
Hemoglobin: 135
Hematocrit: 43.2
Platelet: 97
Neutrophil: 19.6
Lymphocyte: 60.8
Monocyte: 10.1
Eosinophil: 8.4
Basophil: 1.1

6/06/2022
WBC: 7.37
RBC: 5.11
Hemoglobin: 134
Hematocrit: 42.4
Platelet: 118
Neutrophil: 17.8
Lymphocyte: 60
Monocyte: 10.6
Eosinophil: 10.7
Basophil: 0.9
Case Discussion
Dengue (Break-Bone fever)
- Mosquito transmitted virus
- Leading cause of arthropod viral disease in the world
- Aedes mosquito
- Flavivirus
- Four distinct serotypes:
DENV 1
DENV 2
DENV 3
DENV 4
Case Discussion
Epidemiology
- Global incidence
100 – 400 million infections occur each year
80% generally mild and asymptomatic
- Southeast Asia
Out of 3.5 billion people around the world living in dengue endemic countries and at
risk of contracting dengue fever --> 1.3 billion live in dengue endemic areas in 10
countries of the SEA Region
- Philippines
The five year average case of dengue is 185,008
The five year average death is 732
The five year average case fatality is 0.39
Case Discussion
Incubation period: 1- 7 days
Clinical Manifestation
- Febrile Phase -
Fever plus any of the following:
● Severe headache
● Retro orbital pain
● Myalgia
● Arthralgia
● Transient macular or maculopapular rash
● Minor hemorrhagic manifestation
● Facial flushing or erythema
● Injected oropharynx
● Anorexia
Case Discussion
Clinical Manifestation
- Critical Phase -
Typically begins around time of defervescence
Rapid decline in platelet count with a rise in hematocrit
Presence of warning signs for severe disease:
● Clinical fluid accumulation
● Liver enlargement >2cm
● Abdominal pain or tenderness
● Persistent vomiting (at least 3 vomiting episodes within 24 hours)
● Mucosal bleed
● Lethargy or restlessness
Case Discussion
Clinical Manifestation
- Recovery Phase -
Patient improvement
Gradual reabsorption of extravasated fluid (such as from plasma leakage) over
48-72 hours
Increased diuresis
Hemodynamic status stabilizes
Patient can temporarily become bradycardic (but hemodynamically stable)
Pathophysiology
Dermal injection of Dengue Virus
Langerhans and Keratinocytes
Dissemination through lymphatic system

Liver (replication Endothelial Cell Monocyte,

Bone Marrow
in kupffer cells (Infection and Lymphocyte and
(replication on
and replication of Mast Cells
stromal cells)
Hepatocytes) endothelial cells)
Pathophysiology
Dermal injection of Dengue Virus
Langerhans and Keratinocytes
Dissemination through lymphatic system

Liver (replication Endothelial Cell Monocyte,

Bone Marrow
in kupffer cells (Infection and Lymphocyte and
(replication on
and replication of Mast Cells
stromal cells)
Hepatocytes) endothelial cells)

• Suppression of
Hematopoiesis
• Decrease platelet count
• Thrombocytopenia
Pathophysiology
Dermal injection of Dengue Virus
Langerhans and Keratinocytes
Dissemination through lymphatic system

Bone Marrow Liver (replication Endothelial Cell

Monocyte,
(replication on in kupffer cells (Infection and
Lymphocyte and
stromal cells) and replication of
Mast Cells
Hepatocytes) endothelial cells)
• Necrosis and apoptosis
in liver and breach its
function

• Increase
• Increase liver
coagulation
• enzyme
Consumption of
platelet
• Thromobcytope
nia
Pathophysiology
Dermal injection of Dengue Virus
Langerhans and Keratinocytes
Dissemination through lymphatic system

Bone Marrow Liver (replication Endothelial Cell

Monocyte,
(replication on in kupffer cells (Infection and
Lymphocyte and
stromal cells) and replication of
Mast Cells
Hepatocytes) endothelial cells)

• Apoptosis
• Endothelial cell
dysfunction
• Petechiae, easy
bruising,
gastrointestinal and
mucosal bleeding
Pathophysiology
Dermal injection of Dengue Virus
Langerhans and Keratinocytes
Dissemination through lymphatic system

Bone Marrow Liver (replication Endothelial Cell

Monocyte,
(replication on in kupffer cells (Infection and
Lymphocyte and
stromal cells) and replication of
Mast Cells
Hepatocytes) endothelial cells)

• Apoptosis
• Activation of soluble
mediators
• Imbalance profile of
cytokene and other
mediators
• Endothelial cell
dysfunction
 2009 WHO CLASSIFICATION OF DENGUE
WHO CLASS FEVER CRITERIA
Dengue with Warning ● Abdominal pain or tenderness
Signs ● Persistent vomiting
● Clinical fluid accumulation
● Mucosal bleed
● Lethargy, restlessness
● Liver enlargement >2cm
● Increase hematocrit with decrease in platelet

Severe Dengue ● Severe plasma leakage: shock, fluid accumulation with

respiratory distress
● Severe bleeding
● Organ involvement
○ Liver: AST or ALT >1000
○ CNS: impaired consciousness
○ Heart and other organs
2011 WHO CLASSIFICATION OF DENGUE FEVER & GRADING
CLASSIFICATI MANIFESTATION LABORATORY FINDINGS
ON

Dengue ● Fever with two of the ff: ● Leukopenia (WBC ≤ 5000

Fever ○ Headache cells/mm3)
○ Retro-orbital pain ● Thrombocytopenia
○ Myalgia <150,000 cell/mm3
○ Arthralgia ● Rising hematocrit (5-
○ Rash 10%)
○ Hemorrhagic manifestation
● No evidence of plasma leakage

DHF I ● Fever and hemorrhagic manifestation and

evidence of plasma leakage

DHF II ● Grade I plus spontaneous bleeding ● Thrombocytopenia

<100,000 cell/mm3
DHF III ● Grade I or II plus circulatory failure ● Hematocrit rise ≥ 20%

DHF IV ● Grade III plus profound shock with

undetectable BP and pulse
Diagnosis
Dengue NS-1 Antigen- (day 1 until day 3-5 of the illness)
Dengue IgG and IgM- Method of choice at the end of acute phase of infection
IgM- not earlier than 5 days nor later than 6 weeks after
onset
IgG on Primary infection- detectable at the end of 1st
week of illness then increased slowly after (detectable
after several months)
IgG on Secondary infection- detected even in the
acute phase, persist from 10 months to life
CBC- Leukopenia then thrombocytopenia or with hemoconcentration
Diagnosis
PT/PTT- prolonged bleeding time; moderately decreased prothrombin level
Blood Chemistry- Elevation of serum transaminase
Chest radiograph- for detection of pleural effusion
Treatment
- Uncomplicated Dengue fever -
Supportive
Bed rest
Tepid sponge bath
Antipyretics: Keep body temperature to <40℃
Analgesics for pain
Aspirin is contraindicated
Fluid and Electrolyte replacement
Treatment (by type of patient)
Group A: Patients who may be sent home
Group B: Patients who should be referred for in-hospital management
● Dengue without warning signs
● Dengue with warning signs
Group C: Patients with severe dengue requiring emergency treatment and urgent
referral
● Severe plasma leakage (shock) (compensated and hypotensive shock)
● Severe bleeding
● Severe organ impairment
Treatment (by type of patient)

GROUP B: Patients who should be referred for in-hospital

management
Patients with any of the following features:
■ Warning signs
■ Co-existing conditions that may make dengue or its management more complicated such as
pregnancy,
infancy, obesity, DM, renal failure, chronic hemolytic diseases
■ Social circumstances such as living alone or living far from health facility or without reliable means of
transport
Dengue with warning signs
○ Obtain a reference hematocrit before fluid therapy
○ Give only isotonic solutions such as 0.9% NaCl (saline), Ringer’s Lactate. Start with 5-7 mL/kg/hour for 1-
2 hours, then reduce to 3-5 mL/kg/hr for 2-4 hours, and then reduce to 2-3 mL/kg/hr or less according to
clinical response
○ Reassess the clinical status and repeat the hematocrit
○ If the hematocrit remains the same or rises only minimally, continue with the same rate (2-3 mL/kg/hr) for
another 2-4 hours.
○ If there are worsening of vital signs and rapidly rising hematocrit, increase the rate to 5-10 mL/kg/hour for
1-2 hours
Dengue with warning signs
○ Reassess the clinical status, repeat hematocrit and review fluid infusion rates accordingly
○ Give the minimum intravenous fluid volume required to maintain good perfusion and urine output of
about 1 mL/kg/hr.
○ Reduce intravenous fluids gradually when the rate of plasma leakage decreases towards the end of the
critical phase. This is indicated by:
■ Urine output and/or oral fluid intake is/are adequate, or
■ Hematocrit decreases below the baseline value in a stable
patient
Prognosis
DENGUE FEVER
● Good Prognosis
● Avoid use of drugs that suppress platelet activity

DENGUE HEMORRHAGIC FEVER

● Adversely affected by a late diagnosis and delayed or improper treatment
● Death
○ 40-50% of patients with shock but with adequate intensive care
○ <1% of cases
● Prolonged shock or occasionally intracranial hemorrhage → Residual brain
damage
Criteria for discharge
● Afebrile for at least 24-48 hours
● Good well being
● Stable hematocrit without IVF and increasing platelet trend
● At least 2-3 days from the last episode of shock
Discharge advice
Discard all empty paint cans filled with stagnant water
Follow-up after 2 weeks at the OPD
Apply insect repellant always
May resume daily activities
Prevention
Dengue vaccine: Dengvaxia
Prophylaxis in the absence of vaccine:
● Avoiding household-based mosquito bites:
1. Insecticides
2. Repellants
3. Body covering with clothing
4. Screening of house
5. Destruction of aedes aegypti breeding sites

● If water storage is mandatory

1. Tight fitting lid
2. Thin layer of oil
● Larvicide (abate)
● Field, forest and jungle
1. Mosquito repellants
Prevention
DOH 4S Kontra Dengue:
S-uriin at siran ang pinagmumugaran ng mga lamok
S-arili ay protektahan laban sa lamok
S-umangguni agad sa pinakamalapit na pagamutan
S-umuporta sa pagpapausok kapag may banta ng outbreak
EVIDENCE BASED MEDICINE
Clinical question
Is Carica papaya leaf extract effective in children with dengue fever?
JOURNAL TO BE APPRAISED
THE EFFECTIVENESS OF CARICA PAPAYA LEAF EXTRACT IN CHILDREN
WITH DENGUE FEVER
Dr. Deepa Shetty, Dr. Anita Manoj, Dr. Dipti Jain, Dr. Mangala Narayane and Dr.
Amit Rudrakar
Department of Paediatrics, Dr Babasaheb Ambedkar Memorial Central Railway
Hospital Byculla.
EVALUATING DIRECTNESS
Research question Journal article

Population (P) Children with dengue “Children aged 1 to 16 years with

dengue and platelets ≤1.5x105per μL and
≥50x 103per μL were included”
Exposure (E) carica papaya leaf extract to evaluate whether Papaya
leaf extract can be used to treat low platelet
count associated with dengue in children.
Outcome (O) Treat low platelet count in children with Carica papaya leaf extract, showed an
dengue increasing trend in the platelets in dengue
comparable to the control group and it
coincided with the natural increase in
platelets in the recovery phase. Carica
papaya leaf extract has no side effect in
children with dengue.
APPRAISING VALIDITY
1. Were the patients randomly assigned to treatment groups?
Thirty children (n=30) diagnosed as dengue cases by Ns1Ag test were enrolled
and randomized in this study. Fifteen out of thirty children were randomized to
test group where in addition to the supportive management of dengue Carica
papaya leaf extract 1100mg as tablet was given three times a day for children
above 12 years, 550mg as syrup three times a day for children between 6 to
12years and 250mg three times a day for children below 6 years for 5 days were
administered.
APPRAISING VALIDITY
2. Was allocation concealed? No
● Carica papaya leaf extract formulated in appropriate dosage form of tablet in
the strength of 1100mg for children above 12 years, syrup as (275mg/5ml)
10ml for children between 6 to 12years and 5 ml for children below 6 yrs was
given thrice daily for 5 days to test group in addition to the routine
symptomatic treatment given to the control group.
APPRAISING VALIDITY
3. Were baseline characteristics similar at the start of trial
Age Test Control
No.(%) No.(%)
1–4 02(13.3) 01(6.1)

5–8 03(20.0) 05(33.4)

9 – 12 09(59.9) 07(46.7)

13 – 16 01(6.7) 02(13.4)

Total 15(100) 15(100)

Gender Test Control

No.(%) No.(%)
Male 11(73.3) 10(66.7)

Female 04(26.7) 05(33.3)

APPRAISING VALIDITY
4. Were patients blinded to the treatment assignment? No
5. Were caregivers blinded to the treatment assignment? No
6. Were study personnel blinded to the treatment assignment? No
APPRAISING VALIDITY
7. Were all the patients analyzed under the groups they were originally
randomized?

Children diagnosed with severe dengue or dengue shock syndrome, platelets

below 50,000perμL who had received blood products during or within 3months of
diagnosis or children with bleeding disorders or alternative diagnosis(malaria)
were excluded from the study. Blood samples were collected in EDTA
anticoagulated vials and platelet counts were measured by automated count
analyzer. Platelet counts were obtained at baseline and on a daily basis for next
four days.
APPRAISING VALIDITY
8. Was follow-up rate adequate? YES
Interpreting results
● There were 30 children included in which boys were more than girls. Most
children infected are in the age of 9-12 years old, followed by 5-8 years old.
● 73.3% of cases among test group were male which was comparable to 66.7%
of male cases among control group and the difference was not significant.
● The platelet counts of children in the test group was lower than the platelet
counts in the control group and they reached a nadir after which they showed
an increasing trend coinciding with the natural course of platelets in dengue
and the monitoring of platelets clearly indicated that the platelet count is faster
in test group as compared to the control group
Interpreting results
● A steep rising trend in the platelets of the test group was observed, whereas
in the control group there was a gradual rise(shallow) on 4th and 5th day. The
difference between the trend of platelets in test and control group however
was not statistically significant.
Interpreting results
How precise was the estimate of the treatment effect?
Assessing applicability
1. Are there biological issues that may affect applicability of treatment?
Case Journal

Sex Male 70% of patients are male

Comorbidities None Children

diagnosed with severe dengue or
dengue shock syndrome, platelets below
50,000perμL who had received blood
products during or within 3months of
diagnosis or children with bleeding
disorders or alternative
diagnosis(malaria) were excluded from
the study.

Race Asian Conducted in India

Age 7 1 – 16

Pathology Dengue with warning signs diagnosed as dengue cases by Ns1Ag

test
Assessing applicability
2. Are there socio-economic issues affecting applicability of treatment?

Carica papaya leaf capsule are available in the Philippines with price ranging
from 50 to 390 pesos depending on the brand and number of capsules
Conclusion
Carica papaya leaf extract, in the trial, showed an increasing trend in the platelet
count in dengue fever, however not statistically significant and it also coincided
with the natural increase in platelet count in the recovery phase of the illness.
Thank you!