Discussion :
This child has Dengue Hemorrhagic Fever {DHF}. With fluid resuscitation, his intravascular compartment seems to have restored but the oliguria continues. Thus the child seems to have an additional renal component of the cause of oliguria. Even though serum creatinine is normal, the child does have hyperkalemia. Also the respiration seems to be like an acidotic breathing making one suspect metabolic acidosis. Metabolic acidosis without dehydration also suggests a renal involvement. This child also has puffiness of eyes which may be due to third spacing. The distress of breathing especially with activity of lower intercostals suggests congestion of the bases of lung. Congestion can be the lung parenchyma i.e., pulmonary edema or in the pleural spaces due to third space losses. Pulmonary edema in a DHF may occur either due to volume overload {which should lead to increased urine output} or due to myocardial dysfunction. Thus, there seems to be a heart involvement in this child too. Thus, in this child, there seems to be a multisystem organ problem. The pulmonary edema should be treated with a diuretic which may also help the kidneys to open up. Prior to that the extra fluids should be stopped and child would require ionotropic support to maintain the intravascular volume. This child was given Dopamine, extra fluids were stopped and when blood pressure was around 75th centile, a diuretic was given following which the child passed 400 ml of urine in next 6 hours. His blood gases did show metabolic acidosis Echocardiography showed left ventricular dysfunction. With this treatment, child had a marked improvement.
Hence in a patient with DHF, optimum fluid management is very essential to prevent complications.
E-published: October 2010 Vol 7 Issue 10 Art No. 62
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