Ultrasound of Abdomen in Dengue Hemorrhagic Fever: Case Study

The objective of study to evaluate technical scanning and Image result of dengue haemorragic fever (DHF) on abdominal ultrasound examination. The Methods was a case study Presentation from 3 patients, and observations were taken from March 2022 to July 2022 at the RSUD Cengkareng Jakarta. Using a 3.5 MHz frequency convex transducer, take longitudinal and transverse shots with the supine patient position. Scanning focuses on the peritoneal cavity to evaluate the presence of plasma fluid that fills the peritoneal cavities. The results showed that the abdominal ultrasound examination procedure with clinical DHF was well done with patient preparation not eating fibrous at least 4 hours, drinking 3-4 glasses of water and holding urination about 2 hours to fill the bladder. The results show that there is fluid in the peritoneal cavity.


INTRODUCTION
Dengue hemorrhagic fever (DHF) is an infectious disease caused by the dengue virus including the Flavivirus genus of the Flaviviridae family with viral serotypes namely DEN-1, DEN-2, DEN-3, DEN-4 [1][2][3][4] which can result in a spectrum of clinical manifestations that vary between the mildest, dengue fever dengue virus (DD), DHF and dengue fever accompanied by scarring or dengue shock syndrome (DSS), transmitted by Aedes aegypti and Ae mosquitoes. Infected Albopictus [5][6][7] . The incidence of DHF, due to multiple causes, means that the emergence of pain due to various interacting factors, including agents (dengue virus), vulnerable (human) hosts and the environment that allows the growth and proliferation of Aedes mosquitoes [8][9][10] . Besides that, it is also influenced by predisposing factors including population density and mobility, housing quality, distance between homes, education, employment, life attitudes, age groups, ethnicities, vulnerability to diseases, and others 11,12 .
In the first degree the patient experiences symptoms such as fever accompanied by other clinical symptoms, without spontaneous bleeding, high body temperature with a cycle of 2-7 days, positive tourniquet laboratory test, thrombocytopenia, hemoconcentration. When there is an increase to degree II, the patient experiences the same symptoms as first degree symptoms, but is added by the presence of spontaneous symptoms such as petechiae, ecchymosis, melena, bleeding in the gums. In grade III the patient experiences symptoms of circulatory failure such as a weak and fast pulse with a size (> 120x / min) narrow pulse pressure with a size (≤ 120 mm Hg), blood pressure decreases with size (120/80 120/100120 / 110 90 / 70 80/70 80/0 0/0). At the last degree, that is, the degree of the pulse is not palpable, blood pressure is irregular (heart rate ≥ 140x / min) the upper limbs and lower limbs are felt cold, sweaty and the skin looks blue.
According to records with clinical DHF at the Cengkareng Regional General Hospital in Jakarta, abdominal ultrasound examinations within a period of one to two months were recorded in around 2-4 patients. An interesting DHF case related to abnormalities in several organs in the abdomen is the discovery of fluid in the peritoneal cavity.
Basically, an ultrasound examination can strengthen the suspicion of the disease if previously accompanied by laboratory tests, to determine whether or not there is a decrease in the number of platelets and leukocytes in the blood. Therefore the main role of ultrasound on examination with clinical DHF is here, as an important addition to adding clinical and laboratory effectiveness in diagnosing dengue fever and to predict the severity of the disease by linking imaging features with platelet counts (13). According to previous research, if it shows an albumin level of <3.5 g / dL, the subjects were positive for dengue fever (DHF) and DHF and had a plasma leak.
Compared with laboratory results and levels, the ultrasound (USG) modalities are very sensitive and specific in visualizing plasma leakage in the form of pleural effusion and / or ascites. Plasma leakage is identified by the presence of pleural effusion and / or ascites with thrombocytopenia 14,15 .Ultrasound examinations are performed using 3.5 MHz and 5 MHz frequency transducers (16,17). Ultrasound examination of the abdomen is done after 6 hours of fasting to allow for better distension of the gallbladder. In order to be evaluated properly the presence or absence of thickening of the gallbladder wall, which is a definite finding in all positive cases of dengue fever 14,[18][19][20][21] .
Abdominal ultrasonography in all subjects was investigated by using 3MHz -5MHz convex type transducers. Of the 100 research subjects, USG results found the following results: 61.89% had gallbladder walls and bladder wall thickening, 39.44% had ascites, and 61.89% had pleural effusion 22 . The objective of study to evaluate technical scanning and Image result of dengue haemorragic fever (DHF) on abdominal ultrasound examination.

METHOD
This study was case study presentation from 3 patients with clinical indications of DHF from March 2022 to July 2022 at the Cengkareng Regional General Hospital in Jakarta. By conducting an inspection using an aircraft ultrasound Philips HD 15 Pure Wave brand. Transducers used by convex types with a frequency of 3.5 MHz. The technique of moving the transducer is carried out with 4 techniques, namely Pressing, Breathing / Valsalva, Sweeping and Maneuvering.
For the three samples, the same procedure was carried out, namely with the preparation of fasting patients a maximum of 4 hours by holding urination. The position of the research subject is supine on the bed with both hands above the head, the skening is performed with longitudinal and transverse pieces throughout the abdominal organs.

RESULTS
Based on observations made during observations at the Cengkareng Jakarta General Hospital For patients with Dengue Haemorragic Fever indications an examination was carried out in the entire abdominal organs, but more focused on areas susceptible to abnormalities such as the Hepatorenal, Spleenorenal, Cul de sac and biological organs. bile.
The following are the pathology results obtained from the three samples with clinical dengue haemorragic fever. The ultrasound results in clinical DHF are shown in Figures 1,  2, 3 and Figure 4.  In the first patient on the results of the longitudinal skening shown in Figure 1 on the liver, a mirror image was shown firmly on the posterior image, a homogeneous parenchymal texture with an increase in echo with a hyperekhoic appearance, the anterior wall in the liver was not bounded with anechoic edge.

Figure 3. The patient's second ultrasound with a minimum fluid collection at Cul De
Sac.
The vascular system does not widen. Then on other organs The results of the bladder sketch shown in Figure 2 show a picture of a fully filled bladder with anechoic images with a regular wall, showing images of anechoic in subhepatic and intra pelvis. no picture of acoustic shadowing, no picture of an enlarged bladder.
In the second patient on the results of bladder scanning shown in Figure 3, there is a picture of a jar that is not too full, a regular wall, and anechoic picture on the cul de sac. no picture of Acoustic shadowing, no picture of an enlarged bladder.
In the third patient on the results of the longitudinal scanning in the liver shown in Figure 4, an anechoic picture outside the diaphragm was seen, an increase in echogenicity in the form of a hyperechoic image, the structure of the liver parenchyma appeared homogeneous with port veins and branches as a regular, tubular structure. There is no visible widening of the vascular system nodule.

DISCUSSION
The ultrasound procedure performed is correct, the results of abdominal ultrasound in clinical DHF are not only subjects with platelets below 100 thousand / µL who experience plasma seepage depending on the antibody of the study subjects, but in the study subjects with platelet counts above 100 thousand / µL also allows for plasma seepage in the peritonel cavity. Therefore abdominal ultrasound examination in the entire organ carefully and must attach the latest laboratory results to strengthen the diagnosis of DHF Based on observations made during the observation at Cengkareng General Hospital Jakarta, for patients with indications of Dengue Hemorrhagic Fever, examination of all abdominal organs is carried out, but more focused on areas that are prone to abnormalities such as Hepatorenal, Spleenorenal, Cul de sac and Biological. The pathological results were obtained from the three samples with clinical dengue hemorrhagic fever. Ultrasound results in clinical DHF are shown in Figures 1, 2, 3, and 4. In the first patient on the longitudinal scan results shown in Figure 1 of the liver, the mirror image is clearly shown on the posterior image, parenchymal texture is homogeneous with increased echo with a hyperechoic appearance , the anterior wall of the liver is not bounded by the anechoic rim. no Acoustic shadowing images, no enlarged bladder images. In the second patient, the results of the bladder scan are shown in Figure 3, there is a not too full jar, a regular wall, and an anechoic appearance on the cul de sac. no Acoustic shadowing images, no enlarged bladder images. In the third patient, the results of a longitudinal scan of the liver seen in Figure 4 show an anekonic appearance outside the diaphragm, increased echogenicity in the form of a hyperechoic appearance, the structure of the liver parenchyma looks homogeneous with port veins and branches as ordinary tubular structures.trengthen the diagnosis of DHF.

CONCLUSION
The ultrasound procedure that was carried out was correct. The results of abdominal ultrasound in clinical DHF were not only in subjects with platelets below 100 thousand/µL who experienced plasma seepage depending on the study subject's antibodies but in study subjects with platelet counts above 100 thousand/µL it was also possible for seepage to occur. plasma in the peritoneal cavity.

ACKNOWLEDGMENTS
We would like to thank the Director of Radiodiagnostic and Radiotherapy Department of Politeknik Kesehatan Kementerian Kesehatan Jakarta II, Ministry of Health for his contributions during the study. We are sincerely grateful to the Directors, Sonographers and District General Hospital of Cengkareng Jakarta staff for their valuable contributions, facilities, assistance and constructive suggestions during our study.