|Year : 2020 | Volume
| Issue : 3 | Page : 320-321
A rare case of dengue hemorrhagic fever with myocarditis and intracranial hemorrhage
Shalendra Singh, Pothireddy Sreenivasulu, Saurabh Sud, Shibu Sasidharan, Ankur Gupta
Department of Anaesthesiology & Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
|Date of Submission||06-Mar-2020|
|Date of Decision||29-May-2020|
|Date of Acceptance||03-Jul-2020|
|Date of Web Publication||06-Nov-2020|
Dr. Shalendra Singh
Department of Anaesthesiology & Critical Care, Armed Forces Medical College, Pune, Maharashtra.
Source of Support: None, Conflict of Interest: None
| Abstract|| |
We present a rare case of dengue hemorrhagic fever presenting with severe myocardial dysfunction along with intracranial hemorrhage and coagulopathy. It warrants every clinician to be vigilant in diagnosis and management so as to prevent life-threatening morbidity and mortality.
Keywords: Coagulopathy, dengue hemorrhagic fever, intracranial hemorrhage, myocarditis
|How to cite this article:|
Singh S, Sreenivasulu P, Sud S, Sasidharan S, Gupta A. A rare case of dengue hemorrhagic fever with myocarditis and intracranial hemorrhage. J Pediatr Neurosci 2020;15:320-1
| Introduction|| |
Among all the mosquito-borne diseases affecting humans, dengue is the second most common disease after malaria. Dengue fever (DF) is a significant cause of morbidity and mortality due to various complications associated with it. Cardiac complications such as myocarditis (15%–27%), functional abnormalities (40%), atrioventricular conduction disorders, and supraventricular arrhythmia are commonly seen in this disease. Intracranial hemorrhage (ICH) is among the rare central nervous system (CNS) manifestations in DF and is due to the complex interplay of coagulopathy, vasculopathy, thrombocytopenia, and platelet dysfunction., We encountered a case of dengue hemorrhagic fever (DHF) presenting with severe myocardial dysfunction along with ICH. To the best of our knowledge, this is the first case report describing ICH following DF-induced myocarditis in a pediatric patient.
| Case Report|| |
A 12-year-old girl presented with complaints of fever associated with headache and hematemesis of 4-day duration. Vital parameters and oxygen saturation were normal, but she had pallor, cervical lymphadenopathy, and petechial rashes over both lower limbs. No active bleeding was observed from any site. The patient had a history of hospital admission 6 months back for DF, in which the patient developed myocarditis with severe left and right ventricular dysfunction. In addition to this, the patient also had two episodes of seizures, which was managed with syrup levetiracetam. Presently, non-contrast computed tomography (NCCT) and cerebral spinal fluid analysis were done to rule out any infections/structural defect or bleed. Her fresh blood investigations showed low hemoglobin (6.9 gm%), low platelet count (3000/mm3) with normal coagulation profile, and positive dengue serology. Two-dimensional echocardiography again revealed similar findings. The patient was admitted in an intensive care unit (ICU) and resuscitated with intravenous restricted fluids, two units of single-donor platelets (SDP) transfused, and inotropes were started to maintain hemodynamic stability. The patient again had an episode of seizure, following which there was a sudden drop in sensorium to Glasgow Coma Scale of 04/15 with fixed and anisocoric pupils, following which the patient was intubated and placed on mechanical ventilation. Emergency NCCT showed ICH with no mass effect or midline shift [Figure 1]A and [Figure 1]B. Other causes of ICH such as arteriovenous malformations, aneurysm, or dural fistulas were excluded. Serial platelet counts were 8000/mm3 even with multiple SDP transfusions. The patient continued to deteriorate and succumbed to her illness on day 5 of admission.
|Figure 1: Computed tomography images (A and B) of ICH with no mass effect or midline shift|
Click here to view
| Discussion|| |
In 2018, World Health Organization has introduced a new category to classify the severity of dengue, “expanded dengue syndrome” (EDS), which includes unusual presentations of DF with severe organ involvement, including cardiac and neurologic complications. The proposed mechanism of myocarditis is the release of inflammatory mediators and the direct invasion of the virus into cardiac myocytes, as seen in acute myocarditis caused by other viruses. The gold standard diagnostic test of myocarditis in patient with dengue is endomyocardial biopsy (EMB), but the combination of symptoms, electrocardiography, cardiac enzymes, and the cardiac imaging can be done as an alternative of EMB. Early recognition of myocardial involvement and prompt restoration of hemodynamic stability while avoiding fluid overload is the key to treatment. ICH is rare but extremely fatal and forms a part of EDS. The current recommendation for platelet count before the neurosurgical intervention is 100,000/mm3, and those who fail to respond to platelet transfusion have a higher risk of postoperative intracranial hematoma formation. The patient, in this case, had ICH with no bleeding manifestations from any other sites. Therefore, it is imperative on the part of treating physician to have a high index of suspicion for ICH in patients who are disoriented and have altered sensorium during convalescence phase and should not be misinterpreted as toxic encephalopathy or fever delirium. Also, in view of patient’s continuously worsening condition, the decision to take up the patient for surgical decompression under cover of multiple blood product transfusions in the form of packed red cells, fresh frozen plasma, and platelet products may improve the outcome in such fatal complication. With this case report, we want to emphasize that the clinician should have a high index of suspicion for myocarditis, ICH, and coagulopathy in patient with DF. DF involving the myocardium and CNS can have a varied manifestation, which warrants every clinician to be vigilant in diagnosis and management so as to prevent life-threatening morbidity and mortality.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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