Case report on atypical presentation of Dengue - A patient without - PDF document

Case Report Case report on atypical presentation of Dengue - A patient without fever Rushanthini Seevaamirtham 1 , Chamara Sarathchandra 1 Teaching Hospital Anuradhapura 1 . Abstract complain fever. Her systemic inquiry did not reveal any signifjcant symptoms except mild arthralgia Dengue can present with wide spectrum of clinical and myalgia. Examination revealed temperature of manifestations including atypical presentations. 98.4 ◦ F, blood pressure measured as 120/70mmhg, But fever is the most common clinical presenta- pulse rate was 100bpm and her neurological ex - tion even with the atypical presentations. Here amination and other systemic examination was we report a case of dengue hemorrhagic infection normal. Her headache was persistent and severe without fever in a 53-year-old female. Clinically and serologically she was diagnosed to have den- until day 9 of the illness and subsided with regular gue hemorrhagic fever with ultrasound evidence analgesics. Body temperature was normal through- of plasma leakage as well and she was managed out the course of illness. She does not have any successfully and she showed complete recovery clinical features of immune dysfunction such as without any complications. recurrent infections. Introduction Her base line full blood count was, WBC- 8600/ Dengue is the most important mosquito borne µL, Hb-11.5 and platelet 249000. Immediate NCCT human infection of 21 st century. (1) In Sri Lanka brain was taken to rule out possible intracranial pa- the incidence of dengue has markedly increased in thology and reported as normal. A lumber puncture last decade and atypical presentations also report- was performed to rule out possible meningitis and ed with other co infections. (2) Dengue is a viral CSF analysis showed clear in appearance and no infection caused by arbovirus and clinically man- cells were detected and normal range of proteins. ifesting with wide range of difgerent presentations from subclinical infection to severe multi organ CSF sugar was 84mg/dL with RBS of 140mg/dL. failure. (3) Even though, fever is the commonest Her ESR was 22mm in first hour and CRP was and classic presentation of dengue, here we are 4.2mg/L. Her blood, urine and CSF cultures were reporting a case of dengue infection presented all negative. Her blood picture revealed reactive without fever. There are various atypical manifesta- lymphocytes suggestive of possible viral infec- tions of dengue reported so far even though afebrile tion. Her platelets and white blood cells gradually dengue is a very unusual presentation. Acalculous started to drop and lowest counts were 18000/µL cholecystitis, acute pancreatitis, myositis, myocar- and 1500/µL respectively. Her liver function was ditis, encephalitis, seizures, hepatitis, transverse monitored and gradually elevated AST and ALT myelitis, acute respiratory distress syndrome, and from the base line of 80u/l and 40u/L to 272u/l and renal failure were found as some kind of atypical 218u/L as maximum during the course of illness on presentations. (4, 5) day nine and gradually came down from day nine. Case presentation Ultrasound revealed evidence of plasma leakage on day seven with mild ascites. Her HbA1C was 53-year-old previously healthy female from Anu- normal and HIV antibodies were negative and radhapura presented with severe headache, nausea possible immune dysfunction is unlikely. and vomiting for one day duration. She did not Corresponding Author: Dr S. Rushanthini rseevaa@gmail.comORCID0000-0002-6050-5014 This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution and reproduction in any medium provided the original author and source are credited - 30 - Jafgna Medical Journal

Her dengue IgM and IgG performed on day six of Dengue meningitis is another atypical rare clinical illness and both were positive and the diagnosis entity. (8) Here we have excluded the possible was made as second episode of dengue infection. mening itis with normal CSF report and infmamma - She was managed with simple analgesics and tory markers. In a prospective study by Soares et supportive management with reassurance. Fluid al. from Brazil revealed encephalitis with normal management was given as in dengue pre critical CSF cellularity in 75% of patients. (8) But dengue phase and daily bedside ultrasound imaging was presented as meningitis in minority of patients. (9) performed to detect critical phase early as possi- Dengue virus and dengue IgM isolated from CSF ble. Vital signs and fmuid balance were monitored is suggesting that dengue has capacity of causing as per national dengue guidelines. On day seven, central nervous system infections as well. (10) she showed ultrasound and clinical evidence of plasma leakage into pleural and peritoneal space The time of onset of neurological manifestation and critical phase detected. She was managed as for in a dengue fever is averagely on or after day 10 dengue hemorrhagic fever and critical phase hourly of the onset of fever. (10) Our patient had severe monitoring of parameters started. After day nine of headache from the fjrst day of illness and does not her illness her symptoms gradually subsided and have any clinical or biochemical picture suggestive she made complete recovery and discharged from of meningitis rather than headache. ward on day eleven. Afebrile dengue is an interesting case which is Discussion rarely mentioned in the literature. (11, 12) The Dengue is a common infectious disease in Sri exact pathology of the afebrile dengue in a person Lanka even though the atypical presentations of without previous comorbidities is not understood dengue are rare. There are many reported atypical yet. (11) A possibility of afebrile dengue is immune presentations and these can afgect any system of the suppression such as in long term poorly controlled body. The atypical manifestations include quadri- diabetes mellitus where the infmammatory cytokines plegia, seizure, headache, aseptic meningitis, en- (IL-1 and IL-6) secretion by mononuclear cells is cephalitis, mononeuropathy and Guillain-Barre. (6) suppressed. (12) Consequently there will be no Even though these are atypical presentations, most fever in response to infections. Afebrile presen- of these associate with afebrile phase at any time tation of dengue in infants also has been reported in the course of this illness. Here our patient pre- previously due to immature immune system. (13) sented with severe headache as the main complaint, associated with nausea and vomiting without fever. Atypical presentations also end up with critical phase as in our patient and if the diagnosis is missed Cardiac arrhythmias also can occur in the acute phase of dengue fever most likely due to dengue already, there is a high risk of developing dengue myocarditis and can be an atypical presentation. (7) shock and even death without a close precise fmuid Sudden onset of severe headache and neurological management and vital parameters monitoring. manifestations might mimic other conditions such High clinical suspicion and early recognition of as bacterial meningitis. But the blood investiga- dengue regardless of fever is vital for the successful tions including elevated hepatic transaminases, management especially in dengue endemic areas. thrombocytopenia and leucopenia in a patient in dengue endemic area should raise the suspicion Ethics approval and consent to participate of possibility of dengue even in the absence of Ethical approval was not obtained for the publi- a documented fever. To rule out this possibility, cation of this case report as this does not involve serological investigations need to be performed as sharing of the personal details of the patient. in our patient. Vol.31, No.1, July 2019 - 31 -