The presentation of this patient with skin rash, thrombocytopenia and elevated liver and muscle enzymes prompted us to perform dengue serology as dengue fever is endemic in our region. It was positive for IgM and IgG. The ELISA for NS1 viral antigen was also requested on admission in addition to RT-PCR, and the positive results confirmed the diagnosis. The patient was diagnosed with DHF with elevated haematocrit, thrombocytopenia, elevated liver and muscle enzymes, and intracranial haemorrhage. She was admitted to intensive care but succumbed to her intracranial haemorrhage 3 days later in spite of supportive care and an improvement in platelet count.
Dengue viral infections are one of the most important mosquito borne diseases in the world. The dengue virus is a single stranded RNA virus belonging to the Flaviviridae family.1
There are four serotypes (DEN 1–4), classified according to biological and immunological criteria.
Patients may be asymptomatic or their condition may give rise to undifferentiated fever, dengue fever, DHF, or dengue shock syndrome. Annually, 100 million cases of dengue fever and half a million cases of DHF occur worldwide and 2.5 billion people are at risk. Ninety per cent of DHF cases involve children <15 years of age. At present, dengue is endemic in 112 countries in the world. No vaccine is available for preventing this disease. Early recognition and prompt initiation of appropriate treatment are vital if disease related morbidity and mortality are to be limited.
Clinical features of DHF are summarised as follows:
- High fever, intermittent
- Severe headache (especially retro-orbital)
- Myalgia and arthralgia
- Acute abdominal pain.
- Bleeding from gums
- Petechiae and ecchymosis
- Haematemesis and maelena
- Spotting or menorrhagia in females.
Features of plasma leakage
- Circulatory disturbances (low blood pressure, tachycardia, narrow pulse pressure, and poor capillary refill time)
- Periserositis (pleural effusions, ascites sometimes pericarditis).
- Encephalopathy and encephalitis
- Liver failure
- Disseminated intravascular coagulation leading to massive bleeding.