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DENGUE FEVER

P Amin*, Sweety Bhandare**, Ajay Srivastava***
*Consultant, BHIMS. **Resident, Cook Country Hospital, Chicago. ***Resident, Bombay Hospital, Mumbai.

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INTRODUCTION

An acute mosquto-transmitted viral disease characterized by fever, headache, muscle and joint pain, rash, nausea, vomiting, appeared in Bombay after long period of silence.

CASE REPORT

A 54 year old male patient comes with h/o sore throat, mild fever, dry cough and myalgia since past one week. Patient was asymptomatic two weeks ago. Patient had taken a course of Clarithromycin and the fever subsided. The fever recurred again after two days and was started on tablet Cephalexin, however there was no change in the temperature. Patient had high-grade fever with headache, severe myalgia and arthralgia, nausea, loss of appetite, dark coloured urine and streaking of stools with blood. This was followed by difficulty in breathing and appearance of a petechial rash over the trunk and upper limbs. Patient also complained of fatigue and pain in the joints.

Patient is known h/o hypertension since 1984 on cap nifedipine 30 mg bid. Known h/o arthritis on NSAIDs since 2 years. No h/o smoking but had stopped since the past 10 years. Drinks occasionally. Diet - regular.

On examination, general condition fair. Pulse rate - 72/min, BP - 130/80 mmHg, Icterus present, petechial rashes over the trunk and upper limbs.

Laboratory investigations

Haematology - Prothrombin time 13.5 secs (control - 11 sec), INR - 1.26, partial thromboplastin time 63.1 secs (control - 29.5 secs)

Complete blood count - Haemoglobin - 15.5 gm/dl, erythrocytes - 4.98 million/cumm, HCT - 46.5%, MCV - 93.4 Fl., MCH - 31.0 Pg, MCHC - 33.3%, RDW - 12.0%, Leucocytes - 8.3 thous/cumm

Differential Count - neutrophils - 34%, band form - 00%, Eosinophil - 01%, Basophils - 00%,lymphocytes - 60%, monocytes - 05%, platelet count - 46 thous/cumm.

Peripheral count

Erythrocytes - normochromic normocytic. Platelet on smear - markedly reduced.

The following day the platelet count fell to 30,000/cumm

The D-dimers were in range of 1 but < 2 normal range 0.0 to 0.5)

Blood group - O-ve, FBS - 144 mg/dl, S creatinine - 1.3 mg/dl, BUN - 16.0 mg/dl, S uric acid - 7.6 mg/dl, calcium - 8.9 g/dl, Total proteins - 6.2 g/dl (Alb - 3.0 and globulin - 3.2 and A/G ratio - 0.9), Total bilirubin - 1.7 mg/dl (direct - 0.7 and indirect - 1.0)

SGOT - 1320 IU/L, SGPT - 495 IU/L, LDH - 1739 U/L, S. Alk phosphatase - 179 U/L, S cholesterol - 88.0 mg/dl, CPK - 203 U/L

X-ray Chest PA View

There is pleural reaction noted on the right side. No evidence of pulmonary infiltration is seen on either side of chest. The cardiac shadow is within normal size and shape.

Rapid Test for Malarial Antigens : P. falciparum and P. vivax not detected.

Serology : Anti-mycoplasma pneumoniae antibody (IgM) absent, hepatitis E Abs IGG, BY EIA - absent, ANA - positive in titer of 1 : 40, Paul - Bunnel - Neg., HIV I and II by Elisa and Western Blot - neg. IGM and IgG antibodies to Dengue both positive by immuno dot assay and chromatographic immunoassay (rapid test) respectively.

Treatment

Patient was given Tab Acetaminophen for fever. All NSAIDs were stopped. Patient was given cap. Omeprazole 20 mg once in the morning, Tab Folvite once a day, anusol ointment for local application.

Complete bed rest and close observation of the platelet count with daily monitoring was done. Patient was also observed for development of symptoms and signs of DHF.DSS like abdominal pain, vomiting, altered state of consciousness, hypothermia and drop in the blood pressure or narrowing of the pulse pressure.

After the fever sibsided and platelet count rose to more than 1,00,000/cumm, patient was discharged.

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