Hemoperitoneum in dengue Fever with normal coagulation profile.

A 43-year-old male living in Bengaluru sought emergency services due to high-grade fever, headache, myalgia, abdominal pain and distension. Platelet count (except the first-96,000/mm(3)) and coagulation profile was in normal limits. The dengue serology was positive for IgM and Ig G (immunoglobulin M and G) antibodies. Ultrasound abdomen showed gross ascites, mild bilateral pleural effusion and hepatosplenomegaly. The patient continued to have abdominal pain and progressive distention Ascitic tap was hemorrhagic. Later laparoscopy showed 1.5 liters peritoneal fluid with blood clots and mild diffuse congestion of the peritoneum. Liver, spleen and blood vessels were normal. Then what would be the possible mechanism to explain hemoperitoneum, is it the increased vascular permeability caused by the virus? India being endemic for dengue illness, it is an interesting and rare case presentation.

INTRODUCTION

Two-thirds of the world's population lives in areas infested with dengue vectors, mainly Aedes aegypti.[1] The dengue virus was first isolated in India in Kolkata in 1945. Dengue illness is caused by four distinct dengue virus types, 1, 2, 3 and 4 belonging to the genus flavivirus of family togaviridae and all four types are prevalent in India.[1]

Dengue illness is clinically characterized by sudden onset of fever, intense headache, retro-orbital pain, myalgia, maculopapular rash, generalized erythema, and minor bleeding manifestation like petechial rashes, gum bleeding, subconjunctival hemorrhage; severe hemorrhagic manifestations like epistaxis, hematemesis, hematuria and hemoperitoneum are also observed.[2] Hemorrhagic manifestations are observed at every stage of the illness and are probably the summation of the ill-understood viral pathogenesis as well as host factors that result in the incompetence of the vascular endothelium.[3] There are few case reports of dengue illness with hemoperitoneum secondary to spontaneous rupture of the spleen.[4-6] We report an interesting case of serologically confirmed dengue-positive patient with hemoperitoneum.

CASE REPORT

A male aged 43 years, residing in Bengaluru sought emergency services in July 2010. He presented with high-grade fever since four days and headache, myalgia, abdominal pain with distension since two days. He was a known diabetic (blood sugars were under control throughout the course, was on oral hypoglycemic agents) and was a social drinker (occasional alcohol consumption). Patient did not have any history of trauma. On examination he was febrile, anicteric, without any rash or lymphadenopathy. The complete blood count (CBC) showed total leukocyte count–6100 cells/mm3, differential count–neutrophils-50%, lymphocytes–45%, platelet count–96,000 cells/mm3 and packed cell volume–30%. The dengue serology was positive for both IgM and IgG antibodies (immunochromatography) serological test and peripheral smear for malaria was negative. The titers (ELISA) of dengue immunoglobulins was IgM : IgG = 4:1 and 14 days later IgM : Ig G = 5:2. With rising titers new dengue illness was diagnosed. The blood culture was sterile and ultrasound abdomen reported gross ascites, bilateral minimal pleural efflusion and borderline hepatosplenomegaly. We supposed the ascites is transudative and a part of the viral illness and as self-limiting. But the abdominal distension and pain continued to bother the patient so peritoneal tap was planned. Simultaneously, patient developed progressive pallor with drop in hemoglobin (from 9.6 gm/dl to 6.9 gm/dl) and hematocrit (from 30 to 23%), for which patient underwent blood transfusion (twice-packed red blood cells). During the initial two attempts of peritoneal tap, 500 ml of hemorrhagic ascitic fluid was drained. Even after drainage the abdominal pain and distention persisted with drop in hemoglobin, so laparoscopy was planned. Laparoscopic exploration showed 1.5 liters of peritoneal fluid with blood clots in the peritoneal cavity and mild diffuse congestion of the peritoneum. Liver, spleen, bladder and blood vessels were normal. His coagulation profile was within normal limits throughout the course (Prothrombin time (PT)-15.9 sec, Activated Patial thromboplastin time(APTT)-29 sec, International Normalized Ratio(INR)-1.48). Patient underwent blood transfusion (two packed red blood cells) again. The histopathological examination of the peritoneum showed mild hyperemia. Peritoneal drain was there for two days, abdominal discomfort and distention reduced over a week and hemoglobin improved and repeat ultrasound showed that the peritoneum was free of collection. Patient was discharged on oral hypoglycemic agents. The patient was asked to follow up with repeat hemoglobin, fasting and post-prandial blood sugar. During follow-up he is doing fine.

DISCUSSION

The clinical spectrum of dengue illness can range from asymptomatic infection to life-threatening dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). There are various theories of the pathogenesis of DHF/DSS, such as increase in vascular permeability, perivascular edema, vascular endothelial injury and parenchymal necrosis with splenic hyperplasia.[5] Bleeding manifestations in dengue illness are multifactorial. A combination of (a) increased prothrombin time, (b) hemoconcentration, (c) platelet count of less than 50,000 cells/mm3 and (d) elevated alanine transaminase (ALT) is known to be predictive for spontaneous bleeding manifestations.[7] Studies across the world have documented various bleeding manifestations in dengue illness, most common being gum bleeding, bleeding into internal organs, hemorrhagia and bleeding into serous cavities. Hemoperitoneum in dengue fever though rare can be life-threatening if not recognized early. Previous case reports on hemoperitoneum in dengue illness have been commonly associated with spontaneous rupture of the spleen.[4-6] However, our case had an unusual presentation of hemoperitoneum with normal abdominal viscera and coagulation. The patient came with high-grade fever, later found to be positive for dengue on serology. The hemoperitoneum was suspected after hemorrhagic parecentesis and associated decrease in hematocrit. However, the coagulation profile was normal and platelet count remained normal. The ultrasound abdomen showed fluid collection with normal spleen, liver, and major vessels. Although up to 100 million cases of dengue fever are registered per year only a few reports of hemoperitoneum are seen in the literature.[5]

CONCLUSION

The dengue illness is endemic in India and Southeast Asia, so are hemorrhagic complications due to thrombocytopenia. In our case there was spontaneous peritoneal bleeding with significant drop in hemoglobin without dengue hemorrhagic fever or dengue shock syndrome. By ultrasound abdomen it is difficult to differentiate between hemoperitoneum and transudative ascites. So regular monitoring of vital signs, regular hemoglobin estimation, apart from platelet count monitoring are important in dengue illness, for early detection of internal bleeding and associated complications. As per our knowledge this is the only case report of dengue fever with hemoperitoneum with normal spleen, liver, blood vessels and normal coagulation profiles.