Acute gingival bleeding as a complication of dengue hemorrhagic fever.

Dengue fever is mosquito borne disease caused by dengue virus (DENV) of Flaviviridae family. The clinical manifestations range from fever to severe hemorrhage, shock and death. Here, we report a case of 20-year-old male patient undergoing orthodontic treatment presenting with acute gingival bleeding with a history of fever, weakness, backache, retro orbital pain and ecchymosis over his right arm. The hematological investigations revealed anemia, thrombocytopenia and positive dengue non-structural protein-1 antigen and also positive immunoglobulin M and immunoglobulin G antibodies for DENV. Patient was diagnosed as a case of dengue hemorrhagic fever and was immediately referred for appropriate management. This case report emphasizes the importance of taking correct and thorough medical history.

INTRODUCTION

Dengue fever (DF) is an acute mosquito borne transmitted disease caused by the DF virus of family Flaviviridae, the most common cause of arboviral disease in the world.[1] The dengue virus (DENV) are four genetically related, but distinct serotypes designated DENV-1, DENV-2, DENV-3 and DENV-4 are circulating world-wide.[2] The main vector for dengue transmission is Aedes aegypti species of mosquitoes.[3]

Clinical manifestation of dengue infection range from fever, headaches, arthralgia, myalgia and skin rashes to severe hemorrhagic shock and death.[4]

Bleeding, one of the major problem encountered in DF, contributes to worsening morbidity. The toxic hemorrhagic state appears during the 3rd to 5th day of illness following the onset of fever followed by convalescent stage. The most common hemorrhagic manifestation are epistaxis, skin hemorrhages and gastrointestinal hemorrhages.[1] Here, we report a case of patient presenting with acute gingival bleeding with dengue hemorrhagic fever.

CASE REPORT

A 20-year-male patient undergoing orthodontic treatment reported with acute gingival bleeding in the right upper posterior quadrant in the outpatient of our hospital. Patient was bleeding very profusely. On taking history of patient, we got to know that he is having fever since 3-4 days with weakness, retro orbital pain and severe back-ache. Patient gave a history of bleeding from gums for last 24 h [Figure 1]. On physical examination, patient appeared emaciated and pale and there were ecchymoses on his right arm [Figure 2]. We asked the orthodontist to remove the braces from the patient immediately as it was aggravating the hemorrhage. We tried to control the bleeding with cotton gauze and pressure packs, but were unable to achieve satisfactory hemostasis. This alerted us for some systemic cause underneath and we sent the patient for routine hematological investigations viz.; complete hemogram, general blood picture, platelet count and also advised him investigations to rule out DF and malaria as there was the outbreak at that time in the city. His report revealed; the platelet count 24,000, total leukocyte count 2600/cumm, DLC (P45, L53, E2), hemoglobin 6.6%. Patient sera were positive for dengue non-structural protein-1 antigen and also for anti-dengue immunoglobulin M (IgM) and anti-dengue immunoglobulin G (IgG) antibodies. The patient peripheral blood smear was negative for malaria parasite. After seeing the above report, we immediately referred the patient to the department of medicine of our institute where he was admitted and treated as a case of dengue hemorrhagic fever (DHF) with anemia with gingival bleeding. The patient responded very well with complete cessation of gingival bleeding on the next day of admission and within 48 h the platelet count came near to normal (1.43 lakhs). Patient was discharged in satisfactory condition on the 5th day of admission.

Figure 1

Acute gingival bleeding in the patient

Figure 2

Ecchymosis on the right arm of the patient

DISCUSSION

DF is endemic in tropical and subtropical-areas of the world with about 2.5 billion people (40% of the world population) at risk in these regions. World Health Organization estimates 50 million dengue infection occur world-wide every year.[4] The DENV has four distinct serotypes DENV-1, DENV-2, DENV-3, DENV-4 and infection from one serotype confers lifelong immunity to only that serotype.[56] DENV has positive single stranded ribonucleic acid genome packaged inside a core protein, surrounded by an icosahedral scaffold and covered by a lipid envelope.[3]

DENV is transmitted by the bite of A. aegypti mosquito carrying the infectious DENV. The vector (mosquito) can serve as biological host in which the virus replicates before it is transmitted in to the target host (patient) or the vector acting only as transmitting vehicle leading to only mechanical transmission. In both cases, the vector directly injects the virus into capillary blood vessels of the host.[7] After entering into the blood stream, the virus replicates in sufficient quantity to induce the febrile response. Cytokines that induce fever such as tumor necrosis factor-alpha, interleukin (IL)-1 and IL-6 are released. The period of fever following DF lasts for 2-7 days.[8] The spectrum of disease includes undifferentiated DF to dengue shock syndrome with later having an increased mortality.[9]

According to the criteria for diagnosis of dengue hemorrhagic fever:[910]

Clinical criteria: Pyrexia-Sudden onset, high grade lasting 2-7 days. Hemorrhagic manifestations in the form of at least one of the following: Petechiae, purpura, ecchymosis, epistaxis, gingival bleeding, bleeding from mucosa, GIT or injection site, hematemesis and/or malena

Positive tourniquet test and hepatomegaly.

Laboratory criteria: Thrombocytopenia (platelet count <100,000/cumm),

Evidence of plasma leakage manifested by at least one of the following:

Rise in hematocrit 20% above for age, sex and population

Signs of plasma leakage such as pleural effusion.

The pathogenesis of hemorrhage in DHF could be multifactorial and includes vasculopathy, platelet deficiency and dysfunction and blood coagulation defects.[1] Thrombocytopenia occurring in dengue hemorrhagic fever arises from both decreased production[1112] and increased destruction of platelets.[13] Moreover, there is impairment of platelet function, which can cause vascular fragility leading to hemorrhage, an important mechanism of plasma leakage in dengue hemorrhagic fever.[14]

Furthermore, a similar case has been reported by Chen et al. in which 54-year-male patient presented with fever, bone pain, gum bleeding, scrotal and penile edema with thrombocytopenia (platelet count <14,000/mm3) and hematocrit elevated to 45.5%. The patients sera showed positive seroconversion of IgG and IgM antibody to DENV.[15]

Butt et al.[16] examined 104 patients with fever less than 2 weeks duration with generalized morbiliform rash and bleeding manifestations, with positive serum for anti-dengue IgM and IgG using polymer chain reaction. Nearly, 81.73% patients presented with fever followed by generalized morbiliform rash, 62.5% backache and 34.6% with mucosal bleeding manifestations. Laboratory findings in these patients were; thrombocytopenia was seen in all patients (100%), leucopenia in 55 (52.8%), raised hematocrit in 52 (50%) and overall mortality was 2.88%.

CONCLUSION

The prompt referral of the patient, made on the behest of our observations (acute gingival bleeding, fever, ecchymosis on the arms and thrombocytopenia) saved the life of patient. This case report emphasizes the value of taking correct and thorough history along with proper diagnosis in episodes of acute gingival bleeding as the dentist is the first person who can actually diagnose and refer these patients for proper management.