Authors reply.

June 13, 2014

Sir, the recent report on “thrombocytopenic purpura and dengue” is very interesting[1]. AMÂNCIO et al. concluded that “DENV-4 can also result in severe forms of the disease and lead to hemorrhagic complications and death, mainly when dengue infection is associated with coexisting conditions[1]”. In fact, dengue is a common arboviral disease that can be seen in several tropical countries. No doubt that this infection can co-occur with other thrombohemostatic disorders. The concomitant disorder between dengue and thrombocytopenic purpura is not common and can be problematic. This problem can induce to severe bleeding as well as atypical manifestations such as angina[2]. To manage those cases, adding to fluid replacement therapy, steroid therapy seems to be useful[6]. Nevertheless, dengue can be the cause of immune thrombocytopenic purpura[3,4] and it is observed for relationship to severe cardiovascular failure and shock[5]. In the present case, it is needed to clarify whether the observed thrombocytopenic purpura problem is the new superimposed or old problem. Since the clinical management of the dengue case with underlying thrombocytopenic purpura is different from general cases, it is the role of the physician in charge to carefully take the patient past history on personal illness.

To the Editor

We would like to thank JOOB & WIWANITKIT for their comments on our article[1]. In fact, as a variety of conditions associated with dengue could explain the bleeding and thrombocytopenic picture described, it is difficult to ensure that the patient got worse by an exacerbation of immune thrombocytopenic purpura. That is why it makes difficult the use of steroids in such cases. As reported[1], dengue associated with sepsis or just severe dengue with gastrointestinal bleeding are possible explanations for the described clinical picture. Despite anecdotal reports of favorable outcome in specific dengue cases who used steroids[3,4], a thorough review showed no benefit from use of corticosteroids in dengue shock[2]. The steroids use during the early acute phase of dengue infection was also not associated with reduction in the development of shock[7] and there was no benefit of using adjunctive corticosteroid therapy in term of changing the severity of thrombocytopenia[5,6]. We completely agree that the treatment of dengue should be personalized considering comorbidities and clinical history of the patients, however, as corticosteroids can potentially do harm, we believe that their use need to be better defined and limited to very specific dengue situations.

We wish to thank JOOB & WIWANITKIT again for their attention and observations. We enjoyed the opportunity to discuss the case reported and we hope that future studies adequately powered, designed and controlled evaluate the possible beneficial effects of steroids on the various manifestations of dengue infection.