1
|
Akhtar U, Mushtaq MH, Nisar S, Naeem A, Naim F. Dengue and Hypokalemic Paralysis: A Rare Association. Cureus 2023; 15:e44705. [PMID: 37809211 PMCID: PMC10552571 DOI: 10.7759/cureus.44705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 10/10/2023] Open
Abstract
Dengue is one of the most common mosquito-borne viral illnesses in tropical areas, including Pakistan. Presentation varies from a self-limiting flu-like illness to life-threatening conditions like hemorrhagic shock and multi-organ dysfunction leading to death. In the absence of vomiting and diarrhea, electrolyte abnormalities are rare findings. Though Guillain-Barré syndrome is a known association of viral illnesses presenting with flaccid paralysis, there is a possibility for dengue to cause hypokalemia without apparent gut or renal losses. Dengue-associated hypokalemic paralysis is an underrecognized entity but has a favorable outcome. The clinician should suspect this in patients presenting with motor weakness in dengue-endemic areas. Neurological complications of dengue are reported frequently now, so early recognition of these neurological manifestations is needed for the successful recovery of patients. Here, we discuss a case of dengue-induced hypokalemia presenting with acute flaccid paralysis.
Collapse
Affiliation(s)
- Ujala Akhtar
- Medicine, Khyber Teaching Hospital, Peshawar, PAK
| | | | - Sarah Nisar
- Internal Medicine, Khyber Medical College, Peshawar, PAK
| | - Awais Naeem
- Internal Medicine, Khyber Teaching Hospital, Peshawar, PAK
| | - Fahad Naim
- Internal Medicine, Khyber Teaching Hospital, Peshawar, PAK
| |
Collapse
|
2
|
Abstract
PURPOSE OF REVIEW To discuss the neurological complications of dengue virus (DENV) infection and their pathogenesis. RECENT FINDINGS Include recognition of the four different serotypes of DENV and their epidemiology as well as recognition of the expanded dengue syndrome encompassing multisystem involvement in the severe form of the disease including involvement of the central nervous system (CNS). DENV is a neurotropic virus with the ability to infect the supporting cells of the CNS. Neural injury during the acute stage of the infection results from direct neuro-invasion and/or the phenomenon of antibody-dependent enhancement, resulting in plasma leakage and coagulopathy. Immune mechanisms have been implicated in the development of the delayed neurological sequelae through molecular mimicry. A myriad of neurological syndromes has been described as a result of the involvement of the CNS, the peripheral nervous system (PNS), or both. Neurological manifestations in DENV infection are increasingly being recognized, some of which are potentially fatal if not treated promptly. DENV encephalopathy and encephalitis should be considered in the differential diagnosis of other acute febrile encephalopathies, autoimmune encephalitides, and in cases of encephalopathy/encephalitis related to SARS-CoV2 infection, especially in dengue-endemic areas. Acute disseminated encephalomyelitis (ADEM) may be occasionally encountered. Clinicians should be knowledgeable of the expanded dengue syndrome characterized by the concurrent compromise of cardiac, neurological, gastrointestinal, renal, and hematopopoietic systems. Isolated cranial nerve palsies occur rather uncommonly and are often steroid responsive. These neuropathies may result from the direct involvement of cranial nerve nuclei or nerve involvement or may be immune-mediated. Even if the diagnosis of dengue is confirmed, it is absolutely imperative to exclude other well-known causes of isolated cranial nerve palsies. Ischemic and hemorrhagic strokes may occur following dengue fever. The pathogenesis may be beyond the commonly observed thrombocytopenia and include cerebral vasculitis. Involvement of ocular blood vessels may cause maculopathy or retinal hemorrhages. Posterior reversible encephalopathy syndrome (PRES) is uncommon and possibly related to dysregulated cytokine release phenomena. Lastly, any patient developing acute neuromuscular weakness during the course or within a fortnight of remission from dengue fever must be screened for acute inflammatory demyelinating polyneuropathy (AIDP), hypokalemic paralysis, or acute myositis. Rarely, a Miller-Fisher-like syndrome with negative anti-GQ1b antibody may develop.
Collapse
Affiliation(s)
- Sweety Trivedi
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Science, Lucknow, India
| | - Ambar Chakravarty
- Department of Neurology, Vivekananda Institute of Medical Science, Kolkata, India.
| |
Collapse
|
3
|
Nagpal S, Nagpal AS. Acute quadriparesis in dengue – A rare presentation of a common disease. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2021. [DOI: 10.4103/injms.injms_174_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
4
|
Elkins JC. Hypokalemic Periodic Paralysis Secondary to Dexamethasone Injection. J Emerg Nurs 2019; 45:79-81. [PMID: 30616767 DOI: 10.1016/j.jen.2018.09.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
5
|
Changing Trends in Clinical Presentation and Biochemical Spectrum of Dengue Fever: An Observation of a Tertiary Care Centre. ARCHIVES OF CLINICAL INFECTIOUS DISEASES 2017. [DOI: 10.5812/archcid.62221] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
6
|
Kamel MG, Nam NT, Han NHB, El-Shabouny AE, Makram AEM, Abd-Elhay FAE, Dang TN, Hieu NLT, Huong VTQ, Tung TH, Hirayama K, Huy NT. Post-dengue acute disseminated encephalomyelitis: A case report and meta-analysis. PLoS Negl Trop Dis 2017; 11:e0005715. [PMID: 28665957 PMCID: PMC5509372 DOI: 10.1371/journal.pntd.0005715] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 07/13/2017] [Accepted: 06/15/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Dengue is one of the most common infectious diseases. The aim of this study was to systematically review acute disseminated encephalomyelitis (ADEM) and to represent a new case. METHODOLOGY/PRINCIPAL FINDINGS We searched for articles in nine databases for case reports, series or previous reviews reporting ADEM cases in human. We used Fisher's exact and Mann-Whitney U tests. Classification trees were used to find the predictors of the disease outcomes. We combined findings using fixed- and random-effects models. A 13-year-old girl was admitted to the hospital due to fever. She has a urinary retention. The neurological examinations revealed that she became lethargic and quadriplegic. She had upper limbs weakness and lower limbs complete paraplegia. Her status gradually improved after the treatment. She was nearly intact with the proximal part of her legs had a mild weakness in discharge. The prevalence of ADEM among dengue patients was 0.4% [95% confidence intervals (95% CI) 0.1-2.5%], all neurological disorders among dengue was 2.6% [95% CI 1.8-3.8%], and ADEM among neurological disorders was 6.8% [95% CI 3.4-13%]. The most frequent manifestation of ADEM was altered sensorium/consciousness (58%), seizures and urination problems (35%), vision problems (31%), slurred speech (23%), walk problems (15%) then ataxia (12%). There was a significant difference between cases having complete recovery or bad outcomes in the onset day of neurological manifestations being earlier and in temperature being higher in cases having bad outcomes (p-value < 0.05). This was confirmed by classification trees which included these two variables. CONCLUSIONS/SIGNIFICANCE The prevalence of ADEM among dengue and other dengue-related neurological disorders is not too rare. The high fever of ADEM cases at admission and earlier onset day of neurological manifestations are associated with the bad outcomes.
Collapse
Affiliation(s)
- Mohamed Gomaa Kamel
- Faculty of Medicine, Minia University, Minia, Egypt
- Online research Club (http://www.onlineresearchclub.org/)
| | - Nguyen Tran Nam
- Department of Infectious Diseases, Children’s Hospital No.2, Ho Chi Minh, Vietnam
| | - Nguyen Huu Bao Han
- Department of Pediatrics, University of Medicine and Pharmacy, Ho Chi Minh, Vietnam
| | - Abd-Elaziz El-Shabouny
- Online research Club (http://www.onlineresearchclub.org/)
- Kasr Al Ainy School of Medicine, Cairo University, Cairo, Egypt
| | - Abd-ElRahman Mohamed Makram
- Online research Club (http://www.onlineresearchclub.org/)
- Faculty of Medicine, October 6 University, Cairo, Egypt
| | | | - Tran Ngoc Dang
- Online research Club (http://www.onlineresearchclub.org/)
- Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
- Department of Environmental Health, University of Medicine and Pharmacy in Ho Chi Minh, Vietnam
| | - Nguyen Le Trung Hieu
- Department of Neurology, University of Medicine and Pharmacy, Ho Chi Minh, Vietnam
- Department of Pediatric Neurology, Children’s Hospital No.2, Ho Chi Minh, Vietnam
| | - Vu Thi Que Huong
- Department of Immunology and Microbiology, Pasteur Institute, Ho Chi Minh, Vietnam
| | - Trinh Huu Tung
- Department of Infectious Diseases, Children’s Hospital No.2, Ho Chi Minh, Vietnam
| | - Kenji Hirayama
- Department of Immunogenetics, Institute of Tropical Medicine (NEKKEN), Leading Graduate School Program, and Graduate School of Biomedical Sciences, Nagasaki University, 1-12-4 Sakamoto, Nagasaki, Japan
| | - Nguyen Tien Huy
- Evidence Based Medicine Research Group & Faculty of Applied Sciences, Ton Duc Thang University, Ho Chi Minh, Vietnam
- Department of Clinical Product Development, Institute of Tropical Medicine (NEKKEN), Leading Graduate School Program, and Graduate School of Biomedical Sciences, Nagasaki University, 1-12-4 Sakamoto, Nagasaki, Japan
| |
Collapse
|
7
|
Verma R, Holla VV, Kumar V, Jain A, Husain N, Malhotra KP, Garg RK, Malhotra HS, Sharma PK, Kumar N. A study of acute muscle dysfunction with particular reference to dengue myopathy. Ann Indian Acad Neurol 2017; 20:13-22. [PMID: 28298837 PMCID: PMC5341262 DOI: 10.4103/0972-2327.199914] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Acute myopathy is a common cause of acute motor quadriparesis which has various etiologies with different courses of illness and prognosis depending on the cause. Understanding this diversity helps us in proper approach toward diagnosis, predicting the prognosis, and possible complications and in improving the treatments that are being provided. This study was planned to study the clinical, electrophysiological, and etiological profile of patients presenting with acute myopathy. We also studied how dengue-related acute myopathy differs from other causes and also difference between myopathy due to myositis and hypokalemia in cases of dengue. Materials and Methods: This was a prospective, observational study involving all clinically suspected cases of acute myopathy of not more than 4 weeks duration with raised serum creatine kinase (CK) level. They were subjected to detailed clinical evaluation along with hematological, biochemical, microbiological, and electrophysiological studies and followed-up for outcome at 1 and 3 months. Muscle biopsy and histopathological examination were done in selected patients after taking informed consent. Statistical analysis was performed by appropriate methods using SPSS version 16.0 (Chicago, IL, USA). Results: We evaluated thirty patients of acute myopathy with raised CK level. Seventeen patients had fever, 11 had myalgia, and 5 had skin lesions. All presented with symmetric weakness, 17 (56.7%) patients having predominantly proximal weakness, neck or truncal weakness in 6 (20%), hyporeflexia in 12 (40%), with mean Medical Research Council (MRC) sum score of 46.67 ± 6.0. Eight (mean modified Barthel index [MBI] at presentation - 15 ± 3.7) patients had poor functional status according to MBI and 15 according to modified Rankin scale (MRS) (mean MRS score - 2.5 ± 1.2). Etiology was dengue viral infection in 14 patients; hypokalemia due to various causes other than dengue in 8; pyomyositis in 3; dermatomyositis, polymyositis, thyrotoxicosis, systemic lupus erythematosus, and unknown etiology in one each. Only eight patients had abnormal electrophysiology and seven among nine biopsies done were abnormal. At 1 month, 24 (80.0%) and 23 (76.7%) patients had achieved normal MBI and MRS scores with 28 (93.3) and 27 (90%) patients, respectively, at 3 months. Dengue with hypokalemia had less myalgia, more of hyporeflexia, and lower serum CK compared to those without hypokalemia. Conclusion: Dengue infection and hypokalemia due to various causes are the most common causes of acute myopathy and are associated with rapid and complete recovery within 1 month. Shorter duration of illness, higher MRC sum score, better disability status at presentation, lower serum CK correlate with better outcome. Biopsy was decisive in <20% cases; hence, it is not primary investigation in acute myopathy.
Collapse
Affiliation(s)
- Rajesh Verma
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Vikram V Holla
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Vijay Kumar
- Department of Plastic Surgery, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Amita Jain
- Department of Microbiology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Nuzhat Husain
- Department of Pathology, Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kiran Preet Malhotra
- Department of Pathology, Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ravindra Kumar Garg
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India
| | | | - Praveen Kumar Sharma
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Neeraj Kumar
- Department of Neurology, King George Medical University, Lucknow, Uttar Pradesh, India
| |
Collapse
|
8
|
Abstract
Dengue infection is the leading cause of illness and death in tropical and subtropical regions of the world. The common complications associated with dengue fever are usual hematological abnormalities, shock, and organ failure. The neurological complications of dengue are uncommon. However, evidence of dengue virus neurotropism and complications has been slowly but surely rising as seen from increased literature on this subject over the last decade. We report an uncommon case of hypokalemic quadriparesis with dengue that had a favorable outcome.
Collapse
Affiliation(s)
- Vikas Mishra
- Department of Medicine, Bombay Hospital Institute of Medical Sciences and Research, Mumbai, Maharashtra, India
| | - Rishit Harbada
- Department of Medicine, Bombay Hospital Institute of Medical Sciences and Research, Mumbai, Maharashtra, India
| | - Akhilesh Sharma
- Department of Medicine, Bombay Hospital Institute of Medical Sciences and Research, Mumbai, Maharashtra, India
| | - Meenakshi Mishra
- Department of ENT, Seth GS Medical College, Mumbai, Maharashtra, India
| |
Collapse
|
9
|
Joob B, Wiwanitkit V. Dengue-associated hypokalemic paralysis. J Neurol Sci 2014; 344:238. [DOI: 10.1016/j.jns.2014.06.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 06/19/2014] [Indexed: 11/27/2022]
|
10
|
Dengue-associated hypokalemic paralysis: Causal or incidental? J Neurol Sci 2014; 344:239. [DOI: 10.1016/j.jns.2014.06.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 06/19/2014] [Indexed: 11/19/2022]
|