Dengue shock syndrome in a renal transplant recipient

Dengue virus infection in hematopoietic stem cell transplant recipients: A case series and comparative literature review from dengue endemic region

This case series describes the wide spectrum of clinical presentation, laboratory findings, and morbidity/mortality associated with dengue fever in hematopoietic stem cell transplant recipients, treated in a dengue endemic region. The risk of acquiring viral infections increases manifold after transplant due to the severely immunocompromised state amid conditioning toxicity and immunosuppressive therapy. The classical warning signs of dengue viremia are often masked in posttransplant patients, leading to a missed diagnosis of dengue and grave consequences observed in some of the patients. Accurate and timely diagnosis of dengue fever especially in dengue prevalent areas can prevent the unwarranted complications and reduce the morbidity and mortality associated with dengue in allogeneic/autologous transplant recipients.

Dengue infection with warning signs: The 2019 epidemic

Background

Dengue is a common arthropod-borne viral disease with a variable clinical spectrum, course, and outcome.

Method

We conducted a prospective observational study describing the clinical profile of patients hospitalized for dengue with warning signs during the 2019 epidemic.

Result

A total of 1349 patients with dengue, including 459 with warning signs, were seen. It predominantly affects the younger subset of both sexes. A higher proportion of females presented with either a platelet count less than 20,000/mm³ or a rapid fall in platelets. Bleeding manifestations of varying severity were observed in one-fifth of them. Severe bleeding was universal at a platelet count less than 10,000/mm³. Platelet transfusion was indicated in 17 (7.3%) males and 25 (11%) females, with females requiring it at a higher platelet count. While hepatic involvement was frequent, others such as myocarditis, encephalitis, and pancreatitis were infrequent. Coinfections observed included malaria, scrub typhus, and enteric fever. The case fatality rate for the patients with dengue and those with warning manifestations was 0.4% and 1.3%, respectively.

Conclusions

Dengue epidemics often overwhelm health-care resources. Such epidemics can be successfully managed using a protocolized approach, modified as per the available resources. Platelet transfusions are lifesaving at a count less than 10,000/mm³. With meticulous supportive care, the case fatality rate can be reduced to less than 0.5%.

Unusual clinical manifestations of dengue disease - Real or imagined?

The disease caused by each of the four serotypes of dengue virus (DENV) have plagued humans since last century. Symptoms of dengue virus (DENV) infection range from asymptomatic to dengue fever (DF) to severe dengue disease (SDD). One third of the world's population lives in regions with active urban DENV transmission, and thousands of serologically naïve travelers visit these areas annually, making a significant portion of the human population at risk of being infected. Even though lifelong immunity to the homotypic serotype is achieved after a primary DENV infection. Heterotypic DENV infections may be exacerbated by a pre-existing immune memory to the primary infection and can result in an increased probability of severe disease. Not only, age, comorbidities and presence of antibodies transferred passively from dengue-immune mother to infants are considered risk factors to dengue severe forms. Plasma leakage and multiple organ impairment are well documented in the literature, affecting liver, lung, brain, muscle, and kidney. However, unusual manifestation, severe or not, have been reported and may require medical attention. This review will summarize and discuss the increasing reports of unusual manifestations in the clinical course of dengue infection.

Emergent Arboviruses and Renal Transplantation: A Global Challenge

In recent years, Zika, Chikungunya, Dengue, West Nile Fever, and Yellow Fever epidemics have generated some concerns. Besides difficulties related to vector control, there are challenges related to behavior of pathologies not yet fully understood. The transplanted population requires additional care due to immunosuppressive drugs. Furthermore, the potential risk of transmission during donation is another source of uncertainty and generates debate among nephrologists in transplant centers. Do the clinical outcomes and prognoses of these infections tend to be more aggressive in this population? Is there a risk of viral transmission via kidney donation? In this review article, we address these issues and discuss the relationship between arbovirus and renal transplantation.

Kidney Diseases Associated With Parvovirus B19, Hanta, Ebola, and Dengue Virus Infection: A Brief Review

Viral infection-associated kidney diseases are an emerging public health issue in both developing and developed countries. Many new viruses have emerged with new paradigms of kidney injury, either directly through their cytopathic effect or indirectly through immune-mediated glomerulopathy, tubulointerstitial disease, and acute kidney injury as part of multiorgan failure. Herein, we will discuss Parvovirus, which causes glomerulopathy, and Hanta, Ebola, and Dengue viruses, which cause viral hemorrhagic fever and acute kidney injury. Clinical manifestations also depend on extrarenal organ systems involved. Diagnosis of these viral infections is mainly based on a high index of suspicion, serologic testing, and isolation of viral DNA/RNA. Management is largely conservative, as specific antiviral agents are unavailable.

Rare and Emerging Viral Infections in the Transplant Population

Viral infections account for a large proportion of emerging infectious diseases, and the agents included in this group consist of recently identified viruses as well as previously identified viruses with an apparent increase in disease incidence. In transplant recipients, this group can include viruses with no recognized pathogenicity in immunocompetent patients and those that result in atypical or more severe disease presentations in the immunocompromised host. In this chapter, we begin by discussing viral diagnostics and techniques used for viral discovery, specifically as they apply to emerging and rare infections in this patient population. Focus then shifts to specific emerging and re-emerging viruses in the transplant population, including human T-cell leukemia virus 1, rabies, lymphocytic choriomeningitis virus, human bocavirus, parvovirus 4, measles, mumps, orf, and dengue. We have also included a brief discussion on emerging viruses and virus families with few or no reported cases in transplant recipients: monkeypox, nipah and hendra, chikungunya and other alphaviruses, hantavirus and the Bunyaviridae, and filoviruses. Finally, concerns regarding infectious disease complications in xenotransplantation and the reporting of rare viral infections are addressed. With the marked increase in the number of solid organ and hematopoietic stem cell transplants performed worldwide, we expect a corresponding rise in the reports of emerging viral infections in transplant hosts, both from known viruses and those yet to be identified.

Transplantation in the tropics: lessons on prevention and management of tropical infectious diseases

Tropical infectious diseases (IDs) remain a rare complication in transplant recipients even in tropical settings, but this topic has become increasingly important during the last decade due to multiple factors. Interestingly, non-tropical countries report most of the experiences with tropical diseases. The reported experience from non-endemic regions, however, does not always reflect the experience of endemic areas. Most of the guidelines and recommendations in the literature may not be applicable in tropical settings due to logistical difficulties, cost, and lack of proven benefit. In addition, certain post-transplant prevention measures, as prophylaxis and reducing exposure risk, are not feasible. Nonetheless, risk assessment and post-transplant management of tropical IDs in tropical areas should not be neglected, and clinicians need to have a higher clinical awareness for tropical ID occurring in this population. Herein, we review the more significant tropical ID in transplant patients, focusing on relevant experience reported by tropical settings.

Acute kidney injury in dengue virus infection

Background

Dengue is a growing public health problem in Pakistan and acute kidney injury (AKI) is one of the least studied complications of dengue virus infection (DVI). The aim of this study was to determine the frequency, severity and predictors of AKI in patients with DVI and to study the impact of AKI on the length of hospital stay and mortality.

Methods

We retrospectively reviewed medical records of patients aged ≥14 years hospitalized with a primary diagnosis of DVI at Aga Khan University Hospital Karachi between January 2008 and December 2010. Binary logistic regression models were constructed to identify factors associated with the development of AKI and to study the impact of AKI on hospital stays of more than 3 days.

Results

Out of 532 patients, AKI was present in 13.3% (71/532). Approximately two-thirds (64.8%) of these patients had mild AKI and a third (35.2%) had moderate to severe AKI. Independent predictors for AKI were male gender [odds ratio (OD) 4.43; 95% CI 1.92–10.23], presence of dengue hemorrhagic and dengue shock syndrome (DSS, OD 2.14; 95% CI 1.06–4.32), neurological involvement (OD 12.08; 95% CI 2.82–51.77) and prolonged activated partial thromboplastin time (aPTT, OD 1.81; 95% CI 1.003–3.26). AKI was associated with a length of stay ≥3 days when compared with those who did not have AKI (OD 2.98; 95% CI 1.66–5.34). Eight patients (11.3%) with AKI died whereas there were no mortalities in patients without AKI (P < 0.001). Only 5 patients (7%) had persistent kidney dysfunction at discharge.

Conclusions

AKI in DVI is associated with neurological involvement, prolongation of aPTT, greater length of hospital stay and increased mortality.

Biopsy proven acute tubular necrosis due to rhabdomyolysis in a dengue fever patient: a case report and review of literature

Renal histology results are very scarce in dengue-associated rhabdomyolysis patients developing acute kidney injury (AKI). We report a case of dengue fever-induced AKI associated to rhabdomyolysis with a renal biopsy showing acute tubular necrosis (ATN) and renal deposition of myoglobin. A 28-year-old patient who presented dengue fever (DF) complicated by severe AKI and rhabdomyolysis is described. The patient required hemodialysis for three weeks. A renal biopsy revealed ATN with positive staining for myoglobin in the renal tubuli. The patient was discharged with recovered renal function. In conclusion, this case report described a biopsy proven ATN associated to DF-induced rhabdomyolysis, in which renal deposition of myoglobin was demonstrated. We suggest that serum creatine phosphokinase should be monitored in DF patients to allow for an early diagnosis of rhabdomyolysis and the institution of renal protective measures.

Clinical presentation and outcome of dengue viral infection in live-related renal transplant recipients in Karachi, Pakistan

INTRODUCTION

In Pakistan, dengue viral infection has become hyper-endemic. Renal transplantation is also expanding. We aimed to study dengue in renal transplant recipients (RTR).

METHODS

We conducted a study of RTR reported to be anti-dengue immunoglobulin-M antibody positive from January 2009 to December 2010 at our institution in Karachi and follow their clinical course and outcome.

RESULTS

Median age was 28 years; 75 (73.7%) were males. Clinical presentation included fever in 82 (80.4%), gastrointestinal symptoms in 35 (34.3%), hemorrhagic complications in 9 (8.8%), and thrombocytopenia in 97 (95%), which was of >15 days duration in 24%. Fever was seen less frequently in patients on high-dose (>7.5 mg) steroids as compared with low-dose (≤7.5 mg) steroids. Forty-four patients (43%) had primary and 58 (56.8%) had secondary dengue infection. Dengue fever (DF) occurred in 90 (88%), and dengue hemorrhagic fever/dengue shock syndrome (DHF/DSS) occurred in 12 (11.7%). DHF/DSS was seen in 3 (6.8%) of those with primary and in 9 (15.5%) of those with secondary infection (P < 0.22). In secondary infection, patients on cyclosporine-containing regimen had less severe disease, with DHF/DSS in 22% as opposed to DF in 59% (P < 0.04). Of 102 RTR, 68 (66.7%) had graft dysfunction, 5 of whom died. Of the remaining 63, in 54 patients (85.7%) creatinine returned to baseline by an average of 12.6 days. Of 102 patients, 95 (93%) recovered and 7 (6.9%) died, 6 of whom had bacteremia with sepsis and 1 had respiratory failure. None died due to dengue infection alone.

CONCLUSION

In conclusion, in RTR without life-threatening co-morbidities, the clinical course of dengue infection is mild, with good recovery and preserved renal function.

Severe nonfebrile dengue infection in an adolescent after postoperative kidney transplantation: a case report

We herein have reported a case of severe nonfebrile dengue infection complicated with refractory pancytopenia and a large perinephric hematoma with shock in a 16-year-old adolescent during the early postoperative period after kidney transplantation. After the diagnosis of end-stage renal disease she underwent living-related kidney transplantation. Thirteen days after successful transplantation, she exhibited a notable amount of ascites, bilateral pleural effusions, thrombocytopenia, and increased hemoglobin without pre-existent fever. Further investigation revealed positive dengue nonstructural protein 1 antigen (dengue NS1 Ag) and dengue virus serotype 1 by a reverse transcriptase-polymerase chain reaction (RT-PCR) in the patient's serum. She exhibited hemophagocytic syndrome, manifested by refractory pancytopenia and refractory anemia resulting in hypovolemic shock and acute graft failure on day 28 posttransplantation. The anemia was attributed to a large hematoma around the transplanted kidney requiring surgical evacuation of clotted blood. Postoperatively, she gradually recovered with resolution of thrombocytopenia and excellent graft function. Persistent dengue antigenemia and viremia was shown by dengue NS1 Ag and RT-PCR of dengue serotype-1. The viremia was present longer than the dengue antigenemia. Dengue-specific immunoglobulin M (IgM) and IgG by enzyme-linked immunosorbent assay confirmed the primary dengue infection and evidence of a recent donor dengue infection.

Dengue virus infection in renal allograft recipients: a case series during 2010 outbreak

Dengue virus infection is an emerging global threat caused by Arbovirus, a virus from Flaviridiae family, which is transmitted by mosquitoes, Aedes aegypti and Aedes albopictus. Renal transplant recipients who live in the endemic zones of dengue infection or who travel to an endemic zone could be at risk of this infection. Despite multiple epidemics and a high case fatality rate in the Southeast Asian region, only a few cases of dengue infection in renal transplant recipients have been reported. Here, we report a case series of 8 dengue viral infection in renal transplant recipients. Of the 8 patients, 3 developed dengue hemorrhagic shock syndrome and died.

Epidemiology of neglected tropical diseases in transplant recipients: review of the literature and experience of a Brazilian HSCT center

The rising success rate of solid organ (SOT) and haematopoietic stem cell transplantation (HSCT) and modern immunosuppression make transplants the first therapeutic option for many diseases affecting a considerable number of people worldwide. Consequently, developing countries have also grown their transplant programs and have started to face the impact of neglected tropical diseases (NTDs) in transplant recipients. We reviewed the literature data on the epidemiology of NTDs with greatest disease burden, which have affected transplant recipients in developing countries or may represent a threat to transplant recipients living in other regions. Tuberculosis, Leprosy, Chagas disease, Malaria, Leishmaniasis, Dengue, Yellow fever and Measles are the topics included in this review. In addition, we retrospectively revised the experience concerning the management of NTDs at the HSCT program of Amaral Carvalho Foundation, a public transplant program of the state of São Paulo, Brazil.

Transplantation and tropical infectious diseases

The number of transplant recipients with tropical infectious diseases is growing due to increasing international travel and the rising number of transplants taking place in the tropics and subtropics. With increases in population migration, the prevalence of individuals infected with geographically restricted organisms also rises. There are three potential categories of tropical infections in transplant patients: (1) donor-related infections transmitted by the graft or through transfusion of blood products; (2) reactivation or recrudescence of latent infections in the donor recipient; and (3) de novo acquisition of infection in the post-transplant period through the traditional route of infection. We present an overall discussion of the association of parasitic (protozoa and helminths) and non-parasitic (viral, bacterial, and fungal) tropical infectious diseases and solid-organ and hematopoietic transplantation. We also suggest potential screening guidelines for some of these tropical infections.

Dengue has a benign presentation in renal transplant patients: a case series

AIM

Dengue fever and its complications are a poorly described entity in the renal transplant population. Previous reports in renal transplant patients suggest a high mortality rate.

METHODS

We undertook a retrospective study of six cases of dengue fever in renal transplant patients during a dengue outbreak in Singapore in 2005 which involved a total of 1400 cases in the city state.

RESULTS

Mean thrombocytopenia was 130,000/microL on presentation and 80,000/microL at deffervescence. No dengue haemorrhagic fever, dengue shock syndrome, deaths or abnormal graft function were observed. Mean hospital stay was 8.6 days. Four of six patients also had simultaneous CMV reactivation.

CONCLUSION

In common with the majority of adults, dengue fever follows a benign course in the renal transplant population and dengue haemorrhagic fever is rare. This may be related to the relative immunosuppression reducing the risk for antibody-enhanced complications.

Dengue in Renal Transplant Patients: A Retrospective Analysis

We reviewed the impact of dengue in 27 renal transplant recipients (9 females and 18 males) at a mean of 63 (6-287) months after transplantation. Their mean age was 37+/-14 years and all were first transplantations (21 live donors, 6 deceased donors). Twenty-six were dengue fever cases and one had dengue hemorrhagic fever. Symptoms were: fever (100%), muscular pain (90%), malaise (75%), and headache (68%). Eight (29%) patients were admitted to hospital with one death. All other cases had full recovery. Mean serum creatinine before dengue was 1.4+/-0.6 mg/dL, increased to a mean peak of 1.9+/-1.2 mg/dL (P<0.001), and returned to baseline after recovery (1.6+/-0.82 mg/dL, P=NS). After a mean follow-up of 39+/-18 months, four patients lost their grafts due to chronic allograft nephropathy and four died, due to infectious causes not related to dengue. The first episode of dengue in transplanted patients resembled a flu-like syndrome, as in the general population. It did not cause long-term damage to either the patient or the graft.