Dengue hemorrhagic shock and disseminated candidiasis

Liver involvement in dengue: A systematic review

Liver involvement is an unusual yet frequently overlooked dengue complication. Pivotal for an efficient clinical management, the early diagnosis of dengue-associated liver involvement relies on an accurate description of its clinical and biological characteristics, its prognosis factors, its association with severe dengue and its clinical management. We conducted a systematic review by searching PubMed and Web of Science databases for original case reports, cohort and cross-sectional studies reporting the clinical and/or biological features of dengue-associated liver involvement. The study was registered in PROSPERO (CRD42021262657). Of the 2552 articles identified, 167 were included. Dengue-associated liver involvement was characterised by clinical features including abdominal pain, hepatomegaly, jaundice, nausea/vomiting, and an echogenic liver exhibiting hepatocellular necrosis and minimal inflammation. Elevated Aspartate Aminotransferase and Alanine Aminotransferase but also elevated bilirubin, Alkaline Phosphatase, gamma-glutamyl transferase, increased International Normalised Ratio, creatinine and creatine kinase, lower albumin and prolonged prothrombin and activated partial thromboplastin time were prevalent in dengue-associated liver involvement. Cardiovascular and haematological systems were frequently affected, translating in a strong association with severe dengue. Liver involvement was more common in males and older adults. It was associated with dengue virus serotype-2 and secondary infections. Early paracetamol intake increased the risk of liver involvement, which clinical management was mostly conservative. In conclusion, this systematic review demonstrates that early monitoring of transaminases, clinical assessment, and ultrasound examination allow an efficient diagnosis of dengue-associated liver involvement, enabling the early identification and management of severe dengue.

Oro-Pharyngeal Candidiasis in Two Dengue Patients

Dengue, a prevalent arboviral disease, has witnessed a resurgence in India, with outbreaks frequently reported. However, dengue-associated oral (oro-pharyngeal) candidiasis (DAOC) was never reported. We present two severe dengue cases with oral/oro-pharyngeal pseudomembranous candidiasis. Case 1 of a young man without any comorbidities or abuse or immunosuppression presented with fever, headache, altered sensorium, throat pain on recovery, and laboratory reports confirmed dengue with leukopenia, thrombocytopenia, and severe hepatic involvement with oro-pharyngeal candidiasis. Similarly, case 2 of a middle-aged man with a history of smoking and diabetes presented with fever, gum bleeding, and throat pain, later confirmed to be dengue NS1 positive with thrombocytopenia, and mild-moderate hepatic involvement along with oral-oro-pharyngeal candidiasis. Both cases showed improvement with conservative management and oral nystatin suspension. These cases prompt consideration of superadded candida infections in dengue patients, emphasizing the need for further study and clinical vigilance.

Aspergillus coinfection in critically Ill patients with severe dengue

In 2014-2015, a significant outbreak of dengue fever occurred in southern Taiwan, with a subsequent decline in dengue incidence. Despite this, there is emerging concern about virus-associated aspergillosis, yet limited research has explored coinfections involving dengue and aspergillosis. We conducted a retrospective study at a single center in Southern Taiwan, specifically focusing on dengue patients admitted to the intensive care unit during the period between July and November 2015. Among the 142 dengue patients studied, only 8.06 % (10/142) underwent serum galactomannan testing, with a single patient undergoing bronchoalveolar lavage (BAL) galactomannan assay. Out of those tested, 20 % (2/10) returned positive serum galactomannan results. Herein, we present two consecutive cases of coinfection involving dengue and pulmonary aspergillosis in immunocompetent patients.

Causes of death among dengue patients causes of death among hospitalized adults with dengue fever in Tainan, 2015: Emphasis on cardiac events and bacterial infections

INTRODUCTION

The 2015 dengue outbreak in southern Taiwan caused substantial mortality. We analyzed the causes of death among these patients.

MATERIALS AND METHODS

This retrospective study was conducted at a medical center in Tainan from August 2015 to December 2015. Dengue was diagnosed based on the detection of serum dengue NS1 antigen, IgM, or viral RNA in the blood. Causes of death were retrieved from chart reviews by three clinicians.

RESULTS

There were 4488 cases of dengue in the study hospital, with an in-hospital fatality rate of 1.3% (60 cases). The mean age of the 60 fatal cases was 73 years, among whom 90% were aged ≥65 years. Twenty-eight (46.7%) patients died of severe dengue, and 29 (48.3%) deaths were possibly related to dengue. Of the latter, 24 (40%) died of secondary infections. Thirteen cardiac arrest events, including out-of-hospital (5 events) and in-hospital (8) cardiac arrests in the emergency department, occurred during the dengue epidemic. Seven (53.8%) patients did not receive medical aid before the event. Of the 40 deaths that occurred within one week after hospitalization, 60% died of severe dengue. In contrast, 50% of 20 deaths that occurred one week after hospitalization were related to hospital-acquired infections, mainly pneumonia.

CONCLUSION

Of 60 fatal cases, with a predominance of elderly patients, deaths were related to severe dengue within the first week after admission and secondary infections thereafter. The absence of medical care before cardiac arrest events highlights the importance of health education for warning signs of dengue.

A Curious Case of Dengue Fever: A Case Report of Unorthodox Manifestations

Dengue is the major cause of arthropod-borne viral disease in the world. It presents with high fever, headache, rash, myalgia, and arthralgia and it is a self-limiting illness. Severe dengue can occur in some cases resulting in dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). We present a case of a 32-year-old male patient of high-grade fever, bilateral subconjunctival hemorrhages, swelling on hands and lips, and nasal bleeding. After investigations, he was diagnosed with dengue fever and it was observed that he developed systemic fungal infection secondary to Candida tropicalis infection. The patient's bone marrow biopsy showed hemophagocytic activity. He also developed hepatitis E infection while hepatitis A, B, or C serology profile showed no active infection. The bilateral iliopsoas hematoma was also observed on CT scan manifested by decreased power in bilateral lower limbs and pain in the right leg. The patient was treated in the hospital with antibiotics (ceftriaxone 2 g once daily for 14 days) and antifungal (fluconazole 200 mg per oral initially for one day then 100 mg daily for 13 days) medicines, and his condition improved on discharge. There is evidence of variable presentations of dengue fever after the disease burden is increased, and thus, diagnosing with such manifestations can be very challenging.

Atypical Presentation of Methicillin-Susceptible Staphylococcus aureus Infection in a Dengue-Positive Patient: A Case Report with Virulence Genes Analysis

Concurrent bacteraemia in patients with dengue fever is rarely reported. We report a case of a patient who initially presented with symptoms typical of dengue fever but later succumbed to septic shock caused by hypervirulent methicillin-susceptible Staphylococcus aureus (MSSA). A 50-year-old female patient with hypertension and diabetes mellitus presented with typical symptoms of dengue fever. Upon investigation, the patient reported having prolonged fever for four days prior to hospitalization. Within 24 hours post-admission, the patient developed pneumonia and refractory shock, and ultimately succumbed to multiple-organs failure. Microbiological examination of the blood culture retrieved a pan susceptible MSSA strain. Genomic sequence analyses of the MSSA strain identified genes encoding staphylococcal superantigens (enterotoxin staphylococcal enterotoxin C 3 (SEC3) and enterotoxin-like staphylococcal enterotoxins-like toxin L (SElL)) that have been associated with toxic shock syndrome in human hosts. Genes encoding important toxins (Panton-Valentine leukocidins, alpha-haemolysin, protein A) involved in the development of staphylococcal pneumonia were also present in the MSSA genome. Staphylococcus aureus co-infections in dengue are uncommon but could be exceptionally fatal if caused by a toxin-producing strain. Clinicians should be aware of the risks and signs of sepsis in dengue fever, thus allowing early diagnosis and starting of antibiotic treatment in time to lower the mortality and morbidity rates.

Post Dengue Fever Epidural Abscess With or Without Spondylodiscitis: A Case Series of Eight Patients in a Single Season in a Single Center: Does the Dengue Have a Predilection for the Neural Tissue?

STUDY DESIGN

A retrospective case series.

OBJECTIVE

The aim of this study was to report the immunosuppression and secondary bacterial infection after dengue viral infection and the predilection of these infections in the spine. This can trigger further research in to this fact. The possibility of change in the serotype of dengue virus, which are neurotropic, may be looked into.

SUMMARY OF BACKGROUND DATA

This is the largest case series of epidural abscess with or without spondylodiscitis within 6 weeks following dengue virus infection.

METHODS

We performed a retrospective review of all the eight cases treated for epidural abscess with or without spondylodiscitis within 6 weeks following dengue virus infection in our center during the period of 3 months from June 2017 to August 2017.

RESULTS

Of the eight cases, three of them were infected with Methicillin Resistant Saphylococcus Aureus and all of them grew the bug in the blood culture. Three of them had Methicillin Sensitive Staphylococcus Aureus (MSSA), one with MSSA septicemia, and one had associated Elizabeth Kingia meningoseptica infection and one patient had positive Acid Fast Bacilli stained in smears. Two patients were infected with pseudomonas. Some patients had multiple site abscess and epidural abscess without spondylodiscitis. Five of them had neurological deficit, which recovered with abscess drainage and antibiotic treatment. The Erythrocyte Sedimentation rate, C-Reactive Protein, and serum ferritin were elevated in these patients.

CONCLUSION

This is a large case series of epidural abscess with or without spondylodiscitis within 6 weeks following dengue virus infection. The predilection of dengue virus for the neural tissue should be further investigated. Post dengue immunosuppression also needs further study.

LEVEL OF EVIDENCE

4.

Dengue hemorrhagic fever and the kidney

Dengue virus infection (DVI)/dengue hemorrhagic fever (DHF) is a common febrile illness with a variety of severities. The mortality rate is high in dengue shock syndrome (DSS), caused by circulatory failure due to plasma leakage resulting in multi-organ failure. However, acute kidney injury (AKI) is rarely reported. In areas of endemic DVI, the prevalence of AKI due to DVI has been reported to be as high as 6.0 % in children with AKI, and 0.9 % in children with DVI who were admitted to a hospital. The mechanism of AKI in DVI is not clear. It may result from (a) direct injury as in other infectious diseases, (b) an indirect mechanism such as via the immune system, since DHF is an immunological disease, or (c) hypotensive DSS, leading in turn to reduced renal blood supply and renal failure. The mortality rates of DF/DHF, DSS and DHF/DSS-related AKI are <1 %, 12-44 %, and >60 %, respectively. Kidney involvement is not actually that rare, but is under-recognized and often only reported when microscopic hematuria, proteinuria, electrolyte imbalance, or even AKI is found. The prevalence of proteinuria and hematuria has been reported as high as 70-80 % in DVI. A correct diagnosis depends on basic investigations of kidney function such as urinalysis, serum creatinine and electrolytes. Although DVI-related renal involvement is treated supportively, it is still important to make an early diagnosis to prevent AKI and its complications, and if AKI does occur, dialysis may be required. Fortunately, in patients who recover, kidney function usually completely recovers as well.

Role of cognitive parameters in dengue hemorrhagic fever and dengue shock syndrome

Dengue is becoming recognized as one of the most important vector-borne human diseases. It is predominant in tropical and subtropical zones but its geographical distribution is progressively expanding, making it an escalating global health problem of today. Dengue presents with spectrum of clinical manifestations, ranging from asymptomatic, undifferentiated mild fever, dengue fever (DF), to dengue hemorrhagic fever (DHF) with or without shock (DSS), a life-threatening illness characterized by plasma leakage due to increased vascular permeability. Currently, there are no antiviral modalities or vaccines available to treat and prevent dengue. Supportive care with close monitoring is the standard clinical practice. The mechanisms leading to DHF/DSS remains poorly understood. Multiple factors have been attributed to the pathological mechanism, but only a couple of these hypotheses are popular in scientific circles. The current discussion focuses on underappreciated factors, temperature, natural IgM, and endotoxin, which may be critical components playing roles in dengue pathogenesis.

Fatal Staphylococcal infection following classic Dengue fever

Dengue represents an important public health issue in many tropical areas, leading to high morbidity and the employment of substantial health resources. Even though the number of fatalities related to dengue is unknown, several reports warn about the potential occurrence of severe infections and even death. The clinical spectrum of dengue is highly variable, ranging from a mild flu-like syndrome to severe disease, with shock and hemorrhage. The occurrence of bacterial superinfection, or coinfection, in patients with dengue has been noted by some authors, but the available information comes from anecdotic reports. In this study, we show the clinical and anatomopathological data of a patient infected with dengue, who subsequently died of acute multi-organic failure related to Staphylococcus aureus infection. The autopsy revealed a severe disseminated staphylococcal disease and confirmed dengue infection.

Outcome of dengue hemorrhagic fever-caused acute kidney injury in Thai children

OBJECTIVES

To examine the outcome of acute kidney injury (AKI) in children with dengue hemorrhagic fever (DHF), the cause(s) of AKI, and the risk of AKI and fatality.

STUDY DESIGN

The medical records of patients age <15 years during 1989 to 2007 were reviewed. DHF-caused AKI and patients with DHF with no AKI were matched 1:2 by age.

RESULTS

DHF-caused AKI was clinically estimated to be 0.9% (25/2893) of admissions, with a high mortality rate of 64.0%. Risk factors of AKI were DHF grade IV and obesity (odds ratio, 16.9; 95% CI, 4.2 to 68.5, and odds ratio, 6.3; 95% CI, 1.4 to 28.8, respectively). Respiratory failure, hepatic failure, and massive bleeding were complications found in 80.0%, 96.0%, and 84.0% of cases with AKI, respectively. Fatality was more likely in cases with DHF grade IV, oliguric AKI, respiratory failure, or prolongation of prothrombin or activated partial thromboplastin time more than twice that of reference specimens. Among the survivors, none had chronic kidney disease, and serum creatinine levels returned to normal in 32 (1 to 48) days.

CONCLUSIONS

Patients with DHF and AKI had a high mortality rate, although those who survived had a full return to normal function within 1 month. DHF grade IV and obesity were the major risk factors of AKI.

Pulmonary hemorrhage syndrome associated with dengue fever, high-resolution computed tomography findings: a case report

Dengue hemorrhagic fever is an acute infectious disease caused by dengue virus. We described the high-resolution CT findings in a 70-year-old male with the disease, which was diagnosed by clinical examination and confirmed by serological methods. High-resolution CT demonstrated bilateral areas of consolidation with air bronchogram and ground glass opacities, as well as small bilateral pleural effusions. Dengue hemorrhagic fever should be considered in the differential diagnosis of diffuse pulmonary hemorrhage.