Dengue outbreak is common in Indian subcontinent and causes significant morbidity and mortality. Year 2015 has witnessed yet another Dengue epidemic in northern India and the number of cases this year is maximum in a decade. Dengue infection is a viral disease and there are 4 different serotypes DENV1, DENV2, DENV3 and DENV4. This year DENV2 and DENV4 have been isolated from most of the patients. Thrombocytopenia is hallmark of dengue infection and generally recovers within ten days of onset of symptoms. We report a case of dengue haemorrhagic fever in which thrombocytopenia persisted for almost a month and improved after Intravenous immunoglobulin (IVIG) administration. This is the first case where IVIG has been successfully used for treating persisting thrombocytopenia after dengue infection.

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A 55-year-old lady came to our hospital with complaints of multiple blistering skin lesions with ulcerations over the lower abdomen, groin and lower back region for the last 2 days which was associated with pain and low grade fever. She was a diagnosed case of hypertension, ischemic heart disease and hypothyroidism, for which she was on regular medications from a cardiologist. Her medications included aspirin, statins, ramipril, metoprolol, thyroxine and torsemide. She was on these medications for last four years and oral Metolazone tablet (5 mg once daily) was added by her cardiologist a week back for refractory pedal oedema. There was no history of similar illness in the past and was tolerating all her medications well.On examination her Pulse rate was 126/min, Blood Pressure-96/70 mm Hg, Respiratory rate-20/min. She was febrile with a temperature of 38.6 degree Celsius. She had bilateral pitting pedal edema and Jugular Venous Pressure (JVP) was significantly raised. Cardiovascular examination was normal but she had bilaterally basal fine crepitations on auscultation of lung fields.Her skin lesions were irregular erythematous maculo-papular rashes with blister formation and superficial skin excoriation with ulcerations over lower abdomen, groin and lower back and perineum regions [Table/ Fig-1,2]. A tangential mechanical pressure on the erythematous areas induced epidermal detachment suggesting that Nikolsky sign was positive. Skin lesions were involving 10-30% of body surface area. The conjunctiva was congested and there were few erosive lesions over the lips. During her hospital stay the blisters ruptured with raw ulceration causing keywords: Naranjo Probability Scale, SCORTEN score, Thiazide diuretic extensive skin denudation. The Naranjo adverse drug reaction probability scale score was 5, indicating a probable relationship between metolazone and SJS/TEN. A diagnosis of Metolazone induced SJS/TEN overlap syndrome was made with a SCORTEN prognostic score of 5.Haemogram showed a Total leucocyte count of 16,000/cumm with 88% neutrophils and an ESR of 50 mm/h. Renal function test were deranged with urea of 160mg/dl and creatinine of 3.5mg/ dl. Liver function tests and Serum elecrolytes were within normal limits. Repeated blood and urine cultures were sterile. A 2D Echocardiography showed an Ejection Fraction of 30% with global hypokinesia of left ventricle. Metolazone, which was the likely culprit drug in this case was immediately stopped. Intravenous fluids were given to prevent dehydration and to maintain adequate urine output. Broad spectrum antibiotics were added to prevent secondary bacterial infection. A non adhesive wound dressing was done over the raw areas and sulfa containing topical medications were avoided. Managing SJS/TEN in this patient was a difficult as the critical element of management of SJS/TEN is giving intravenous fluids which in our case were a challenging task as the patient had congestive heart failure. Patient succumbed to her illness on sixth day of admission due to sepsis and septi...

A 55-year-old gentleman presented with chief complaints of multiple joint pain for last one week. He was apparently normal 10 days back when he developed fever which was high grade, continuous and associated with chills and rigors. His fever subsided on third day and on same day he developed pain in his both ankle joints which was associated with swelling. Pain gradually progressed to involve multiple joints of upper and lower limbs symmetrically over next five days. Pain was additive and severe in intensity causing severe limitation of day to day activities. There was no history of dysuria, loose stools and rash in recent past.On physical examination, he had temperature of 36.4 o C, pulse rate was 102 per minute and blood pressure was 110/70 mm Hg. Bilateral ankle, knee, shoulder, elbow, wrist, metacarpophalangeal, proximal and distal interphalangeal joints were swollen and tender. There was no lymphadenopathy but conjunctival injection was present. No organs were palpable on per abodomen examination and rest of the systemic examination was essentially normal.Blood investigations showed ESR of 45 mm/h, haemoglobin of 13 g/dl, TLC of 52,000/cumm with a DLC of 68% neutrophil, 8% lymphocyte, 2% monocyte, 6% myelocyte, 8% metamyelocyte and 8% stab cells. Platelet count was 1.5 lacs/cu mm. Peripheral smear showed neutrophilic leukocytosis with shift to left and red cells were normocytic normochromic [Table/ Fig-1]. Kidney function tests, liver function tests and serum electrolytes were normal. Blood and urine culture were sterile. Serology for Brucellosis, Leptospirosis, parvovirus B19 and dengue were negative. Anti nuclear antibody, Rheumatoid factor and Anti CCP were negative. HbsAg, Anti HCV and HIV were non reactive. A bone marrow examination was planned in view of persistently raised leukocyte count. Bone marrow biopsy showed hypercellular marrow with normoblastic reaction of erythroid series, normal maturation of myeloid series and adequate megakaryocytes. Neutrophil Alkaline Phosphatase (NAP) score was normal. A bone marrow culture was also sent which came sterile. Ultrasound abdomen and chest x ray were normal. IgM ELISA for Chikungunya was positive. CRP levels were significantly raised (21mg/dl). He remained afebrile during his hospital stay and was given oral naproxen for arthritis. His symptoms improved markedly after starting NSAID'S and was discharged on oral naproxen. Repeat leukocyte count done after two and four weeks of discharge were 25,000 and 10,000/cumm respectively. Keywords: Chronic myelogenous leukaemia, Chronic neutrophilic leukaemia, Neutrophil alkaline phosphatase Internal Medicine SectionLeukemoid Reaction in Chikungunya Fever ABSTRACTChikungunya is a viral illness caused by an arbovirus which is transmitted by Aedes mosquito. Fever and polyarthralgia are hallmark of this viral illness. Viral infections are generally associated with leucopenia and bacterial infections with leukocytosis. Leukemoid Reaction (LR) is defined by reactive increase in leukocyte count of more than 50,000/cu mm w...