Deadly intracranial bleed in patients with dengue fever: A series of nine patients and review of literature

Abstract

Introduction:Dengue fever is a global pandemic threat with increasing incidence. To date, there are no cures and the effectiveness of dengue vaccines is still uncertain. World Heath Organization introduced expanded dengue syndrome to include unusual presentations of dengue fever including severe neurologic complications. One of the deadly complications is intracranial hemorrhage (ICH).Methodology:We collected data of patients with ICH diagnosed via a plain computed tomography of the brain (CT brain) with thrombocytopenia and positive Dengue virus type 1 nonstructural protein (NS1) antigen test or positive dengue serology IgM from January 2014 till June 2015 at our center. Nine patients were included and all 20 other remaining patients reported in literature so far are discussed.Discussion:We found that all patients in our center requiring neurosurgical intervention died. Another interesting observation is that detection of Dengue IgG usually meant more severe ICH and poorer outcomes. From our series, platelet levels did not seem to influence the outcome.Conclusion:We recommend that for early detection of ICH, Dengue IgG should be routinely screened and a high index of suspicion be maintained. Future research should be focused on determining predictors of ICH in patients with dengue fever so that preventive steps can be taken as mortality is high and no treatment seems beneficial at the moment once severe ICH occurs.

Spontaneous intracranial hemorrhage associated with dengue fever: An emerging concern for general physicians

“…Clinical experience from prior studies suggests that patients with secondary dengue infection identified by the detection of IgG early in the course of the disease with a positive NS1 antigen test and negative IgM are at higher risk of ICH carrying poor prognosis and should be monitored more closely with lower thresholds for diagnostic CT of the brain when suspicion of ICH is present. [ 3 ] In the present case report, though the patient was a female without any comorbidities, presence of risk factors of profound shock requiring vasopressor support, seizures, low platelet, and viremia, suggested by positive NS-1 antigen along with altered sensorium prompted early CT scan which revealed suggesting ICH.…”

“…ICH, a potential life-threatening complication of dengue, is of uncommon occurrence in patients with severe dengue. [ 3 ] The incidence of dengue encephalopathy is estimated to range from 0.5% to 6.2%. [ 4 5 6 ] However, the incidence of ICH associated with DF is still uncertain.…”

“…A literature review of case reports as well as series describing demographic and clinical profile including the outcome of ICH in patients with DF are listed in Tables 1 and 2 , respectively. [ 3 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 ] Presence of fever, reduced or altered consciousness, vomiting, seizures, and headache are common chief complaints in patients with ICH. The occurrence of ICH associated with DF can be localized or diffuse involving commonly cerebrum, ventricles, and less commonly cerebellum.…”

“…Platelet counts did not correlate with the incidence of ICH suggesting a complex interplay of multifactorial pathogenetic mechanisms for the occurrence of ICH. [ 3 ] The various postulated mechanisms include vasculopathy, coagulopathy, platelet dysfunction, and thrombocytopenia. [ 26 ] Detection of dengue IgM, IgG, and NS1 Ag in cerebrospinal fluid (CSF) of patients with dengue suggests breach of blood–brain barrier and blood–CSF barrier and vasculopathy secondary to immunopathological-related mechanisms.…”

Severe dengue categories as research endpoints—Results from a prospective observational study in hospitalised dengue patients

“…The terminology of 'DF with unusual hemorrhage' was included in the PAHO guidelines in 1994 [20]. More recently, a series of dengue cases presenting with intracranial haemorrhage, but without evidence of severe leakage, were reported by Sam et al [21].…”