Dengue fever with diffuse cerebral hemorrhages, subdural hematoma and cranial diabetes insipidus

Abstract

BackgroundNeurological manifestations in dengue fever occur in <1 % of the patients and known to be due to multisystem dysfunction secondary to vascular leakage. Occurrence of wide spread cerebral haemorrhages with subdural hematoma during the leakage phase without profound thrombocytopenia and occurrence of cranial diabetes insipidus are extremely rare and had not been reported in published literature earlier, thus we report the first case.Case presentationA 24 year old previously healthy lady was admitted on third day of fever with thrombocytopenia. Critical phase started on fifth day with evidence of pleural effusion and moderate ascites. Thirty one hours into critical phase she developed headache, altered level of consciousness, limb rigidity and respiratory depression without definite seizures. Non-contrast CT brain done at tertiary care level revealed diffuse intracranial haemorrhages and sub arachnoid haemorrhages in right frontal, parietal, occipital lobes and brainstem, cerebral oedema with an acute subdural hematoma in right temporo- parietal region. Her platelet count was 40,000 at this time with signs of vascular leakage. She was intubated and ventilated with supportive care. Later on she developed features of cranial diabetes insipidus and it responded to intranasal desmopressin therapy. In spite of above measures signs of brainstem herniation developed and she succumbed to the illness on day 8. Dengue was confirmed serologically.ConclusionsExact pathophysiological mechanism of diffuse cerebral haemorrhages without profound thrombocytopenia is not well understood. Increased awareness and high degree of clinical suspicion is needed among clinicians for timely diagnosis of this extremely rare complication of dengue fever. We postulate that immunological mechanisms may play a role in pathogenesis. However further comprehensive research and studies are needed to understand the pathophysiological mechanisms leading to this complication.

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

“…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.…”

Neuroimaging in dengue:CTandMRIfeatures

“…A study by Bhoi et al ., in their series of 21 patients with dengue encephalitis, one patient who had a cranial CT done showed an acute‐on‐chronic subdural hematoma, acute cerebellar hemorrhage, and evidence of midline shift. Another study showed diffuse ICH, with acute subarachnoid and subdural hemorrhages and hydrocephalus. We have seen patients undergoing cranial CT with multiple foci of hemorrhage (with intraventricular extension) and associated edema, as well as hydrocephalus (Figs and ).…”

Beyond thrombocytopaenia, haemorrhage and shock: the expanded dengue syndrome

“…Encephalopathy is the most common presentation [37,39,[41][42][43][44], and is an important cause of death in dengue [39]. It occurs mostly in the presence of organ [30], Lee et al [31] Pericarditis/effusion NA -Tayeb et al [33], Bendwal et al [34] NEUROLOGICAL Encephalitis, encephalopathy, meningitis 0.2-52% Solomon et al [36], Misra et al [40], Laul et al [41], Pancharoen et al [42], Sil et al [43], IKumar et al [44], Cam et al [45] Aggarwal et al [37], Muzzafar et al [46], Goswami et al [47] Intracranial haemorrhage 0.04-0.1% Koshy et al [35], Kumar et al [49] Ahamed et al [38], Bharti et al [51], Jayasinghe et al [48], Sam et al [50] Transverse myelitis 0.28-5% Weeratunga et al [60], Sil et al [43], Misra et al [ [42]. Of these 80 children, 83.3% presented with altered consciousness, 45.2% with seizures and 21.4% showed nuchal rigidity.…”