Dengue shock syndrome complicated with acute liver failure and kidney injury, infective endocarditis, and deep vein thrombosis: a case report

Abstract

BackgroundDengue fever is a mosquito-borne viral disease with a very high incidence in Southeast Asia. Most patients with dengue fever recover following a self-limiting febrile illness, while a small proportion may progress to develop severe disease with complications such as acute liver failure, acute kidney injury, and multiorgan failure. Secondary bacterial infections and thrombotic events are very rare.Case presentationA 38-year-old previously healthy Sri Lankan woman from Colombo, Sri Lanka, presented with dengue shock syndrome leading to acute liver failure and kidney injury. She was managed with intravenously administered fluid resuscitation with close monitoring of her hemodynamic status, and hemodialysis. Her renal and liver functions and platelet count improved gradually, but the fever persisted and there was a neutrophil leukocytosis. A clinical examination and investigations to identify a focus of secondary infection revealed staphylococcal infective endocarditis. She was started on intravenously administered vancomycin, but as the response was poor the antibiotic was changed to intravenously administered linezolid, to which the response was good. She also developed right proximal femoral deep vein thrombosis, and was commenced on subcutaneous enoxaparin and warfarin. Enoxaparin was stopped after her international normalized ratio reached the desirable range, and warfarin was continued for 3 months.ConclusionsDengue virus is known to cause endothelial dysfunction that allows bacteria to invade tissues, defective functioning and reduction in the number of cells of the immune system, and alteration of cytokines leading to immune dysregulation, predisposing patients to develop secondary bacterial infections. Evidently, patients with dengue fever who have prolonged fever (more than 5 days) and acute kidney injury are at high risk for concurrent bacteremia. Dengue virus interferes with the components of the anti-clotting pathway, such as thrombomodulin-thrombin-protein C complex. It also activates endothelial cells and increases the expression of procoagulant factors. These factors may predispose patients with dengue viral infections to develop thrombotic complications. Therefore it is important to be aware of the possibility of serious secondary bacterial infections occurring following dengue viral infections, especially in patients with prolonged fever and acute kidney injury, and to keep in mind that thrombotic events may occur as complications of dengue viral infections.

Understanding Infection-Induced Thrombosis: Lessons Learned From Animal Models

“…There is some discussion about the inter-relationship between infection-induced thrombosis and pre-existing risk factors, such as smoking, lipid levels, and sedentarism, in terms of whether these risk factors directly influence pathogen-driven thrombosis (5). Nevertheless, it is likely that infection promotes the risk of thrombosis in such individuals, although it is important to consider that infection alone is sufficient to drive thrombotic events (7–12). For example, ischemic stroke is associated with acute infections (particularly in the first 3 days after respiratory or urinary tract infection) as are chronic infections such as chronic bronchitis (5).…”

Dengue fever complicated with acute ST elevation myocardial infarction - a therapeutic conundrum: our experience from two cases

“…In a Brazilian case series, 5.4% of all thrombotic events were reported in patients without dengue shock syndrome or dengue hemorrhagic fever. 4 Deep vein thrombosis 4,18 , pulmonary thrombo-embolism 4 , mesenteric vein thrombosis 4 and central retinal vein occlusion 19 are among the reported thrombotic events in dengue fever.…”

An unusual case of dengue shock syndrome complicated by ilio-femoral deep vein thrombosis; a case report

“…Three other reported cases of deep vein thrombotic events were found in the literature. All those patients developed deep vein thrombotic events after the recovery from the acute illness and the recovery of the platelet count [8,9]. Another two cases of cerebral venous thrombosis were reported where dehydration associated with the illness was thought to be the causative factor [10,11].…”

“…All of them had dengue fever without evidence of plasma leakage. Three other reported cases, including two from Sri Lanka had deep vein thrombotic events following recovery from the initial infection, but none of them had severe thrombocytopenia (< 20,000/μl) during the time of occurrence of the thrombotic event [5,6,8,9].…”