Retroperitoneal Haematoma in a Patient with Dengue Haemorrhagic Fever: A Rare Case Report

Abstract

A 30-year-old male diagnosed as a case of dengue fever, presented to the emergency department with high grade fever of two days duration with marked weakness in both the legs (unable to stand) and bleeding from oral and nasal cavities. The patient was febrile, vitals were stable and physical examination revealed evidence of hepatomegaly. His initial investigations showed Non-Structural Protein 1 (NS1) Antigen positive, Hemoglobin 14.6gm%, Total Leucocyte Count (TLC)-4500/cumm, Differential Leucocyte Count (DLC)-80% polymorphs, 15% lymphocytes, 3% monocytes and 2% eosinophils; platelet count of 50,000/cumm with a normocytic normochromic blood picture and International Normalized Ratio (INR)-1.29. Ultrasound showed liver of size 17.2cm with fatty infiltration, gallbladder slightly oedematous whereas, size of spleen, kidneys and pancreas was within normal limits. Patient was treated symptomatically with intravenous fluids, platelet transfusions and anti-pyretics and his general condition improved and he became afebrile, although his platelet count was consistently between 30,000 and 60,000/cumm. But on fourth day of admission patient developed intense pain in the right iliac fossa referred to back. The pain was of continuous type, associated with marked nausea, and not relieved by medication. Additionally he had developed breathlessness and abdominal distension. Physical examination revealed he was afebrile, had developed pallor, mild icterus and a distended abdomen with marked tenderness; bowel sounds were sluggish and air entry was decreased in bilateral lung fields.Laboratory investigations revealed a complete haemogram of Hemoglobin (Hb)-3.5gm%; TLC-10,000/cumm, with predominant neutrophilia and platelet count of 20,000/cumm, serum bilirubin-3.9mg%; SGOT/SGPT were 95/90 IU; serum alkaline phosphatase-132 IU; serum proteins-4.9gm%; Prothrombin Time Index (PTI)-1.2; and serum creatinine-1.1mg%. Serology was negative for HIV, HBsAg and anti-HCV. The second ultrasound showed free fluid in the abdomen, bilateral pleural effusion and alteration in the echotexture of liver and kidneys and a hypoechoic lesion of 14cm by 6cm size lateral to right kidney in the right pararenal space extending along right psoas muscle; possibly retroperitoneal haematoma. Follow-up CT abdomen showed possibility of an intra-parenchymal haematoma in the liver with extension to right peritoneum and right psoas muscle haematoma. Active extravasation of contrast on CT scan suggestive of active bleeding was not found [Table/ Fig-1]. Surgeon opined for conservative management. Patient was given prophylactic antibiotics, multiple blood transfusions including platelet transfusions and other supportive care. His symptoms and platelet count slowly improved to normal in a week. He was discharged in stable condition with advice to follow-up especially for sonography of the intraabdominal collection. His thrombophilia profile done after 6 weeks of discharge from the hospital was reported normal. DIsCUssIoNAlthough spontaneous hematomas have been describ...

Spontaneous retroperitoneal haematoma in severe dengue: A case report

“…CT or CTA of the abdomen is usually considered the appropriate imaging modality in a patient with clinically suspected retroperitoneal bleed [17]. CT can determine the location/s of the bleed and assess for recent or active contrast extravasation, while CTA has a higher sensitivity for detecting active bleeding [7, 8, 11, 14, 17]. In our case, CTA abdomen demonstrated the presence of the retroperitoneal haematoma and evidence of active bleeding.…”

“…Patients who developed iliopsoas haematoma also reported hip pain as a presenting complaint [9, 11–13]. These symptoms mainly occurred between Days 4 and 6 of their illness [7–9, 11, 14]. A summary of the salient features of other case reports is shown in Table 1.…”

“…Our patient presented with abdominal pain on Day 6 of illness, with decreasing haemoglobin level. Hypotensive shock, abdominal pain and abdominal fullness or distension accompanied by a significant drop in haemoglobin level have been reported in other patients with dengue infection who develop retroperitoneal haematoma [7][8][9][10]. Patients who developed iliopsoas haematoma also reported hip pain as a presenting complaint [9,[11][12][13].…”

A Fatal Case of Dengue-Associated Hemophagocytic Lymphohistiocytosis and Retroperitoneal Hematoma in a Patient With Autoimmune Hemolytic Anemia

“…Dengue infection has various bleeding manifestations, ranging from asymptomatic petechial skin hemorrhage to life-threatening cerebral, pulmonary, and gastrointestinal hemorrhages [12]. Retroperitoneal hematoma is a very rare hemorrhagic complication of dengue infection and has only been described in several case reports [12,13].…”

Vocal cord hematoma: an unusual complication of dengue fever

“…There is now an unquestionable quantum of good quality evidence associating viral and/or dengue-associated thrombocytopenia with bleeding and subsequent hematoma formation [2]. Spontaneous hematomas secondary to dengue fever have been described in other sites like thorax, abdominal cavity, retroperitoneum, muscle parenchyma, joints, and rarely even lingual hematomas have been described [3][4][5][6]. A vocal cord hematoma due thrombocytopenia in a chronic myeloid leukemia has been reported in the literature [7].…”