Abstract. We report a case of thrombotic thrombocytopenic purpura (TTP) that immediately followed symptomatic dengue virus infection in a pregnant lady. The patient developed dengue fever at 16 weeks of gestation, resulting in spontaneous abortion. Subsequently, fever reappeared with persistent thrombocytopenia and jaundice. Investigations revealed microangiopathic hemolysis; there was no evidence of disseminated intravascular coagulation. The TTP episode resolved after six cycles of therapeutic plasma exchange with fresh-frozen plasma. An ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 motif 13 repeats) activity assay, done during convalescence, showed normal activity. The patient had an uneventful second pregnancy and has remained free of TTP recurrence for more than 2 years now. We review the pathophysiological basis of TTP in dengue infection, and suggest that jaundice with disproportionate elevation of serum aspartate aminotransferase level in a patient with dengue should arouse the suspicion of TTP.
SUMMARYThrombocytopenia and bleeding manifestations are consistent features of dengue fever. Usually thrombocytopenia resolves and platelet count normalises by day 10 of fever. Persistent thrombocytopenia is not a feature of dengue fever. Proposed mechanisms behind thrombocytopenia are many. Direct platelet destruction by dengue virus, immune-mediated platelet destruction and even megakaryocytic immune injury have been proposed as underlying mechanisms. We are reporting a case of an old man who presented in dengue season in 2012 with fever and bleeding and was diagnosed as a case of dengue fever. He developed persistent thrombocytopenia requiring treatment on the lines of immune thrombocytopenia and responded to steroids. Other causes of thrombocytopenia were ruled out.
BACKGROUND
NCPF is common in South India. Transient ascites occurs due to decompensation of liver function after variceal bleeding and in long standing cases of NCPF. Our study used Tc-sulphur scan for diagnosing NCPF in patients where liver biopsy was contraindicated in view of severe thrombocytopenia; however, the diagnostic utility of Tc-sulphur nuclear scan to diagnose NCPF in patients with severe hypersplenism needs to be further evaluated in future studies.
Hyperglycaemia induced involuntary movements are uncommon in clinical practice though Chorea Hyperglycaemia Basal Ganglia syndrome (CHBG) or Non-ketotic Hyperglycaemic Hemichorea (NHH) is being reported with increasing frequency due to the clinical awareness and widespread availability of neuroimaging. Prompt recognition of CHBG is essential, since correction of hyperglycaemia usually leads to early resolution of the involuntary movements. It is usually seen in elderly patients with uncontrolled Type 2 diabetes mellitus who present acutely with hemichorea or hemiballismus. It is rarely reported in Type 1 diabetes mellitus. Here, the author presents a 25-year-old male patient diagnosed with Type 1 diabetes mellitus with persistent chorea involving the left upper and lower extremity in whom the movement disorder persisted despite correction of hyperglycaemia.
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