Atypical Presentation of Severe Dengue in a Patient following a Major Abdominal Surgery

Abstract

Severe dengue infections in a postoperative patient may lead to significant derangement in the body’s homeostasis resulting in morbidity and sometimes even mortality. Reports on presentation and clinical manifestations of dengue in patients following major surgical procedures are scarce and restricted to few case reports. We describe a 26-year-old male with atypical presentation and late detection of dengue haemorrhagic fever following a major abdominal surgery. On postoperative day 6, he developed spontaneous bleeding from the drain site and moderate-to-massive bilateral pleural effusion with respiratory distress. His dengue IgM and IgG were positive. Therefore, a diagnosis of dengue haemorrhagic fever with bilateral lower zone pneumonia was made. A right-sided intercostal tube was inserted. Intensive care was given and was managed with intravenous antibiotics, targeted fluid therapy, and supportive care. He recovered from the infection and was discharged uneventfully. This case is unique because during the postoperative period, he went into critical phase with significant fluid leakage and developed bleeding manifestations without a clear febrile phase and deterioration in the haemodynamic parameters. High degree of suspicion and early detection are necessary to guide the fluid therapy and provide organ support in such patients.

Dengue Infections and the Surgical Patient

“…7 There has been a change in disease patterns with increasing involvement of gastrointestinal, hepatic, renal, hematological, neurological, respiratory, and cardiac systems. [8][9][10][11][12][13][14][15] Abdominal pain is a recognized feature during the critical phase of DHF. 1,7 Some patients with dengue may present with surgical complications such as gastrointestinal bleeding, acute pancreatitis, and splenic rupture, and others may mimic an acute abdomen without any true complications.…”

Clinical and Biochemical Characteristics of Dengue Infections in Children From Sri Lanka

“…1 Reports from different parts of the world suggest a changing pattern in the incidence of dengue infections and associated organ involvement such as respiratory, cardiac, gastrointestinal, hepatic, renal and neurological. 2 - 9 …”

Anesthesia and perioperative care management in patients with Dengue Fever: considerations and challenges

“…Mild to moderate thrombocytopenia (considered a severity marker) occurs 3 to 7 days after infection and returns to normal levels on day 8 or 9 of infections in adults without Severe Dengue. 12 , 13 …”

“…Severe Dengue causes fluid leakage, microvascular changes, and coagulopathy. 13 Moreover, the immunological imbalance of Dengue Fever superimposes surgical trauma, leading to surgical complications and major postoperative adverse events, including hemorrhage, systemic inflammation, and shock. 13 , 21 …”

“…Limited evidence from case reports suggests significant postoperative complications due to Dengue, mainly hemorrhage and respiratory distress. 11 , 13 , 21 , 32 , 33 , 34 , 35 Hence, it is strictly advised to avoid surgery during acute Dengue infection, even in mild cases. This recommendation is supported by the existing literature and experience with perioperative Dengue Fever patients.…”