Unusual Presentation of Dengue Fever-Cerebral Venous Thrombosis

Abstract

A 16-year-old boy presented to our tertiary care centre in puducherry in the month of October 2014 with high grade, intermittent fever for 10 days duration. He had double vision involving left eye and headache for two days duration. He had multiple erythematous lesion all over the body on 3 rd day of fever. At home his skin rash was assumed as chicken pox by mother; he was kept at home and treated conservatively with antipyretics.As he developed double vision he was referred to our hospital. There was no vomiting. On admission, his vitals were normal. There was no skin rashes. His fundus showed-bilateral papilloedema, left eye restricted abduction. There was no neck stiffness. Other system examination was normal.His investigation revealed thrombocytopenia with platelet count 45000 /cumm, total count-7100/cumm Hb-13gm%, PCV -39.4, elevated liver enzymes SGOT-82u/L SGPT-187U/L. Dengue infection can present as febrile illness with thrombocytopenia, dengue shock syndrome and dengue haemorrhagic fever. Neurological manifestation of dengue infection is more predominant in endemic region. Here, we report a case with unusual neurological presentation of dengue infection. A 16-year-old boy presented with fever for two week duration, headache and double vision involving left eye for two days. He had multiple erythematous rashes all over the body on 3 rd day and treated conservatively. On examination he had bilateral papilloedema, left eye restricted abduction. His investigation revealed thrombocytopenia and positive dengue serology. His MRI brain with venogram showed bilateral transverse sinus thrombosis. Hence he was diagnosed as cerebral venous thrombosis due to dehydration with underlying dengue infection. He was hydrated and managed conservatively. On 3 rd day his double vision started improving. His repeat MR Venogram was done after two week duration, which revealed recanalisation of bilateral transverse sinus.He was diagnosed as cerebral venous thrombosis due to severe dehydration with underlying dengue infection. As main treatment option in dengue fever is proper hydration, he was hydrated well and serial platelet count was monitored. His initial CSF analysis showed total count-81 with lymphocytic predominance 88%, elevated protein-321mg/dl sugar-65 mg/dl.On 3 rd day his double vision started improving. On 5 th day it disappeared. As CVT is due to severe dehydration with underlying viral infection, and there was improvement in vision, anticoagulation was not started. He was treated conservatively with antipyretics and parenteral fluid replacement. After two week his repeat MRI brain with venogram [Table/ Fig-2] was done which revealed recanalisation of bilateral transverse sinus.

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Case of Near Fatal Massive Intracerebral Bleed Secondary to Cerebral Venous Thrombosis in a Patient with Dengue and Refractory Thrombocytopenia

“…1 We were able to find two case reports of CVT in dengue in literature. 2,3 In both these reports, patients improved subsequently with adequate fluids and anticoagulation, with none of them requiring surgical intervention. Our patient had normal hematocrit values and she was being adequately hydrated.…”

A perfect storm: acute portal vein thrombosis in a patient with severe dengue and hemorrhagic manifestations—a case report

“…Da Costa et al reported an incidence of 5.4% thrombotic events in patients with severe dengue with a total of 5 venous thrombotic events, 4 of the cases were DVT and 1 mesenteric venous thrombosis; nonetheless, it was not an isolated event since concomitantly Escherichia coli bacteremia, a well-known risk factor for portal vein thrombosis, was diagnosed [ 4 ]. Other thrombotic events associated with dengue described in the literature are mainly cerebral venous thrombosis and DVT; in many of these cases, an associated procoagulant factor was not found either [ 5 , 6 ].…”

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