Abstract
Dengue fever is one of the most prevalent viral equatorial diseases
which has recently become a major health concern globally. The disease
stems from a single-stranded positive RNA virus, which belongs to the
family Flaviviridae, genus flavivirus. The disease is characterized by
fever along with two of the following associated symptoms; (1)
headaches, (2) myalgias, (3) leukopenia, and (4) rash. Plasma leakage is
also a usual finding and its progress manifests as either compensated,
or uncompensated shock. The shock syndrome may confer lethality by
causing multi-organ failure or death. The term Expanded Dengue Syndrome
(EDS) was coined by WHO in 2012 when the clinical presentation became
vague and showed generalized impacts on normal physiology which could
not be confined to a specific clinical spectrum. It amalgamates the
findings exacerbating from the usual clinical picture and manifesting as
an unusual presentation. Liver involvement is among the mainstay
features of DF. Liver injury in DF is usually manifested by nausea,
vomiting, abdominal discomfort, and anorexia concurrent with the
findings of hepatomegaly and elevated serum transaminase levels.
Laboratory parameters including a mean Platelet count <
20,000/mm, Aspartate Transaminase Levels > 45 IU, and
lymphocytes < 1500 were significantly associated with severe
disease. This case report exemplifies a case of Expanded Dengue Syndrome
in 29 years old male who was received by a Tertiary Care Hospital in
Karachi and expired after a week secondary to liver failure.
Introduction
Dengue fever is one of the most prevalent viral equatorial diseases
which has recently become a major health concern globally. The disease
stems from a single-stranded positive RNA virus, which belongs to the
family Flaviviridae, genus flavivirus. The Dengue Virus has four
identified serovars labeled as DENV-1, DENV-2, DENV-3, and DENV-4 and is
transmitted by the vector, female Aedes Mosquito, particularly Aedes
aegypti and Aedes
albopictus [1].
It is now endemic in more a than hundred countries including The
Americas, South-East Asia, and Western Pacific
regions [2].
Dengue virus has an incubation period of 3-7 days, followed by symptoms
that can appear in three distinct phases; febrile phase (2-7 days and
persists throughout the illness), critical phase (3-7 days when the
disease may disseminate and involve further organ systems), and finally
the convalescent, or recovery
phase [3].
The disease is characterized by fever along with two of the following
associated symptoms; (1) headaches, (2) myalgias, (3) leukopenia, and
(4)
rash [3].
Dengue hemorrhagic fever (DHF) is among the clinically complicated
pictures which may present with a severe fever, hemorrhage with or
without hepatosplenomegaly, and occasionally circulatory
failure [1].
Dengue Shock Syndrome (DSS) is another variant characterized by
hypotension and accompanying chills and
agitation [4].
The term Expanded Dengue Syndrome (EDS) was coined by WHO in 2012 when
the clinical presentation became vague and showed generalized impacts on
normal physiology which could not be confined to a specific clinical
spectrum [5].
Liver involvement is among the mainstay features of
DF [3].
Dengue virus blunts the physiologic hepatic functioning by diverse
mechanisms involving direct disruption of hepatocytes and Kupffer cell
function, and indirectly by impairment of the immune system via a
cytokine surge mediated by t-cells and circulatory failure causing
ischemic liver
injury [6].
Liver injury in DF is usually manifested by nausea, vomiting, abdominal
discomfort, and anorexia concurrent with the findings of hepatomegaly
and elevated serum transaminase
levels [7].
A recent outbreak of DF occurred in Pakistan starting from 1st January
to 27th September 2022, with around 25,932 people being afflicted and 62
deaths reported by the National Institute of Health in
Islamabad [8].
Case Presentation
A 29-year-old Pakistani male was presented to the Emergency Department
of a Tertiary Care Hospital in Karachi on 19th October 2022 with altered
level of consciousness for 1 day and a history of fever, vomiting, and
abdominal pain for the past 5 days.
On history, the fever was reported to be high-grade (maximum spike of
104◦F), with rigors and chills, intermittent with a peak after every
twelve hours. Vomiting was described as projectile, occurring three to
four times a day, watery, and not blood-stained. Abdominal pain was
localized to the right hypochondriac regions, with no shifting or
radiations. It was described as an aching, intense pain that aggravated
after vomiting and was not relieved despite the administration of
analgesics. He then gradually developed an altered loss of consciousness
which initiated with irrelevant conversation and progressively worsened.
The patient was under hospital care for 4 days before being referred to
the current set-up after behavioral alterations were evident. His viral
markers for Hepatitis A ,B and hepatitis E infection were negative,
Dengue Antigen and Malaria parasite were also negative on 17th October
2022. A chest X-Ray was also performed
(Figure 1).