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).