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LETTERS TO EDITOR
Year : 2020  |  Volume : 21  |  Issue : 1  |  Page : 77-78
 

A rare case of dengue hemorrhagic fever in the postoperative period


1 Department of Anaesthesia and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Orthopedics, Command Hospital, Chandigarh, India

Date of Submission21-Nov-2019
Date of Decision09-Dec-2019
Date of Acceptance09-Dec-2019
Date of Web Publication13-Feb-2020

Correspondence Address:
Dr. Shalendra Singh
Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_88_19

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How to cite this article:
Singh S, Pradip K C, Sud S, Sood M. A rare case of dengue hemorrhagic fever in the postoperative period. Indian Anaesth Forum 2020;21:77-8

How to cite this URL:
Singh S, Pradip K C, Sud S, Sood M. A rare case of dengue hemorrhagic fever in the postoperative period. Indian Anaesth Forum [serial online] 2020 [cited 2020 Apr 4];21:77-8. Available from: http://www.theiaforum.org/text.asp?2020/21/1/77/278194




Sir,

Dengue hemorrhagic fever (DHF) is a major cause of morbidity and mortality in endemic areas.[1] Co-existence of DHF is also reported in patients admitted for some other ailments such as pregnancy, neurosurgery, and cardiac surgery.[2] We managed a case of fracture tibia fibula with postoperative DHF, suspected as a case of postoperative sepsis.

A 25-year-old male was brought to the hospital after a road traffic accident (RTA) and diagnosed as a case of Grade II open fracture proximal end of left tibia and fibula [Figure 1]. There was no history of loss of consciousness, vomiting, fever, rashes over the body, headache, and reduced oral intake. The patient was hemodynamically stable. His blood investigations showed white blood cells: 12.1 × 109/L, platelets: 160 × 109/L, hemoglobin: 12.2 g/dL, and normal coagulation profile. The patient was taken up for surgery under combined spinal–epidural anesthesia, and intramedullary nailing of the tibia and fibula was done. On the 3rd postoperative day, the patient developed a high-grade continuous fever (104°C) which was concomitant with headache and dry cough. A mild oozing over dressing was present with no discharge. A clinical suspicion of postoperative sepsis associated with local infection was made, and broad-spectrum antibiotics and antipyretics were started. The patient became afebrile on the 4th postoperative day. On the 7th postoperative day, the patient had epistaxis, with pink frothy sputum and sudden onset dyspnea with pleuritic chest pain. Clinical examination revealed tachypnea, tachycardia with bilateral coarse crepts, a normal chest X-ray, and electrocardiogram. Computer tomography–pulmonary angiography showed perivascular hollow patchy consolidation and ground-grass opacities predominantly in bilateral lower lobes, suspected to be due to pulmonary hemorrhage. On the 8th day, an investigation revealed leukopenia (3100/mm3), thrombocytopenia (32,000/mm3), and positive IGM NS 1 for dengue. Management was ensued as per the national guidelines for the management of dengue fever (DF). The patient was transfused four units of single donor platelet over the next 3 days, and platelet counts gradually normalized (1.7 lakh/mm3) by the 10th day and was discharged to the home after the 14th day.
Figure 1: Showing Grade II open fracture proximal end of the left tibia and fibula

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DF is a common tropical infection with three stages: the febrile, afebrile (defervescence), and recovery phases.[3] Of these three stages, the most critical stage is the afebrile stage which can be deceiving to an inexperienced physician because patients may have massive leaking of fluids and internal bleeding.[4] Therefore, monitoring and normalizing hematocrit and not platelet should be the main therapeutic goal to prevent the severe complication of DF such as massive bleeding. In our case, the patient presented as a case of RTA, though being endemic locality for DF, concomitant occurrence of the fracture deviated the clinician from the suspicion of dengue. DHF detected in the postoperative period is rare, and only a few cases are reported in the literature. Although no separate guidelines are available for surgical patients, those who demonstrate petechiae and thrombocytopenia should be hospitalized and observed carefully for impending circulatory shock.[4] Treating physicians should keep in mind that in a postoperative patient with unexplained thrombocytopenia in an endemic area, DF should be ruled out by specific investigations.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pang X, Zhang R, Cheng G. Progress towards understanding the pathogenesis of dengue hemorrhagic fever. Virol Sin 2017;32:16-22.  Back to cited text no. 1
    
2.
Singh S, Dwivedi D, Sethi N, Paul D. A rare case of thoracic subdural hematoma after recovery from dengue fever. J Neurosci Rural Pract 2019;10:380-1.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Halstead SB. Dengue. Lancet 2007;370:1644-52.  Back to cited text no. 3
    
4.
Rawat SK, Mehta Y, Juneja R, Trehan N. Dengue fever in a patient recovering from coronary artery bypass grafting. Ann Card Anaesth 2011;14:155-6.  Back to cited text no. 4
[PUBMED]  [Full text]  


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