Acute Hepatic Failure-An Unusual Complication of Dengue Fever in Adults

Jalal MJA; Mathew J; Pratap T; Joseph JKÂ and Alexander J

doi:10.23880/jidtm-16000102

Journal of Infectious Diseases & Travel Medicine Research Article 4 min read

Acute Hepatic Failure-An Unusual Complication of Dengue Fever in Adults

Jalal MJA^*, Mathew J, Pratap T, Joseph JKÂ and Alexander J

^* Corresponding author

ISSN: 2640-2653 10.23880/jidtm-16000102 Received: July 24, 2017 Published: August 17, 2017

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Keywords

Dengue fever liver enzymes Haematuria Melena petechial rash leucocytosis Hepatic Failure

Abstract

Dengue fever usually results in a mild to moderate elevation of liver enzymes. Hepatic failure is indeed a rare clinical picture in the scenario of adult dengue fever. We present a case of dengue haemorrhagic fever in an adult female, leading to acute liver failure. She was conservatively managed with adequate supportive care and discharged after 10 days. She had complete recovery and no residual symptoms were observed during follow up after one week.

Case Report

A 48-year-old female presented with symptoms of high-grade fever, generalized myalgia and diffuse abdominal pain with non-bilious, non-projectile vomiting of 7 days duration. She also had symptoms of mucosal bleeding in the form of haematuria and melena. She did not have any past co-morbidities. Clinical examination revealed a temperature of 101°F, pulse rate of 92/min, blood pressure 110/80 mm Hg and respiratory rate of 24/min. She was hemodynamically stable with saturation (SPO2) of 98% in room air. The patient was icteric and had bilateral subconjunctival haemorrhages. She had petechial spots over the soft palate and extensive petechial rash all over the trunk and limbs. Rest of the general examination was unremarkable; there was no eschar. On systemic examination, the cardiovascular system had normal heart sounds and no murmur; examination of the chest revealed bilaterally equal air entry with basal creps; abdominal examination revealed mild hepatomegaly. She was conscious and oriented without any focal neurological deficits.

Journal of Infectious Diseases & Travel Medicine

Table 1 shows the patient’s haematological and biochemical investigations at admission, during hospital stay and on the day of discharge. Hemogram showed leucocytosis [15,510 per cu mm] with thrombocytopenia [25,000 per cu mm]. Her liver enzymes were significantly elevated [AST: 15,051 and ALT: 4122]. She also had

deranged coagulation parameters as evidenced by a pro- thrombin time of 26.1 seconds and INR of 2.26. Chest radiograph revealed bilateral hazy bases. Ultrasound scan showed mild hepatosplenomegaly with Grade 2 fatty liver and Gall bladder wall thickening (Figures 1A & 1B).

(A) (B) Figure 1A: USS of liver showing hepatomegaly with diffuse fatty changes.

Figure 1B: USS showing GB wall thickening with tram-track pattern (hypoechoic zone separated by two echogenic layers). There was no ascites or pleural thickening. Plain CT showed normal lung fields with hepatomegaly (Figure 2).

Journal of Infectious Diseases & Travel Medicine
Day of illness
Day of admission
[Day 1]
Day 2
Day 3
Day 4
Day 7
Day of
Discharge
Hb [g/dl]
11
8.9
8.2
10.2
10.4
10.8
Total white cell count [per cu mm]
15510
16270 14200
12700
10400
9550
Platelet count [per cu mm]
25000
87000 1,40,000 1,40,000 2,44,000
2,50,000
Total Bilirubin [mg/dl]
3.9
3.8
4.5
4.3
1.9
1.6
Direct Bilirubin [mg/dl]
2.3
2.6
2.4
2.1
1
1.1
Total protein [g/dl]
6
6
6
5.5
6
6
Albumin [g/dl]
3.1
3.4
3.3
2.7
3.5
3.6
Aspartate aminotransferase [U/L]
15051
12984
7803
4048
345
217
Alanine aminotransferase [U/L]
4122
3260
2370
1692
384
239
Alkaline phosphatase [U/L]
181
191
166
175
178
180
Creatinine [mg/dl]
1.1
1.2
----
----
1.1
1.2
Prothrombin time [sec]
26.1
24.5
20
20.6
19.4
18.2
International normalized ratio
2.26
2.08
1.63
1.67
1.52
1.4 aPTT [activated partial thromboplastin time - sec]
29
----
----
----
----
26
Creatinine phosphokinase [U/L]
140
144
----
----
----
148
Serum Sodium [mEq/L]
130
135
136
139
136
136
Serum Potassium [mEq/L]
4
4.2
3.8
3.7
3.4
3.6
Serum Ammonia [µg/dl]
99
90
40
25

Table 1: Laboratory profile of the patient during the course of illness.

Journal of Infectious Diseases & Travel Medicine

Ultrasound findings of hepatosplenomegaly, GB wall thickening, pleural effusion and ascites in patients presenting with signs and symptoms of Dengue Fever are virtually diagnostic of this entity. Gall bladder wall oedema has been reported as one of the most common ultrasound findings in Dengue fever. In GB wall oedema there is preservation of mucosal echogenicity with hypoechoic appearance of muscle layer. There are 4 patterns of GB wall thickening described in Dengue fever [6]. They are A) Uniform wall thickening; B) Tram -track pattern; C) Asymmetric wall thickening; D) Honeycomb pattern. Uniform wall thickening was mostly seen in mild forms while tram- track or honeycomb pattern should alert possibility of severe forms of Dengue. Our case had tram –track pattern of wall thickening with central hypoechoic zone in between two echogenic layers indicating severe form of Dengue fever. Supportive measures focusing on hydration and hemodynamic stability with serial monitoring of liver enzymes and coagulation parameters forms the crux of acute hepatic failure management. Sepsis and systemic inflammatory response syndrome should be anticipated by close surveillance periodically and treated promptly with initiation of adequate antibiotics. Fresh frozen plasma and platelet transfusion should be reserved for active bleeding and thrombocytopenia respectively. Dengue fever related hepatic failure has considerably low case fatality in contrast to other aetiologies of acute hepatic failure in adults. In 2013, Tan SS and Bujang MA, described eight patients managed with standard medical therapy alone having 100% survival rates [7]. Dengue fever in children usually has a relatively higher rate of acute fulminant hepatic failure leading to 50% mortality [8]. Likelihood of spontaneous recovery in dengue related acute hepatic failure can be determined by King’s College criteria or Model for End-Stage Liver Disease (MELD) score.

References

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Acute Hepatic Failure-An Unusual Complication of Dengue Fever in Adults

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