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Indian Pediatr 2010;47:
280-282 |
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Fulminant Hepatic Failure in Primary Dengue
Infection |
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AM Vijayalakshmi and S Devaprasath
Department of Pediatrics, PSG Institute of Medical
Sciences and Research, Peelamedu, Coimbatore 641 004,
Tamil Nadu, India.
Email: [email protected]
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Fulminant hepatic failure is a rare manifestation of dengue hemorrhagic
fever. We describe fulminant hepatic failure in two infants due to primary
dengue infection. Both the infants recovered completely with supportive
measures.
A 9-month-old child presented with four days fever and
altered sensorium for 2 days. He developed seizures in the emergency
department and was in a state of shock. His blood sugar was 9 mg/dL. He
was resuscitated with intravenous fluids. The child had fever, altered
sensorium and erythematous skin. His liver was palpable 4 cm below right
costal margin and spleen was just palpable. The limbs were spastic and
deep tender reflexes were brisk. His initial blood count showed a total
count of 23.1 ´
103/mL,
hematocrit of 33%, platelet count of 22,000/mL.
His liver function test were SGPT of 5907 U/L, SGOT of 20,480 U/L and
serum bilirubin of 2.7 mg/dL. His prothrombin time was prolonged(68s).
Serology for hepatitis A, C and E, and HBs Ag were negative. Imaging
showed right sided pleural effusion and moderate ascites. Dengue IgM
antibodies were positive and dengue IgG was negative, suggestive of
primary dengue infection. He developed progressive jaundice with the
maximum bilirubin level of 22.9 mg/dL, which resolved completely 8 weeks
after onset.
A 1-year-old boy presented with fever and rash for 4
days. On examination, he was sick looking, febrile, irritable and had cold
extremities. He had right pleural effusion and ascites. His liver was
palpable 4 cm below costal margin. Investigations on admission showed a
total count of 6.4 ´
103 /mL,
hemoglobin of 6.8 g/dL and platelet count of 11,000/mL.
His liver function test was grossly deranged with SGPT level of 3713 U/L,
SGOT of 1401 U/L, serum bilirubin of 2 mg/dL and prothrombin time of 22 s.
Imaging revealed pleural effusion, and moderate ascites. His anti HAV IgM,
anti HCV, anti HEV and HBs Ag were negative. Dengue IgM was positive and
Dengue IgG was negative, suggestive of primary dengue infection. Both
infants were treated with intravenous fluids, fresh frozen plasma,
platelet concentrate and ceftriaxone.
Liver failure has been associated with dengue
hemorrhagic fever particularly during epidemics in Indonesia and
Thailand(1). Acute liver failure has also been reported in adults with
primary dengue fever(2,3). Fulminant hepatitis in dengue infection has a
very high mortality(4). Dengue is a major cause of acute hepatic failure
in Thailand(5). The important differential diagnosis in cases presenting
with fever and acute hepatic failure includes acute viral hepatitis and
Reye syndrome. In dengue endemic regions, dengue fever should also be
considered as one of the differential diagnosis in children presenting
with fever and fulminant hepatic failure.
References
1. Dengue Haemorrhagic Fever. Diagnosis, Treatment,
Prevention and Control. 2 nd edn.
Geneva: World Health Organization; 1997.
2. Vinodh BN, Bammigatti C, Kumar A, Mittal V. Dengue
fever with acute liver failure. J Postgrad Med 2005; 51: 322- 323.
3. Ling LM, Wilder–Smith A, Leo YS. Fulminant hepatitis
in dengue hemorrhagic fever. J Clin Virol 2007; 38: 265-268.
4. Shah I. Dengue and liver disease. Scand J Infect Dis
2008; 40: 993-994.
5. Poovorawan Y, Hutagalung Y, Chongsrisawat V,
Boudville I, Bock HL. Dengue virus infection: A major cause of acute
hepatic failure in Thai children. Ann Trop Paediatr 2006; 26: 17-23.
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