https://imcjms.com Ibrahim Medical College Journal of Medical Science https://imcjms.com/registration/journal_full_text/298 Thu, 06 Sep 2018 14:57:40 +0000 Abstract We report a case of nephrotic range proteinuria with 24-hour urine protein level of 18.3 g/day, which developed following dengue fever (DF). The patient did not exhibit classical features of nephrotic syndrome (NS) and his renal function was not compromised during his illness. Proteinuria resolved without any specific treatment and precluded renal biopsy. Though the dengue fever and associated renal disorders are self-limiting, renal involvement in severe dengue infection is growingly seen in recent years and could cause increased mortality and long-term morbidity. IMC J Med Sci 2018; 12(2): 86-89. EPub date: 06 September 2018. DOI: https://doi.org/10.3329/imcjms.v12i2.39667 Address for Correspondence: Dr. Shapur Ikhtaire, Department of Internal Medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU); Email: ikhtaireshapur@yahoo.com   Introduction Dengue fever is an acute febrile illness accompanyied by constitutional symptoms. Dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS) are the severe forms of dengue infection, which have become a major international public health issue [1]. Expanded dengue syndrome (EDS) is a relatively new entity which incorporates a wide spectrum of unusual manifestations of dengue virus infection involving kidney, liver, brain, heart and muscle [1]. The dengue virus is an RNA arbovirus from the genus Flavi virus (family Flaviviridae). It has four closely related serotypes: DEN-1, DEN-2, DEN-3 and DEN-4 based on antigenic characteristics of dengue virus. More recently, a new serotype DEN-5 was identified, which caused an epidemic of dengue in Malaysia in 2007 [2,3]. Over the past three decades, there has been a global increase in the frequency and epidemics of DF, DHF, DSS with a concurrent rise in disease incidence [1]. Though it is a self-limiting disease, in the recent years complications involving specific organ systems and dengue related mortality and morbidity have been observed at an increasing rate [4-6]. Here, we describe a case of dengue virus infection who exhibited massive nephrotic range proteinuria (18.3 g/day) following DF. Proteinuria improved without any specific treatments and precluded renal biopsy. To date, proteinuria of 18.3 g/day in DF has never been reported from Bangladesh and rarely from the other parts of the world.   Case report A 17-year-old boy without any past medical illness presented through emergency department of a hospital in Dhaka city with a 3-day history of high grade fever, chills, myalgia and headache. On admission, he was febrile (1020 F), with congested eyes without any systemic signs and bleeding manifestations. His pulse was 100 beats/min and blood pressure was 120/85 mm of Hg. Initial investigation on admission showed hemoglobin 116 gm/L, total white blood cell (WBC) 7.6x109/L, platelet count 155x109/L, which dropped to 110x109/L the next day. Packed cell volume (PCV) 35%, erythrocyte sedimentation rate (ESR) 05 mm in first hour and Dengue NS-1 Ag was positive (3rd day of his fever). His liver transaminase, renal function, blood urea and electrolytes were within normal limit. The case was diagnosed as DF and treated symptomatically with adequate fluid and anti-pyretic (paracetamol). By day 5 of fever, he noticed excessive frothiness of urine and he developed mild puffiness of face without any oedema, ascites, plural effusion and rise of blood pressure. Immediate urine examination revealed, presence of proteinuria (+++), RBC 2-3/HPF and pus cell 6-8/HPF. This proteinuria was quantified by 24 hours urinary total protein (UTP) test, which surprisingly exhibited as UTP 18.3 gm/24 hours (UTV 5000 ml). Accordingly, other relevant tests were done to exclude other potential systemic causes of nephrotic range proteinuria and pre-existing glomerulonephritis (GN). These included urine phase contrast microscopy to delineate glomerular pathology, which showed RBC 6-8/ HPF, dysmorphic RBC-15%, pus cell 8-10/HPF without the presence of any cast. Urine and blood culture revealed no growth. Anti-nuclear antibody (ANA), Anti ds-DNA, cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA),perinuclear antineutrophil cytoplasmic antibody (p-ANCA), C3, C4, immunochromatograpic test for malaria and hepatitis B surface antigen (HBsAg) were found negative. Serum creatinine and albumin were within normal reference limit. Surprisingly, regardless of massive nephrotic range proteinuria the patient did not have the essential criteria of classical nephrotic syndrome of hypoalbuminaemia, dyslipidaemia and oedema. By the 7th day of his illness, he noticed yellow coloration of eyes, severe myalgia and gum bleeding. At this stage his serum bilirubin was 37.62 µmol/L (normal 3-22 µmol/L) AST 246 U/L (normal-15-37 U/L), CPK 667 U/L (normal-24-190 U/L). Therefore, along with his initial presentation, additionally he developed hepatitis and myositis. Although, he had no bleeding manifestation, relevant tests were done which included bleeding and clotting time (BT, CT), reticulocyte count, activated partial thromboplastin time (APTT), INR, direct and indirect Coomb¢s tests. All of them were within normal limit. His platelet count was 125x109/L and peripheral blood film (PBF) showed normocytic normochromic anaemia without any features of haemolysis. Anti-dengue IgG was positive while IgM was negative. During his spectrum of illness, he did not exhibit any significant bleeding manifestation or any features of plasma leakage like ascites, plural effusion and rise of hematocrit value. His chest x-ray was normal and ultra sonogram of abdomen revealed mild splenomegaly. Based on clinical features and laboratory investigation he was diagnosed as a case of expanded dengue syndrome with unusual manifestation of nephrotic range proteinuria along with hepatitis and myositis. 2026 Ibrahim Medical College. All rights reserved.