https://imcjms.com Ibrahim Medical College Journal of Medical Science https://imcjms.com/registration/journal_full_text/63 Tue, 02 Aug 2016 11:48:11 +0000 Dengue is an arboviral disease endemic in many parts of the world. The clinical presentation of dengue viral infection ranges from asymptomatic illness to fatal dengue shock syndrome. Although, it is known to cause hepatic involvement, it occasionally results in acute hepatic failure. We report a case of dengue hemorrhagic fever presenting with acute liver failure. The case recovered completely after treatment. Introduction   A 35-year-old housewife came to the emergency with the complaints of high grade fever with chills, myalgia for 4days and severe abdominal pain with non-bilious vomiting for 2 days. There was no history of bleeding from any site and she was not exposed to any hepatotoxic drugs. There was no significant past medical or surgical history. On examination, she was febrile, dehydrated and normotensive. Abdomen was diffusely tender and chest examination revealed reduced air entry in right infrascapular and infra-axillary area. On the following day, platelet count dropped to 8. 0x109/L and haematocrit level rose to 53%. There were petechial hemorrhages and mild gum bleeding. By the next day, she became dyspnoic and her level of consciousness deteriorated. Her pulse rate was 140/min, blood pressure was 100/60 mm of Hg, respiratory rate was 44/min and Glasgow coma scale was 10/15. She became icteric and developed tender hepatomegaly and moderate ascites. The platelet count rose to 38.0x109/L and haematocrit became 42% after one unit of apheretic platelet was transfused. The liver function tests further deteriorated: serum bilirubin 3.2 mg/dL, ALT -2150 IU/L, AST – 3050 IU/L. Prothrombin time (PT) was 32 seconds against control of 13 seconds and activated partial thromboplastin time (APTT) was 43.8 second (normal 13-25 seconds). Serum ammonia was 70 mmol/L and serum lactate was 108 mg/dl. She was shifted to intensive care unit and intubated due to severe metabolic acidosis with increased oxygen requirement. Antibodies to hepatitis A, C, and E as well as hepatitis B surface antigen were negative. Peripheral smear for malarial parasites were negative. Dengue NS1 antigen and dengue IgM antibody against dengue virus were positive. Computed tomography of brain showed diffuse cerebral edema. Based on the above findings, she was diagnosed as a case of dengue hemorrhagic fever with hepatic encephalopathy.   Dengue infections are caused by a flavivirus which has four serotypes (DEN1-4). It is the commonest arbovirus and a common cause of hemorrhagic fever in the world. The virus is transmitted by mosquitoes of Aedes genus, mainly Aedes aegypti. Dengue virus can infect many cell types in the body to cause diverse clinical effects. Liver involvement appears to occur more commonly with serotypes DEN3 and DEN4.5 Although liver is not the main target organ, direct infection of hepatocytes and Kupffers cells by dengue virus can be observed.6 An increase in liver transaminases is observed in the first week of dengue infection mainly in dengue hemorrhagic fever rather than in dengue fever. This can vary from 2-3folds to more than 10 fold rise from normal level. AST raises more than ALT which is different from other types of hepatitis.6 Similar pattern was observed in our patient as well. The management in such cases includes supportive therapy in the form of adequate and cautious fluid replacement, timely ventilator support, prophylactic antibiotic coverage, anticerebral edema measures and continuous monitoring of neurological status.     1.    World Health Organization: Dengue haemmorhagic fever: diagnosis, treatment, prevention and control. 2nd edn. World Health Organization, Geneva 1997; 12-23. 3.    George R, Lum LCS. Clinical spectrum of dengue infection. In: Gubler DJ, Kuno G (eds). Dengue and dengue hemorrhagic fever. Washington: Cab International; 1997. 5.  Gasperino J, et al. Fulminant hepatic failures secondary to hemorrhagic fever in an international traveler. Liver Int. 2007; 27: 1148-51. 7.  Sirivichayakul C, Sabcharoen A, Chanthavanich P, Pengsaa K, Chokejindachai W, Prarinyanupharb V: Dengue infection with unusual manifestations: a case report. J Med Assoc Thai 2000; 83: 325-329. 9.   Malavige GN, Ranatunga PK, Velathanthiri VGNS, Fernando S,  Karunatilaka DH,  Aaskov J,  Seneviratne SL. Patterns of disease in Sri Lankan dengue patients. Arch Dis Child 2006; 91: 396-400. 10.   de Souza LJ, Alves JG, Nogueira RMR, Neto CG, Bastos DA, et al. Aminotransferase changes and acute hepatitis in patients with dengue fever: analysis of 1,585 cases, Braz J Infect Dis 2004; 8: 156-63. 2026 Ibrahim Medical College. All rights reserved.