2488 Severe Dengue Fever With Impending Liver Failure in Thalassemic Patient With Pregnancy: A Diagnostic Challenge

Abstract

INTRODUCTION: Dengue infection is a leading fatal arthropod-borne disease in the tropics. Gastrointestinal presentation of dengue fever (DF) includes abdominal pain, vomiting, jaundice, hepatomegaly and liver failure. The presentation in a patient with thalassemia, during pregnancy poses a clinical challenge in differential diagnosis between the severe form of dengue infection and a complication of pregnancy, HELLP syndrome. CASE DESCRIPTION/METHODS: A 36 years old female with thalassemia during 34 weeks of pregnancy was admitted due to fever with chills. She later developed dyspnea and uterine contraction on the third day of fever. The physical examination revealed body temperature of 39°C, marked pale conjunctiva, mild icteric sclera and mild hepatosplenomegaly. The initial investigation showed white blood cell count of 34020 × 106/L with lymphocytic predominance, hemoglobin of 9.8 g/dL, platelet count of 62000 × 106/L and INR 2.09. Liver function test revealed total bilirubin 4.4 mg/dL, direct bilirubin 3.4 mg/dL, aspartate aminotransferase (AST) 813 IU/L, alanine aminotransferase (ALT) 350 IU/L, and alkaline phosphatase (ALP) 180 IU/L. She underwent cesarean section due to fetal distress with the diagnosis of HELLP syndrome. After the operation, her fever persisted. The follow-up blood tests showed leukocytosis, worsening thrombocytopenia and high level of transaminase enzymes (AST 3285 IU/L and ALT 1279 IU/L). The following investigation showed hemolytic anemia and coagulopathy. No evidence of microangiopathic hemolysis was detected. The dengue NS1 antigen was positive. She was treated with intensive fluids replacement and intravenous N-acetyl cysteine. Her fever lasted for five days and abnormal blood tests become normal within 2 weeks. DISCUSSION: Concurrent DF in a pregnant woman with thalassemia poses difficulty in the diagnosis and might lead to a poor prognosis. Severe dengue infection can cause liver injury with severe thrombocytopenia and hemolytic crisis in thalassemic patients mimicking those occurs in HELLP syndrome. The clinical clues for diagnosis of DF in this situation include fever, thrombocytopenia and acute non-microangiopathic hemolytic anemia. However, awareness of the disease during an outbreak, especially in a rainy season, is probably the most important clue for an early diagnosis. Intensive fluids and hemodynamic management is the key for dengue treatment. Evidence of therapeutic role of N-acetyl cysteine or other liver support systems in DF with liver failure are limited.