A case of cerebellar hemorrhage in a patient with severe dengue

Abstract

Background: Degue is the most rapidly spreading mosquito-borne viral infection in the world with various symptoms and clinical presentation. Neurological complication of dengue is rare (0.5 to 7.4%) and its pathophysiological basis of is not fully understood. Data on cerebellar hemorrhage as a complication of severe dengue is rare. Case Description: This is a case of a 25 y old female, household helper presented with a 5 d history of fever, headache, nausea, vomiting and diarrhea. She consulted a physician, diagnosed was acute gastroenteritis, advised supportive care. Workups showed leukopenia, thrombocytopenia, positive dengue NS1Ag. She was hydrated intravenously at home. In 2 d, platelet count further decreased and transaminases were elevated. On the 5th day of illness, fever and diarrhea resolved, but was noted disoriented. At the ER, vital signsBP 100/70 mmHg, CR 78, RR 26, temperature 36.5C, GCS13 (E3V4M6) with petechiae on both upper extremities. Manual muscle and sensory testing were normal but unable to do finger to nose test, no meningeal and Babinski signs. Repeat workups showed leukocytosis (22.70 x 109/L), thrombocytopenia (47.00 x 109/L). She was hydrated with PNSS and started on cefepime and moxifloxacin to cover for a possible pneumonia. She was noted to be unresponsive and was intubated. ET secretion was frothy. Other workups: 12LECG sinus tachycardia with anterior wall ischemial; chest X-ray pulmonary edema; cranial CT scan showed cerebro-cerebellar edema with uncal herniation, non-communicating hydrocephalus with possible subarachnoid hemorrhage. Her blood pressure decreased requiring vasopressors. She was to be transfused with platelet concentrate, when she had cardiac arrest and attempted resuscitation 3 times. Patient eventually expired. Post-mortem examination showed pulmonary congestion (right lung 700 g, left lung 750 g); pleural effusion (right 300 mL light red, thin fluid), cerebellar hemorrhage and gastric pinpoint hemorrhages. Discussion: Prevalence of hemorrhage on dengue, especially in the central nervous system, especially in the cerebellum is rare. Further studies may be done to determine certain risk factors that may be predict such complications. Conclusion: We were able to present a case of severe dengue presenting with cerebellar hemorrhage and circulatory collapse and exemplified that these cases possessed high mortality despite early diagnosis.