SAT-433 RENAL CORTICAL NECROSIS IN NON-HEMORRHAGIC DENGUE FEVER- A RARE CASE REPORT

Abstract

Dengue fever is a tropical febrile illness caused by one of the 4 genotypes of dengue virus. Acute Kidney Injury (AKI) is a rare complication of Dengue Fever and is usually associated with severe forms of the disease as in Dengue hemorrhagic fever (DHF) and Dengue shock syndrome (DSS). We present a patient diagnosed as a case of Dengue fever without Shock or any Hemorrhagic manifestation, developing Acute Cortical Necrosis and requiring maintenance Haemodialysis. Patient was admitted with Acute febrile illness, diagnosis of Dengue Fever was confirmed by positive IgM for Dengue. He underwent extensive diagnostic workup to rule out other causes of Acute Kidney Injury. 30 year old married, male, patient was admitted complaints of Abdominal pain and fever since 3 days with history of decreased urine output since one day. There was no history of any Malena or hematemesis or any chronic illness like Hypertension or Diabetes. Blood pressure was within normal limit. His blood investigations revealed Hb 12.7g/dl, Total Leucocyte count-10860/cumm, Platelet counts-3,65000/cumm, Hematocrit-37.3%, Reticulocyte count-1%, ESR-02, APTT-26, INR was 1.20, Peripheral Smear showed Normocytic Normochromic RBCS with no schistocytes. SGPT-92, SGOT-94, Total bilirubin-0.8, Total Serum Proteins-6.2g/dl, Serum Albumin-3.5g/dl, Serum Globulin-2.7g/dl, Lipase-65, Amylase-73, LDH-1297, TSH-1.67, RBS-102, Blood urea-111mg/dl, Serum Creatinine-6.27mg/dl, Na-138, K-4.3, Bicarbonate-18.1mmol/L, Creatinine Phosphokinase-193, C3 level was normal, Calcium-8.4mg/dl, iPTH-75 pg/ml, Dengue Serology showed positive IgM for Dengue, Malaria antigen was negative. His Direct coombs test, Antinuclear Antibody, ANCA c & p, Lupus anticoagulant, Antiphospholipid antibody, Anticardiolipin antibodies, Protein C and S deficiency were negative.G6PD quantitative was within normal limits and Sickling test was negative. His heavy metal screening was also negative. Urine RM showed Protein 3+, WBCs-03, RBCs-02(isomorphic type). Patient was initially managed with Intravenous fluids and later Haemodialysis was started in view of severe acidosis and fluid overload. He underwent extensive radiological evaluation with Ultrasonography of Abdomen showing normal liver echoes with bilateral normal sized kidney and intact corticomedullary differentiation with decreased cortical blood flow on power doppler, CT Contrast study of Abdomen confirmed poor renal cortical blood flow. Renal Biopsy was done which showed Cortical Necrosis with near complete thrombotic occlusion in medium sized vessels. In view of persistent Anuria, the patient was put on maintenance Haemodialysis. Irreversible Kidney Injury is an extremely rare complication of Dengue fever as most of the patients of AKI recover with supportive treatment. In our case a young patient with a short clinical history of Dengue Fever presented with AKI. Renal Biopsy showed Renal Cortical Necrosis with medium sized vessels showing near complete occlusion of vascular lamina by thrombi suggesting Thrombotic Microangiopathy. Hence, delay in recovery of AKI in Dengue patients presenting without Hemorrhage or shock should prompt the clinician to evaluate further regarding the underlying pathological mechanisms of Acute Kidney Injury.