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| CASE REPORT |
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| Year : 2021 | Volume
: 58
| Issue : 3 | Page : 285-287 |
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Dengue induced reversible blindness
Anju Dinkar1, Jitendra Singh2, Virendra Atam3
1 Department of Microbiology, Institute of Medical Science, BHU, Varanasi, UP, India
2 Department of General Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
3 Department of Medicine, King Georges's Medical University, Lucknow, UP, India
| Date of Submission | 02-May-2020 |
| Date of Acceptance | 02-Oct-2020 |
| Date of Web Publication | 15-Feb-2022 |
Correspondence Address:
Dr Jitendra Singh
Assistant Professor, Department of General Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0972-9062.328817
Dengue is spread by the bite of infected Aedes aegypti mosquito. It is usually a self-limiting viral infection but sometimes complicates to mortality. In the last few decades, literature has shown that clinical and biochemical profile of dengue is expanding due to the addition of unusual manifestation day by day. Hereby, we report a young male student suffering from dengue complicated to retinal hemorrhage and severe pancytopenia who recovered near fully on treatment.
Keywords: Pancytopenia; Anaemia; Thrombocytopenia; Retinal haemorrhage; Ophthalmic complication
How to cite this article:
Dinkar A, Singh J, Atam V. Dengue induced reversible blindness. J Vector Borne Dis 2021;58:285-7 |
| Background | |  |
Dengue is usually a self-limiting viral infection but sometimes complicates to mortality[1]. In the last few decades, literature has shown that clinical and biochemical profile of dengue is expanding due to the addition of unusual manifestation day by day[2]. Subconjunctival hemorrhage, gum bleeding, epistaxis, hematuria, and menorrhagia are commonly observed hemorrhagic manifestations in dengue which are usually mild and self-limited[3]. However, cases of severe and life-threatening bleeding such as intracranial, epidural spinal hematoma and gastric hemorrhage have been reported in the medical literature[1],[4]. Retinal hemorrhage with severe and prolonged pancytopenia is the first case as no similar case was found on PubMed and Google-based search engine.
| Case Presentation | | |
A 20-year-old male student was admitted in medicine department with complaints of low to high-grade fever without chills and rigor, body pain, generalized weakness and nausea for 7 days, a progressive diminished vision of both eyes (right>left) for 2 days. The diminished vision was progressive in nature and not associated with eye pain, photophobia, or increased tearing without any trauma. His vitals were as BP 110/ 76 mmHg in the right arm, pulse rate 100 per minute, respiratory rate 18 per minute and mouth temperature 101 °F. General and systemic examination was unremarkable. Mental and physical status was normal. There were no symptoms and signs suggesting of CNS pathology. His both pupils were of normal size and reaction to light. There was no significant family, past and personal history regarding present illness. After detailed history and examinations, blood samples were sent for relevant investigations.
His complete blood count showed hemoglobin 7.6 g/ dl (12-15), total leucocyte count 3.5×103/μL [4-11], and platelet count 22×103/μL (150-410). His liver enzymes were mildly elevated with serum bilirubin total 0.8 mg/ dL [upto 1.0], alanine aminotransferase 74 U/L [upto 41], aspartate aminotransferase 88 U/L [upto 40], alkaline phosphatase 112 U/L (0-105), serum protein 7.2g/dL [6.4-8.3] and serum albumin 4.0 g/dL [3.4-4.8]. His renal function test, serum electrolytes, random blood sugar, and urine examination were within normal limit. Serum vitamin B12 and folic acid level were normal. Dengue serology for IgM antibody by MAC ELISA was positive. Smear examination for malaria parasite was negative. Serology for hepatitis A, B, and C, HIV and IgM leptospira, IgM Typhi, IgM cytomegalovirus, IgM Epstein Barr virus, and IgM parvovirus were negative. Computed tomography (CT) of the head, ultrasonography of abdomen, chest x-ray and electrocardiography were normal. Bone marrow aspiration examination showed erythroid hyperplasia with megaloblastic changes and decreased number of megakaryocytes [Figure 1]. An ophthalmic opinion was taken and bilateral retinal hemorrhage (right>left) was detected on fundoscopic examination [Figure 2]. On the basis of clinical examination and investigation, the final diagnosis of dengue fever complicated with severe pancytopenia and retinal hemorrhage was established. | Figure 1: Bone marrow aspiration examination showing erythroid hyperplasia with megaloblastic changes and decreased number of megakaryocytes
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Broad spectrum antibiotics (Piperacillin with tazobactam and doxycycline) were administered along with oral vitamin A and E, folic acid and paracetamol. Intravenous fluids and other supportive management were given accordingly. Two units packed RBCs and 2 units single donor platelets [SDP] were transfused during hospitalization. Clinical and laboratory parameters were started to improve on Day 4 and he was discharged on the Day 10 of hospitalization in improving clinic state on haematinics and vitamins (Folic acid, A and E).
He was then on continuous follow-up under medicine and ophthalmic department. Pancytopenia was persisted still on the first visit (Day 15 of hospitalization) and worsening. Oral prednisolone (1 mg/kg body weight) was started. Bone marrow depression was completely resolved in 3 weeks and no further signs of reactivation have been detected on 3 months follow-up. The left eye vision became normal and right eye improved to near normal.
| Discussion | | |
Dengue is one of the important emerging viral diseases and remains a major public health issue especially in Southeast Asian Countries[3]. On the basis of clinical criteria, National guidelines (2014) classified dengue as dengue fever (DF), dengue hemorrhagic fever, dengue shock syndrome and expanded dengue syndrome (EDS). EDS is a new entity incorporating a range of atypical presentations affecting various body systems including hepatic, neurological and gastrointestinal, pulmonary, renal and ophthalmic[5]. Dengue was further divided into mild, moderate, and severe dengue as follows[6]. [I] Mild dengue: Fever without any complications or evidence of capillary leakage. [II] Moderate dengue: Fever with recurrent vomiting, abdominal pain/tenderness, generalized weakness/lethargy/restlessness/palpitations/breathlessness, decreased urine output, mild pleural effusion/ascites, hepatomegaly,increased hematocrit>20%, and DHF I and II with minor bleeding (scanty hemoptysis, hematemesis, hematuria, gum bleeding, increased menstrual flow, etc.) [III] Severe dengue: DF/DHF with significant hemorrhage, DHF with shock, severe organ involvement, and severe metabolic disorder.
The various ocular manifestations reported in dengue[7] are: (A) Mostly in posterior segments, such as macular edema, vascular occlusion, vitreous hemorrhage, optic neuropathy, chorioretinitis, vasculitis with retinal hemorrhages, and cotton wool spots. (B) Anterior segment manifestation has been mostly reported in the form of sub-conjunctival hemorrhages and anterior uveitis. (C) Other very rare associations such as ptosis and periorbital ecchymosis and globe rupture are also reported.
However, retinal bleeding due to dengue is an extremely rare entity but potentially serious complication[8]. The clear mechanism of retinal bleeding in dengue hemorrhagic fever is not well known but most of the cases were related to the level of thrombocytopenia[8]. Therefore, the possible cause of hemorrhage could be thrombocytopenia with coagulation defects, capillary fragility, consumptive coagulopathy, and platelet dysfunction[7]. Dengue-related ocular changes are generally resolved completely[7]. In this case, the vision was recovered near fully. Another unusual finding, in this case, was prolonged and severe bone marrow depression which recovered very slowly within 3 months of duration. However, in the acute phase of viral infection, different types of cytopenia can occur by viral-induced inhibition of multiplication of hematopoietic cells[9],[10]. Pancytopenia is reported for a short time in the acute phase of dengue infection but it is a rare complication[10]. Few very uncommon cases reporting pancytopenia due to Hemophagocytic syndrome and aplastic anemia are also reported in dengue fever[9],[11]. We ruled out other possible causes of pancytopenia with the help of history, clinical examination, and investigations. It was considered that peripheral cellular destruction by immune complexes and direct viral injury to born marrow may be the underline cause of persistent pancytopenia in the present case[9]. One utmost important step to emphasize is that immunosuppressive therapy can lead to complete remission[9]. We found a favourable outcome in this case on initiation of steroid.
The results of several studies had shown anti-dengue activity and anti-inflammatory activity of doxycycline which may reduce the severity of dengue such as dengue hemorrhagic fever and dengue shock syndrome. Keeping this point, doxycycline was given in doubt of clinical benefit. Afterward clinical symptoms were improving on therapy[12]. Patients with dengue fever should be evaluated promptly for any unusual association. Because of an unexpected increase in epidemicity of dengue fever in India, atypical manifestations affecting different body systems are expected to report. Based on clinical experience, there is generally complete resolution of dengue-related most of complications.
| Conclusion | | |
This case report highlights the awareness of such an association because of prompt recognition and early institution of appropriate therapy is factored of paramount importance in determining the progression, severity, and reversibility of complications.
Ethical statement
Patient consent: Written informed consent was taken from the patient to publish this case report.
Conflict of interest: None
| Acknowledgements | | |
Authors owe thanks to attendants for their cooperation and faith in us. Thanks to Jaitik and Jenika for their kind support.
| Learning Points | | |
- Retinal hemorrhage and prolonged pancytopenia are the unusual complications in dengue which do not exist before in the same patient.
- Clinical and biochemical profile of dengue is expanding due to the addition of unusual manifestation.
- The clinician must be aware of atypical presentations in the dengue-endemic region. Accurate clinical history and thoroughly examination are needed to detect early complication.
- Dengue-related complications are generally resolved completely. Early diagnosis and prompt management are paramount to halt the progression of complications.
| References | | |
| 1. | Singh J, Dinkar A, Atam V, Misra R, Kumar S. A deadly combination of acute encephalitis and gastric hemorrhage in dengue fever: A rare case. J Med Sci Clin Res 2014; 2:3187–93.  |
| 2. | Singh J, Singh A, Dinkar A, Atam V. A rare presentation of dengue fever: Acute motor quadriparesis due to hypokalemia. Int J Res Med Sci 2014; 2:132–4. |
| 3. | Singh J, Dinkar A, Atam V, Himanshu D, Gupta KK, Usman K, et al. Awareness and outcome of changing trends in clinical profile of dengue fever: a retrospective analysis of dengue epidemic from January to December 2014 at a tertiary care hospital. J Assoc Physicians India 2017; 65:42–46. |
| 4. | Singh J, Dinkar A, Atam V, Misra R, Kumar S, Gupta KK, et al. Intracranial hemorrhage in dengue fever; a case series. J Med Sci Clin Res 2015; 3:4447–52. |
| 5. | Dinkar A, Singh J, Prakash P, Das A, Nath G. Hidden burden of chikungunya in North India; A prospective study in a tertiary care centre. J Infect Public 2018; 11:586–91. |
| 6. | Singh J, Dinkar A, Singh RG, Siddiqui MS, Sinha N, Singh SK. Clinical profile of dengue fever and coinfection with chikungunya. Tzu Chi Med J 2018; 30:158–64. |
| 7. | Sujatha R, NousheenS, NazlinA, Prakash S. Ocular manifestations of dengue fever. Int J Med Sci Public Health 2015; 4:690–693. |
| 8. | Sumardi U, Nelwan EJ. Retinal hemorrhage in dengue hemorrhagic fever. Acta Med Indones 2011;43(1):66–7. |
| 9. | Ramzan M, Yadav SP, Sachdeva A. Post-dengue fever severe aplastic anemia: a rare association. Hematol Oncol Stem Cell Ther 2012;5(2):122–124. |
| 10. | Dinkar A, Singh J. Dengue infection in North India: An experience of a tertiary care center from 2012 to 2017. Tzu Chi Med J 2020;32(1):36–40. |
| 11. | Ray S, Kundu S, Saha M, Chakrabarti P. Hemophagocytic syndrome in classic dengue fever. J Glob Infect Dis 2011; 3(4): 399–401. |
| 12. | Garg P. Role of doxycycline in the management of dengue fever. Indian Journal of Clinical Practice 2018;18(2): 132–35. |
[Figure 1], [Figure 2]
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