Dengue Shock Syndrome Presenting as Acute Cholecystitis - Springer

Digestive Diseases and Sciences, Vol. 50, No. 5 (May 2005), pp. 874–875 ( C○ 2005)
DOI: 10.1007/s10620-005-2656-z
CASE REPORT
Dengue Shock Syndrome Presenting
as Acute Cholecystitis
Y.-M. TAN, MD, FRCS, C.-C. ONG, and A. Y. F. CHUNG, MD, FRCS
KEY WORDS: dengue shock syndrome; dengue fever; cholecystitis.
Dengue fever (DEF), estimated to affect 100 million people
annually worldwide, may present as a mild febrile
illness or as hemorrhagic fever with shock (1). However,
unusual clinical presentations that mimic other common
emergencies can occasionally occur (2). A high clinical
suspicion is required to make an early diagnosis and initiate
prompt treatment. If unrecognized, delay in treatment
can lead to disastrous outcomes. Here we describe an unusual
clinical presentation of DF mimicking a common
surgical and gastroenterology emergency.
CASE REPORT
A 45-year-old lady presented with a 5-day febrile illness associated
with epigastric discomfort radiating to the right hypochondrium.
Her pain was dull and intermittent but escalating in intensity.
This was associated with generalized myalgia and weakness.
She had no significant medical or travel history. At presentation
in the emergency room, she was tachycardiac, with a pulse rate
of 100/min and a blood pressure of 68/45. Clinically, she was
flushed and dehydrated. Exquisite tenderness with guarding was
elicited in the right hypochondrium, corresponding to a positive
Murphy’s sign. The rest of the abdomen was mildly distended but
soft. There was no discernible skin rash and the rest of the systemic
examination was normal. The clinical diagnosis of acute
cholecystitis with septic shock was made.
The patient was resuscitated with intravenous crystalloid and
started on intravenous ceftrioxone therapy. A bedside ultrasound
confirmed the presence of a thickened gallbladder wall of
1cmand a positive ultrasound Murphy’s sign but no gallstones
(Figure 1). No ascites was evident. A complete blood count revealed
a normal hemoglobin, a hematocrit of 48% (reference,
36–46%), and thrombocytopenia (platelet count, 26 × 10 9 /L;
reference, 150–400). Liver function test revealed hypoproteinemia
(total serum protein, 56 g/L; reference, 62–82), hypoalbuminemia
(serum albumin, 30 g/L; reference, 37–51), and mildly
Manuscript received August 11, 2004; accepted September 27, 2004.
From the Department of Surgery, Singapore General Hospital,
Singapore.
Address for reprint requests: Dr. Yu-Meng Tan, Department of
Surgery, Singapore General Hospital, Outram Road, Singapore 169608;
gsutym@sgh.com.sg.
elevated serum alanine transaminase, aspartate transaminase,
and alkaline phosphatase. Coagulation profile was deranged,
with an activated partial prothrombin time (APTT) of 53.5 sec
(reference, 28–37) but a normal prothrombin time. Renal function,
serum lipase, and arterial blood gases were normal. The
blood pressure normalized with 1.5 L of crystalloid and the
hematocrit decreased to 37%.
The patient’s symptoms and clinical and radiological findings
were typical of acute cholecystitis. However, the blood profile
was unusual. In addition to the blood cultures, this prompted us to
perform serology for dengue (ELISA for IgM). All blood cultures
were negative but dengue virus IgM was positive. The patient
continued to have fever and a falling platelet count of 10 × 10 9 /L
requiring high-dependency monitoring. Although cholecystectomy
was initially considered, her symptoms began to subside
on day 3 after admission, with recovery of the platelet count. She
was discharged uneventfully on day 6. There was no recurrence
of symptoms at 4-month follow-up.
DISCUSSION
DF is an acute mosquito-transmitted disease caused
by dengue virus and characterized by headache, myalgia,
rash, and hemorrhagic manifestations. When associated
with thrombocytopenia, evidence of plasma leakage,
hemorrhagic manifestations, and hypotension, it is termed
dengue shock syndrome (DSS). This is associated with a
mortality of over 40% without early appropriate treatment
(3). Diagnosis often requires a high index of suspicion, especially
in areas where dengue is endemic or in patients
who have visited such areas in their recent travels.
Abdominal manifestations of DF include acute pancreatitis
and fulminant hepatitis (4). In our patient, initial presentation
was classic for acute cholecystitis rather than DF.
Thickening of the gallbladder wall, pericholecystic fluid,
and a positive ultrasound Murphy’s test confirmed our
diagnosis. Suspicion of DSS was heightened for two reasons.
The first clue was the thrombocytopenia and shock
at presentation. This is unusual even for patients who have
acute cholecystitis. The second clue was that dengue viral
infections are endemic to our region.
874 Digestive Diseases and Sciences, Vol. 50, No. 5 (May 2005)
0163-2116/05/0500-0874/0 C○ 2005 Springer Science+Business Media, Inc.

DENGUE SHOCK SYNDROME PRESENTING AS ACUTE CHOLECYSTITIS
Fig 1. Ultrasound showing thickening of the gallbladder wall but no gallstones, suggestive of
acalculous cholecystitis.
Ultrasound examination failed to reveal any calculi and
our patient was diagnosed with the acalculous variant of
cholecystitis. The etiology of acalculous cholecystitis in
DF is not clear. In DSS, the underlying pathophysiological
mechanism results from endothelial damage and increased
vascular permeability. Local inflammation of the
gallbladder can be attributed to “plasma leakage” leading
to wall thickening and hypotension leading to ischemia of
the gallbladder. Direct viral involvement of the gallbladder
may also contribute to this unusual presentation. A search
of the English literature showed only one previous report
of cholecystitis and DF (5). In that report, the patient was
not as acutely ill and/or in shock. With conservative treatment,
the patient recovered uneventfully. Our patient similarly
had acalculous cholecystitis but presented in shock
with DSS. Definitive treatment for patients with acalculous
cholecystitis from other causes is cholecystectomy
(6). This is because of the high incidence of complications
like gangrene, perforation, and abscess formation. However,
we chose to manage our patient conservatively, due
to the severe thrombocytopenia, and to monitor closely for
any complications. Cholecystectomy in this patient would
have been fraught with danger due to bleeding intraoperatively
or postoperatively. Moreover, her symptoms began
to settle by the third day. This conservative approach was
justified, as acalculous cholecystitis in the background of
DF appears to be a self-limiting event.
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