Vol 44 # 2 June 2012 - Kma.org.kw

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Dengue Fever among Travelers
June 2012
Fig. 1: Maculopapular rash involving the abdomen
Fig. 2: Peticheal rash over the right lower limb
test was performed to detect viral causes showed
positive results for Dengue virus immunoglobulin M
(IgM) and for Dengue virus immunoglobulin G (IgG).
Otherwise, his serum was negative for Hepatitis A
virus immunoglobulin M (HAV AB IgM), Hepatitis B
virus surface Antigen (HBsAg), and Hepatitis C virus
antibodies. The tests were carried out in the virology
laboratory in Mubarak Al-Kabeer hospital. Dengue
IgM and IgG Capture Elisa were used to isolate
the immunoglobulin through panbio-diagnostics.
The patient was treated conservatively with good
hydration using intravenous fluids, and he was
transfused with blood and fresh frozen plasma.
DISCUSSION
The clinical suspicion of Dengue fever, as in our
case, depends on a triad of symptoms and signs,
namely, the hemorrhagic manifestation evident as
petechial rash, in addition to low platelet count and
plasma leakage, as in pleural or ascitic fluid [3] . Our
patient had a low platelet count and ascitic fluid,
with the history of recent travel. This increased our
suspicion of Dengue virus infection. Other tropical
Fig. 3: Ecchymosis of the right forearm
diseases should be suspected, such as malaria,
typhoid fever, leptospirosis, and other illnesses that
can manifest in the acute phase as undifferentiated
febrile syndrome. The most serious forms of infection
are Dengue shock syndrome, which is characterized
by weak pulse and profound hypotension and
dengue hemorrhagic fever. The mortality rate can
go up to 40 percent [3] . However, this is rare among
travelers [1,4] .
The pathogenesis of hemorrhagic fever is capillary
leakage, associated with hemorrhagic manifestations.
The plasma leak develops within the first four to
seven days after the onset of the disease and manifests
as pleural effusion, ascites and hypoproteinemia.
Laboratory tests were helpful in the diagnosis.
Specific tests such as polymerase chain reaction
(PCR), cultures and serological assay would confirm
the diagnosis [3,4] . Other laboratory findings that
supported our diagnosis were the low platelet counts,
leukopenia and the increased liver aminotransferase
levels. An increased hemotocrit of 20 percent may
suggest plasma loss [1,3] .
The treatment is based on supportive measures
and prompt restoration of circulating plasma volume
is the cornerstone of therapy of dengue fever and its
complications [5,6] . Other supportive measures such
as bed rest and antipyretics can be used. If there is
evidence of bleeding or disseminated intravascular
coagulation, blood and fresh frozen plasma should be
administered [1,3,5] .
The fluid restoration should be tapered down
when the hematocrit decreases by 40 percent in
order to avoid complications of fluid overload. The
risk of acquiring dengue fever is high in immunecompromised
patients.
For prevention of dengue fever, travelers should
avoid mosquito bites in endemic areas. A vaccine
that provides immunity against all four serotypes
of dengue is needed and this is still under clinical
trial [3,7] .