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In daily clinical practice we are all
familiar with the word „ dengue „
making us think of an acute febrile
illness accompanied by hematologic
abnormalities, mainly leukopenia and
thrombocytopenia, that may generate plasma leakage to third space.
Dengue, for apparatus and systems
Luis del Carpio Orantes1
1. Department of Internal Medicine, General Hospital 71, Mexican Institute of Social Security, Veracruz, Veracruz, Mexico
#Corresponding author: Luis del Carpio Orantes, E-mail: [email protected].
RUNNING TITLE
Dengue
KEYWORDS
dengue, leptospirosis, diagnosis
WORD COUNT
1 361
CONFLICT OF
INTERESTS
no conflicts of interest
ABSTRACT
In daily clinical practice we are all familiar with the word „ dengue „ making us think of an acute febrile illness.
In order to obtain an overview of the aforementioned, we look closely at and review the damage caused by
dengue to various organ systems of human body.
I
n daily clinical practice we are all familiar with the
word „ dengue „ making us think of an acute febrile
illness accompanied by hematologic abnormalities,
mainly leukopenia and thrombocytopenia, that may
generate plasma leakage to third space, however ,
some-times we face an atypical or unusual cases ,
that leaves the previous definition useless and, with
no knowledge of them, our attention may be diverted to other diseases. lost time for the diagnosis and
early treatment are the prerequisites for all medical
personnel to be aware that dengue goes beyond
a fever and thrombocytopenia , , affecting major
organs , what, if not prevented , leads to the death of
the patient and no clarification of the cases, most
of which often fulfill the criterion of severe dengue ,
according to the new WHO definition.
In order to obtain an overview of the aforementio-
MEDtube Science Sep, 2015; Vol.III (3)
ned, we look closely at and review the damage caused by dengue to various organ systems of human
body, summarized in Table 1.
Nervous System. In dengue, the involvement of the
nervous system is always constant , starting with a
holocranial and persistent headache, , relieved by
simple analgesics. Fever in children and sometimes
adults may cause seizures, cases of which are
reported, as rare or unusual cases include encephalopathy (which may be multifactorial and mental
disorders accompanied by acute electrolyte disturbances, etc.), or encephalitis, meningoen-cephalitis;
parenchymal and subarachnoid hemorrhage, related
to thrombocytopenia have also been reported. The
pathophysiology of these disorders lies in the fact
that the virus is neurotropic in nature , by capillary
bleeding , concomitant metabolic disorders and coag
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-ulopathy type CID ( hepatic, renal , etc.) . The rarest
neurological manifestations are: Guil-lain Barre Syndrome, myelitis (acute disseminated encephalomyelitis), mononeuropathy and polyneuropathy syndrome.
There is an isolated case of phrenic neuropathy with
dia-phragmatic paralysis that resolved to cure dengue [4,6,28,29].
Ocular apparatus. It would appear that eyes have
no interaction with viral infections, how-ever in
dengue, the entities and features unique to this virus
have been identified, thus af-fecting primarily the
macula, with the so-called dengue maculopathy,
multiple case reports and series cases. Rare cases
include optic neuropathy, and vitreous retinal hemorrhages, retinal cotonosos infiltrates, foveolitis ,
among others [12,19,22,24,30].
Breathing apparatus. The most common and not
directly related to lung disease, pleural effusion is
the demonstration that rarely becomes massive and
warrant thoracentesis . However, there are atypical,
bleeding and severe cases present with pulmonary
hemor-rhage, manifested by hemoptysis to acute
respiratory failure, which may cause patient’s death
unless prompt measures are taken . In exceptional
cases of concomitant pneumonia where theetiological relationship has not been established, primary
dengue viral or second-ary bacterial, leveraging
inflammation of the lung parenchyma caused by viruses (phenom-enon observed in influenza). Isolated
case of diaphragmatic paralysis in relation to phrenic
neuropathy [27,28,31].
Circulatory system. The circulatory system is the
first to be affected as vascular endotheli-um is
directly targeted by the virus , , resulting in thrombocytopenia, plasma leakage and circulatory collapse
(shock dengue). Similarly, another of the circulatory
system key ele-ments , the heart, is affected mainly
as myocarditis, which may manifest itself as anginal
syndrome or rhythm disturbances or cardiac conduction. The untrained eye may interpret the symptoms
as coronary artery disease or heart disease aggravated by dengue , being a reflection of the same viruses
in primary form . There are case reports, which show
rise in the enzyme levels and ST -T abnormalities,
bradyarrhythmias tachycardia, atrioventricular block
in varying degrees, mainly segment as well. Symptoms of myocarditis resemble viral myocarditis and
toxic, causing myocardial necrosis, which explains
enzymatic and electro-cardiographic abnormalities.
Report indicates ephemeral pericardial effusions,
that may exist in the context of plasma leakage or a
viral serositis at that level [2,17,23,28].
Digestive system. One of the most affected systems
after the reticuloendothelial one, some of its organs
are of particular importantce (liver and spleen) and
hence the close relationship. Always, in all cases
of dengue , severe and not severe ones, the liver
enzymes rise may be observed (primarily ALT, AST,
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GGT, LDH) mentioning that the enzyme level is
higher than 300 IU TGP are prognostic factors for
renal failure , bleeding, and death. On the other hand
it has been shown that there exists a discriminating
factor between severe and non- severe dengue and
hypoalbuminemia as well , not as a manifestation of
the ex-pense of liver synthetic function , but capillary
plasma leakage and rarely with coagulopathy (which
regards whether this alteration in the synthesis function ) , developed serious cases of dengue hepatitis,
fulminant hepatic failure or consumptive coagulopathy mainly IDC , which in most cases are mortal.
A common manifestation is ascites and acalculous
chole-cystitis, that are part of DHF (dengue with
warning signs, according to the new WHO classi-fication) and that deserve close scrutiny because they
may be the symptoms of develop-ment to a severe
or serious condition. In a rare form of mumps, cases
of dengue, diarrhea, dengue pancreatitis have been
reported and more frequently spontaneous splenic
rupture withformation of intra and perisplenitis hematomas. Jaundice, although rare, may also occur in
cases of dengue and is not dominant over direct or
indirect hyperbilirubinemia. In a cohort study in Veracruz in 2011, 8,559 cases of dengue were studied, of
which 67 % had gastrointestinal manifestations, the
most common: nausea, abdominal pain, vomiting,
he-patomegaly, ascites and gastrointestinal bleeding
what leads to the conclusion that gastro-intestinal
manifestations are mainly accompanied with fever
[3,7,11,13,15,21].
Renal system. The most common renal manifestation is proteinuria, which may be of vary-ing degrees, from microalbuminuria to nephrotic syndrome.
secondarily, relative to the degree of shock, acute
renal failure may occur. Usually acute renal failure
is transient and do not stay long. There have been
reports of secondary glomerulonephritis and hemolytic uremic syndrome that is quite uncommon. It is
mentioned that greater proteinuria 0.55g/day may
lead to the development of a severe hemorrhagic
dengue [8,11,14,25].
Locomotor apparatus. The muscular system, which
is an important part of the musculoskel-etal system, is primarily affected and symptomatic, since
the patient always has the typical “fever bearded”,
i.e. from mild to severe muscle aches, which fortunately is usually con-trolled with simple analgesics.
However atypical or uncommon manifestations may
include myositis, rhabdomyolysis (fortunately rare
but in severe forms may contribute to acute renal
failure by myoglobinuria) and acute myopathies,
severe neuropathies and Guillain Barré syndrome
[1,9,10,11,16,18,23].
Hematologic system. Of the major biochemical
manifestations of dengue, , hematologic abnormalities are mainly 3 cell lines, it is necessary to monitor
hematocrit, hemoglobin, leukocytes and platelets,
with typical findings of dengue - elevated hematoMEDtube Science Sep, 2015; Vol.III (3)
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crit, which con-firms hemoconcentration, capillary
leakage and dehydration, with the subsequent risk
of shock, leukopenia and lymphopenia characteristic
of viruses, and thrombocytopenia, which is used as
a criterion for admission or hospital discharge. In
more analytical way, altera-tions in the endothelium
have been demonstrated, with increased activation
of endothelial cells; high levels of circulating von
Willebrand factor and low levels of ADAMTS- 13
(a met-alloprotease and disintegrin regulating partly thrombogenesis) the latter are those that favor
severe thrombocytopenia and complications surrounding dengue, mainly thrombotic thrombocytopenic
purpura and hemolytic uremic syndrome. Another
complication mostly seen in children, is the secondary hemophagocytic syndrome, a range in which there
is pan-cytopenia with histiocytic infiltrate in bone
marrow, which corresponds to class II histiocyto-sis
, and clinical courses, in addition to prolonged fever (
which is characteristic ) with ab-dominal pain mainly
in school . Isolated cases of purpura fulminans with
multiple organ involvement and death. Secondary
coagulopathy [5,26,28,32].
Apparatus or
system
Typical and atypical manifestations
Ocular apparatus
•
•
•
•
•
•
Conjunctivitis
Vitreous Hemorrhage
Retinal hemorrhages
retinal Departed
Foveolitis
Maculopathy
Breathing
apparatus
•
•
•
•
•
•
Pleural effusion
Hemoptysis
Acute respiratory failure
Pneumonia
Pulmonary hemorrhage
Diaphragm Paralysis
•
•
•
Acute circulatory collapse - shock
Myocarditis (conduction and rhythm disturbances, ST-T)
Pericarditis, pericardial effusion.
Digestive system
•
•
•
•
•
•
•
•
•
•
•
Nausea and vomiting
Ascites
Hepatomegaly-hepatalgia
Gastrointestinal bleeding
Hepatitis for dengue
Acalculous cholecystitis
Mucositis
fulminant hepatic failure
Pancreatitis dengue
Mumps
splenic rupture
Renal system
•
•
•
•
•
Proteinuria - nephrotic syndrome
Glomerulonephritis
Acute renal failure
hemolytic uremic syndrome
Electrolyte Disorders
Locomotor
apparatus
•
•
•
•
Muscle aches
Myositis
Rhabdomyolysis
Acute myopathy
•
hemoconcentration (hematocrit> 20%,
ratio Ht / Hb> / = 3.5)
Leukopenia, lymphopenia
Thrombocytopenia
thrombotic thrombocytopenic purpura
hemolytic uremic syndrome
Purpura fulminans
Circulatory
system
Dermal system. The skin is not beyond dengue influence on the body . Common skin mani-festation is a
skin rash characterized by tiny hypochromic macular
lesions on an erythema-tous circular niche, known
colloquially as “white islands in a sea of red.” Followed by pruri-tus, petechiae and ecchymosis . Rarely
conjunctivitis and mucositis [20,28].
In summary, it is important to note that dengue is
not always typical, especially in terms of bleeding
or severity, and may be complicated when there is
multiorgan involvement, which leads to severe dengue cases with high mortality, that fortunately is still
rare in our envi-ronment , but in Asia and the Middle
East, is very common.
Hematology
system
CITE THIS AS
MEDtube Science 2015, Sep 3(3), 21-24
•
•
•
•
•
TAB. 1. TYPICAL (UNDERLINED ITALICS) AND ATYPICAL MANIFESTATIONS OF DENGUE
•
Dermal system
•
Apparatus or
system
Dermatitis and rash with „white islands in
a sea of red”
Itching
Typical and atypical manifestations
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Nervous System
•
•
•
•
•
•
•
•
•
•
Headache
Seizures
Mononeuropathies
Polyneuropathies
Encephalopathy, acute psychosis or dementia
encephalitis-meningitis
parenchymal hemorrhages
Subarachnoid hemorrhage
Guillain Barré Syndrome
acute encephalomyelitis
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2.
3.
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