Ahmad Mursel Anam

Subsequent pancreatitis and haemothorax in a patient of expanded dengue syndrome

We report a case of expanded dengue syndrome, where two different presentations occurred subsequently. A patient of dengue haemorrhagic fever initially was admitted with acute pancreatitis, complicated with left pancreatic effusion, but later on, during resolution of pancreatitis and effusion, developed spontaneous right haemothorax. Such presentations, besides being rare themselves, have not been reported to occur subsequently, in the same patient, during the same disease process.

Ogilvie's syndrome in severe dengue

In August, 2012, a 66-year-old woman presented to us with generalised weakness, lack of appetite, and gradual abdominal distension. She had had a fever for 3 days, which had subsided 1 day before admission. On examination her Glasgow Coma Scale score was 13/15, pulse rate was 110 beats per min, blood pressure was 100/70 mm Hg, and she was afebrile. She had erythematous skin with the appearance of white islands, and her chest was clear on auscultation. She had a distended abdomen with no palpable organomegaly. Initial laboratory investigations, showed thrombocytopenia (platelet count 42 000 per μL), altered liver enzymes alaninine amino transferase (ALT) 1259 U/L, aspartate aminotransferase (AST) 2150 U/L, normal bilirubin, raised lactate de hydrogenase (3473 U/L), and hyponatraemia (124 mmol/L). Anti-dengue antibodies (IgM and IgG) were positive. Radiograph of the abdomen showed dilatation of her colon (fi gure). Another patient, a 40-yearold woman presented to us at the same time with shortness of breath and abdominal disten sion. She had had a fever for 4 days, which had resolved 4 days before her admission. She was haemodynamically stable, with low oxygen saturation rate (SpO2 85% in room air). She had tachypnoea (respiratory rate 22 beats per min), right pleural eff usion, and distended abdomen with no organomegaly. Laboratory tests showed a platelet count of 110 000 per μL, ALT 82 U/L, AST 141 U/L, and positive IgG but negative IgM anti-dengue antibody. Radiograph of the abdomen showed dilatation of the colon, and a right pleural eff usion. PCR was not done for either patient because it was not readily available in this setting. Severe dengue was diagnosed and managed in both the cases according to WHO criteria with co-existing large bowel pseudo-obstruction. Both patients were managed with fl uid and supportive care. Symptoms subsided within a few days and they were discharged in stable condition. Both patients were followed up 1 month after their discharge (on Sept 15 and 18, 2012, respectively), and were well. Dengue is a mosquito borne (of the genus Aedes), selflimiting, systemic, viral infection, caused by one of four single-stranded RNA viruses (dengue virus type 1–4) of the genus fl avivirus. Most infections are asymptomatic, but a wide variety of clinical manifestations, from mild febrile illness to severe and fatal disease, can occur. Dengue virus infection presents with or without warning signs, and patients recover without major complications or develop severe dengue. Young age, female sex, high body-mass index, virus strain, and genetic variants have been identifi ed as risk factors for severe dengue. Secondary dengue infection, in the form of two sequential infections by diff erent serotypes, is also an epidemiological risk factor for severe dengue. Criteria for severe Lancet 2013; 381: 698

Expanded dengue syndrome: three concomitant uncommon presentations in the same patient.

We report a case of expanded dengue syndrome, where three uncommon presentations occurred concomitantly. A patient with dengue haemorrhagic fever presented initially with acute acalculous cholecystitis along with acute pancreatitis, but later on, during resolution of pancreatitis and cholecystitis, developed pancytopenia, most likely due to haemophagocytic syndrome. Such presentations, besides being rare themselves, have not been reported to occur concomitantly, in the same patient, during the same disease process.

Cutaneous leucocytoclastic vasculitis in visceral leishmaniasis

In June 2014, a 50-year-old Bangladeshi woman presented for evaluation of her six-month history of irregular fever, significant weight loss and recurrent, painful purpuric lesions. The cutaneous eruptions were bilateral, painful, associated with leg oedema and used to disappear spontaneously. She had neither significant symptoms nor any past or family history, and she had not taken any recent medication. Physical examination revealed purpura, confined to her lower limbs (Figure 1), moderate anaemia and hepato-splenomegaly (4 cm and 8 cm from the right and left costal margins, respectively). Laboratory investigations revealed anaemia (Hb 79g/L), normal white cell count (2K/mcL) with normal differentials and normal platelet count (150K/mcL). The total protein was raised (108 g/L) but albumin was low (26 g/ L). The erythrocyte sedimentation rate and C-reactive protein were elevated (135mm/h and 440mg/L, respectively). Immuno-chromatography for VL was positive and the splenic aspirate also showed the presence of Leishman-Donovan (LD) bodies. The histopathological analysis of a skin biopsy taken from a purpuric lesion revealed leucocytoclastic vasculitis, but there was no deposition of immunoglobulin or complement in the immunofluorescence test. Serology for rheumatoid factor (RF) and anti-citrullinated peptide antibodies were positive, but antinuclear antibodies and anti-neutrophil cytoplasmic antibodies were negative. Complement levels were normal and serological markers for hepatitis B and C were also negative. Polyclonal gammopathy was detected in protein electrophoresis. A diagnosis of cutaneous leukocytoclastic vasculitis, associated with VL, was made. Treatment with a single dose of liposomal amphotericin-B was given. The fever subsided and the rash disappeared after five days, leaving hyper-pigmented areas over the legs (Figure 2). On follow-up four months later, there was no LD-body in a repeat splenic aspirate. After eight months of treatment, both the spleen and the liver had reduced to 3 cm and 2 cm from the left and right costal margins, respectively, and there was no reappearance of purpura.

Spontaneous calf haematoma in severe dengue

We report a case of spontaneous calf muscle haematoma, formed during the recovery phase of dengue haemorrhagic fever, which, to the best of our knowledge, has never been encountered before. A 45-year-old man presented with features of severe dengue and got admitted to our intensive care unit. He was treated with intravenous fluid therapy and supportive measures, and gradually improved, initially. However, during the recovery phase, he suddenly developed painful left calf, which was found tender, hot and swollen on physical examination. Colour Doppler ultrasound revealed left calf haematoma. As the patient rapidly developed local compartmental syndrome, surgical evacuation of the haematoma followed by urgent fasciotomy was performed. He recovered without further complication and was discharged home. At follow-up after 2 months, he remained well.

Spontaneous bilateral perirenal and splenic haematoma in childhood onset polyarteritis nodosa

Spontaneous bilateral perirenal haematoma, as well as splenic haematoma, are rare occasions in polyarteritis nodosa (PAN). We report a case of a young man, who suffered from various typical and atypical manifestations of PAN since childhood. The diagnosis was delayed due to symptoms mimicking with other clinical conditions. Finally, the diagnosis was confirmed when presented with perirenal and splenic haematoma and was managed successfully.

Acute arsenic poisoning diagnosed late

Acute arsenicosis, although having a ‘historical’ background, is not common in our times. This report describes a case of acute arsenic poisoning, missed initially due to its gastroenteritis-like presentation, but suspected and confirmed much later, when the patient sought medical help for delayed complications after about 2 months.

Dengue Fever induced Myocarditis

Dengue is an arthropod-borne viral illness, mostly asymptomatic, but may present with a wide variety of clinical manifestations, from mild febrile illness to severe and fatal disease. Cardiac involvement is a significant yet under-reported one because of lack of awareness. We report a case of myocarditis in Dengue Fever with an intention to create awareness among the physicians. Bangladesh Crit Care J September 2016; 4 (2): 125-127