A healthy 23-year old woman has been travelling through Thailand for 4 weeks, also trekking in rainforest areas and she has been bitten by mosquitoes often. Two days after returning to Germany the patient presented in the emergency room of the University Hospital of Duesseldorf because of fever (39,2 °C) since 2 days, headache, myalgia and watery, not bloody diarrhoea. The clinical examination showed a maculopapular exanthema at extensor sites of arms and chest. The blood pressure was 111/66 mmHg, heart frequency 71/min, peripheral oxygen saturation 98% and respiratory rate 18/min, body temperature 39,2°Celcius. The chest-X-ray did not show any pathological result. Laboratory parameters showed leukopenia of 2.600/μl (4.0–11.0/μl), elevated c-reactive protein of 8,2 mg/dl (< 0,5 mg/dl) and Aspartat-Aminotransferase of 47 U/l (< 31.0 U/l), the international normalised ratio (INR) was lightly increased to 1.2 (0.9–1.1).
A Dengue rapid test (SD BIOLINE Dengue Duo) was negative for IgG and IgM, but positive for NS1-Antigen, tests of Malaria and other bacteria were negative. No further virologic tests were performed because the rapid test for dengue was already positive and the history and clinical presentation were consistent.
The following days the patient presented with low blood pressure under 100 mmHg systolic and under 50 mmHg diastolic with increasing haematocrit despite of daily administration of up to 4 l of crystalloids intravenously. Thus, according to the new WHO definition, the criteria for a Dengue Shock Syndrome (DSS) were fulfilled. The heart rate was still normal and only in the evening did the temperature rise slightly to a maximum of 38 °C. Two days later, the watery diarrhea stopped, but the nausea remained.
After 3 days of hospitalization the leukopenia decreased to 1.900/μl (4.0–11.0/μl) and for the first time a thrombocytopenia was detectable with a nadir of 29.000/μl (150-400 × 1000/μl) on day 6 after beginning of the symptoms, clinically no bleeding manifestations were present. At this time the patient complained of severe upper abdominal pain. Blood tests revealed elevated liver enzymes, Aspartat-Aminotransferase 106 U/l (< 31.0 U/l), Alanin-Aminotransferase 47 U/l (< 35.0 U/l) and gamma-GT 87 U/l (< 38.0 U/l) while the C-reactive Protein declined to an almost normal value and there was no abnormal bilirubin. Fever did not recur. Also, the lactate dehydrogenase increased significantly to 459 U/l (< 247 U/l) and we detected a rising haematocrit up to 45.4% (37.0–45.0%). The abdominal sonography showed a thickened gallbladder wall up to 21 mm with a reticular pattern, also free fluid in the gallbladder base and a punctual pressure pain. The spleen was only marginally increased with 12,4 cm, the liver was normal sized. There was a small pleural effusion on either sides but no ascites or further pathological findings in sonography - especially no cholestasis, no gallstones, and no hepatomegaly.
Because of classical morphological signs in sonography (Fig. 1) and the clinical presentation of an acute cholecystitis we were discussing the further treatment also with the surgical department, especially whether a surgical therapy is indicated. Because the patient was clinically stable with a decrease in C-reactive protein and no elevated bilirubin or cholestasis, we initiated antibiotic therapy only with ceftriaxone 2 g intravenously daily. We decided against surgical therapy, assuming that the ultrasound image of acute cholecystitis should be interpreted as GBWT due to dengue virus infection. Daily sonographies showed a rapid regression of the GBWT, the free fluid in the gallbladder base and the abdominal pain was not detectable anymore after 4 days (Fig. 2).
Seven days after hospitalization the general condition of the patient improved, there was no increased temperature in the last 4 days. Leucocytes and thrombocytes counts increased slowly and liver enzymes continued to decrease. Therefore we stopped the intravenous fluid substitution and the antibiotics, 2 days later the patient could be discharged from hospital.
Blood examinations 8 days after discharge and 20 days after beginning of the symptoms showed a positive serology for Dengue: Dengue-IgG was higher than 200.00 RU/ml (< 22 RU/ml) and the Index to Dengue-IgM was 2,12 (Index >/= 1.1), confirming Dengue-Infection. Leucocytes, thrombocytes, liver enzymes and the lactate dehydrogenase were in a normal range. Clinically, the patient was in good general condition, and the exanthema had completely disappeared.
