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Hemoperitoneum in Dengue Fever with Normal Coagulation Profile

Nagesh Kumar Talakad Chandrashekar, Rashmi Krishnappa1, Chandra Sekara Reddy,
Arun Narayan
Departments of Internal Medicine and 1Pathology, MS Ramaiah Medical College and Teaching Hospital, Bengaluru,
Karnataka, India

A 43-year-old male living in Bengaluru sought emergency services due to high-grade fever, headache, myalgia, abdominal pain
and distension. Platelet count (except the first-96,000/mm3) and coagulation profile was in normal limits. The dengue serology
was positive for IgM and Ig G (immunoglobulin M and G) antibodies. Ultrasound abdomen showed gross ascites, mild bilateral
pleural effusion and hepatosplenomegaly. The patient continued to have abdominal pain and progressive distention Ascitic tap was
hemorrhagic. Later laparoscopy showed 1.5 liters peritoneal fluid with blood clots and mild diffuse congestion of the peritoneum.
Liver, spleen and blood vessels were normal. Then what would be the possible mechanism to explain hemoperitoneum, is it the
increased vascular permeability caused by the virus? India being endemic for dengue illness, it is an interesting and rare case

Key words: Coagulation profile, Dengue, Hemoperitoneum, Laparoscopy, Ultrasound

INTRODUCTION secondary to spontaneous rupture of the spleen.[4-6] We

report an interesting case of serologically confirmed

T wo-thirds of the world’s population lives in areas

infested with dengue vectors, mainly Aedes aegypti.[1]
The dengue virus was first isolated in India in Kolkata
dengue-positive patient with hemoperitoneum.

in 1945. Dengue illness is caused by four distinct dengue
virus types, 1, 2, 3 and 4 belonging to the genus flavivirus of A male aged 43 years, residing in Bengaluru sought
family togaviridae and all four types are prevalent in India.[1] emergency services in July 2010. He presented with
high-grade fever since four days and headache, myalgia,
Dengue illness is clinically characterized by sudden abdominal pain with distension since two days. He was
onset of fever, intense headache, retro-orbital pain, a known diabetic (blood sugars were under control
myalgia, maculopapular rash, generalized erythema, and throughout the course, was on oral hypoglycemic
minor bleeding manifestation like petechial rashes, gum agents) and was a social drinker (occasional alcohol
bleeding, subconjunctival hemorrhage; severe hemorrhagic consumption). Patient did not have any history of trauma.
manifestations like epistaxis, hematemesis, hematuria On examination he was febrile, anicteric, without any rash
and hemoperitoneum are also observed.[2] Hemorrhagic or lymphadenopathy. The complete blood count (CBC)
manifestations are observed at every stage of the illness showed total leukocyte count–6100 cells/mm3, differential
and are probably the summation of the ill-understood count–neutrophils-50%, lymphocytes–45%, platelet
viral pathogenesis as well as host factors that result in the count–96,000 cells/mm3 and packed cell volume–30%.
incompetence of the vascular endothelium.[3] There are The dengue serology was positive for both IgM and
few case reports of dengue illness with hemoperitoneum IgG antibodies (immunochromatography) serological
test and peripheral smear for malaria was negative.
Access this article online The titers (ELISA) of dengue immunoglobulins was
Quick Response Code:
IgM : IgG = 4:1 and 14 days later IgM : Ig G = 5:2. With rising titers new dengue illness was diagnosed. The blood

DOI: Address for correspondence:

10.4103/0974-777X.107172 Dr. Nagesh Kumar Talakad Chandrashekar,

Journal of Global Infectious Diseases / Jan-Mar 2013 / Vol-5 / Issue-1 29

Chandrashekar et al.: Profile of H1N1 infected patients in ICU and their outcome in tertiary care center

culture was sterile and ultrasound abdomen reported can be life-threatening if not recognized early. Previous
gross ascites, bilateral minimal pleural efflusion and case reports on hemoperitoneum in dengue illness have
borderline hepatosplenomegaly. We supposed the ascites been commonly associated with spontaneous rupture
is transudative and a part of the viral illness and as self- of the spleen.[4-6] However, our case had an unusual
limiting. But the abdominal distension and pain continued presentation of hemoperitoneum with normal abdominal
to bother the patient so peritoneal tap was planned. viscera and coagulation. The patient came with high-grade
Simultaneously, patient developed progressive pallor with fever, later found to be positive for dengue on serology.
drop in hemoglobin (from 9.6 gm/dl to 6.9 gm/dl) and The hemoperitoneum was suspected after hemorrhagic
hematocrit (from 30 to 23%), for which patient underwent parecentesis and associated decrease in hematocrit.
blood transfusion (twice-packed red blood cells). During However, the coagulation profile was normal and platelet
the initial two attempts of peritoneal tap, 500 ml of count remained normal. The ultrasound abdomen showed
hemorrhagic ascitic fluid was drained. Even after drainage fluid collection with normal spleen, liver, and major vessels.
the abdominal pain and distention persisted with drop in Although up to 100 million cases of dengue fever are
hemoglobin, so laparoscopy was planned. Laparoscopic registered per year only a few reports of hemoperitoneum
exploration showed 1.5 liters of peritoneal fluid with blood are seen in the literature.[5]
clots in the peritoneal cavity and mild diffuse congestion
of the peritoneum. Liver, spleen, bladder and blood vessels CONCLUSION
were normal. His coagulation profile was within normal
limits throughout the course (Prothrombin time (PT)-15.9 The dengue illness is endemic in India and Southeast Asia, so
sec, Activated Patial thromboplastin time(APTT)-29 sec, are hemorrhagic complications due to thrombocytopenia.
International Normalized Ratio(INR)-1.48). Patient In our case there was spontaneous peritoneal bleeding
underwent blood transfusion (two packed red blood with significant drop in hemoglobin without dengue
cells) again. The histopathological examination of the hemorrhagic fever or dengue shock syndrome. By
peritoneum showed mild hyperemia. Peritoneal drain was ultrasound abdomen it is difficult to differentiate between
there for two days, abdominal discomfort and distention hemoperitoneum and transudative ascites. So regular
reduced over a week and hemoglobin improved and monitoring of vital signs, regular hemoglobin estimation,
repeat ultrasound showed that the peritoneum was free apart from platelet count monitoring are important in
of collection. Patient was discharged on oral hypoglycemic dengue illness, for early detection of internal bleeding and
agents. The patient was asked to follow up with repeat associated complications. As per our knowledge this is the
hemoglobin, fasting and post-prandial blood sugar. During only case report of dengue fever with hemoperitoneum
follow-up he is doing fine. with normal spleen, liver, blood vessels and normal
coagulation profiles.
The clinical spectrum of dengue illness can range from
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(DSS). There are various theories of the pathogenesis 2. Rao CV. Dengue fever in India. Indian J Pediatr 1987;54:11-4.
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fever. VI. Hypotheses and discussion. Yale J Biol Med 1970;42:350-62.
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combination of (a) increased prothrombin time, (b) the spleen due to dengue fever. Braz J Infect Dis 2003;7:423-5.
hemoconcentration, (c) platelet count of less than 6. Sharma SK, Kadhiravan T. Spontaneous Splenic Rupture in Dengue
50,000 cells/ mm3 and (d) elevated alanine transaminase Hemorrhagic Fever. Am J Trop Med Hyq 2008;78:7.
(ALT) is known to be predictive for spontaneous 7. Shivabalan SO, Anadnathan K, Balasubramanian S, Datta M, Amalraj E.
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documented various bleeding manifestations in dengue
How to cite this article: Chandrashekar NT, Krishnappa R, Reddy CS,
illness, most common being gum bleeding, bleeding into Narayan A. Hemoperitoneum in dengue fever with normal coagulation
internal organs, hemorrhagia and bleeding into serous profile. J Global Infect Dis 2013;5:29-30.

cavities. Hemoperitoneum in dengue fever though rare Source of Support: Nil. Conflict of Interest: None declared.

30 Journal of Global Infectious Diseases / Jan-Mar 2013 / Vol-5 / Issue-1

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