See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/324389711

Expanded Dengue Syndrome: Gastrointestinal Manifestations.

Article · March 2018

CITATIONS READS

0 304

9 authors, including:

Ahmad Mursel Anam Farzana Shumy

Western General Hospital Bangabandhu Sheikh Mujib Medical University
45 PUBLICATIONS   34 CITATIONS    29 PUBLICATIONS   19 CITATIONS   

SEE PROFILE SEE PROFILE

Raihan Rabbani Mohammad MUFIZUL ISLAM Polash

SQUARE Hospital, Dhaka, Bangladesh Square Hospitals Limited, Dhaka, Bangladesh
34 PUBLICATIONS   27 CITATIONS    17 PUBLICATIONS   19 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Critical care View project

Clinical profile, outcome and predictors of outcome in Bangladeshi patients with Expanded Dengue Syndrome View project

All content following this page was uploaded by Ahmad Mursel Anam on 10 April 2018.

The user has requested enhancement of the downloaded file.

Bangladesh Crit Care J March 2018; 6 (1): 34-39

Review Article

Expanded Dengue Syndrome: Gastrointestinal Manifestations

Ahmad Mursel Anam1, Farzana Shumy2, Raihan Rabbani3, M Mufizul Islam Polash4, Shihan Mahmud
Redwanul Huq5, Adnan Shareef6, Shahzadi Sayeeda Tun Nessa7, Mst. Arifa Sultana8, Mirza Nazim Uddin9
Abstract
Dengue, the most common and fastest emerging arboviral infection, has become a major public health concern
throughout the world. This mosquito-borne infection has got a wide variety of clinical presentation, ranging from mild
febrile illness to severe and fatal disease. However, reports of atypical or unusual features, involving multiple organ
systems, are on the rise. ‘Expanded dengue syndrome (EDS)' is a new category in the World Health Organization
(WHO) classification of dengue infection and includes atypical presentations of dengue. EDS, in the form of organ
dysfunction, may require management support from various disciplines for aggressive and effective measures.
Recognition of features of EDS is very important for targeting treatment option. Sometimes unnecessary surgery even
takes place under confusion as EDS may present in form of acute abdomen. Features of Dengue Haemorrhagic Fever
or Dengue Shock Syndrome are well-known to clinicians. Physicians, intensivists and surgeons should also be aware of
EDS, especially the gastrointestinal (GI) features and have a high degree of suspicion for early recognition and
appropriate management. This review intends to throw light on the various under-recognized unusual GI manifestations
of dengue/EDS for the benefit of the practicing physicians, intensivists and surgeons.
Key word: Expanded Dengue Syndrome, Atypical manifestation of dengue, Intensive Care Unit, Critically ill,
Bangladesh.

Introduction: distribution of vectors,4,5 and its incidence has jumped-up

Dengue is a self limiting, systemic arboviral infection. This
mosquito-borne (by Aedes aegypi and A. albopictus) disease
is caused by one of four single-stranded RNA viruses (dengue
virus type 1–4) of the genus flavivirus.1-3 Dengue is endemic
in more than a hundred countries, especially throughout the
tropics.2,4 Its transmission is greatly influenced by local
weather, rainfall, mean temperature, urbanization and
1. Dr. Ahmad Mursel Anam, MRCP(UK), Specialist, ICU, Square
Hospitals Ltd. Dhaka, Bangladesh
2. Dr. Farzana Shumy, FCPS(Medicine), MRCP(UK), Medical
Officer, Department of Internal Medicine, Bangabandhu Sheikh
Mujib Medical University, Dhaka, Bangladesh
3. Dr. Raihan Rabbani, FCPS(Medicine), Certified-American Board
of Internal Medicine, Consultant, Internal Medicine & Critical Care,
Square Hospitals Ltd. Dhaka, Bangladesh
4. Dr. M Mufizul Islam Polash, MBBS, Clinical Staff, ICU, Square
Hospitals Ltd. Dhaka, Baangladesh
5. Dr. Shihan Mahmud Redwanul Huq, MRCP(UK), Specialist, ICU,
Square Hospitals Ltd. Dhaka, Bangladesh
6. Dr. Adnan Shareef, MBBS, Clinical Staff, HDU, Square Hospitals
Ltd. Dhaka, Baangladesh
7. Dr. Shahzadi Sayeeda Tun Nessa, MBBS, Clinical Staff, ICU,
Square Hospitals Ltd. Dhaka, Baangladesh
8. Dr. Mst. Arifa Sultana, MBBS, Clinical Staff, ICU, Square
Hospitals Ltd. Dhaka, Baangladesh
9. Dr. Mirza Nazim Uddin, MRCP, Consultant, Internal Medicine &
Critical Care, Square Hospitals Ltd. Dhaka, Bangladesh
Corresponding Author :
Dr. Ahmad Mursel Anam, MRCP (UK)
Specialist, ICU, Square Hospitals Ltd. Dhaka, Bangladesh
Email: murselanam@gmail.com
about 30-folds in the last five decades.2 The number of actual
cases of dengue infection are under reported6, but, it is
estimated that around 390 million dengue infections occur
every year, of which around 96 million manifest clinically,2,6,7
and about 3.9 billion people in 128 countries are at risk of
infection.8 According to the World Health Organization
(WHO), approximately 500,000 cases per year develop severe
disease, and about 2.5% die.6,9 Most infections are
asymptomatic. However, after an average incubation period of
4–6 days (range 3–14 days), widely variable clinical
manifestations, from flu-like illness to death at its most severe
form, may occur. Most patients present with fever,
non-specific constitutional symptoms and features of plasma
leakage.1-3 The infection can be easily detected and confirmed
by different investigations from serum (Table 1)1,10. Dengue
infection, besides becoming widespread globally, is also
unfolding itself with unusual features and increased severity,
and thus emerging as a major threat to global health.1,11-14
According to presence of plasma leakage, dengue infection is
classified as dengue fever (no plasma leakage) and dengue
haemorrhagic fever (DHF). Depending on the level of
thrombocytopenia and degree of hypotension, DHF is further
divided into grades I to IV (Table 2).1 Dengue infection is
considered severe when there is severe plasma leakage and/or
severe haemorrhage and/or severe organ impairment (Alanine
aminotransferase or Aspertate aminotranferase > 1000 U/L,
impaired consciousness, heart or other organ involved).10
‘Expanded dengue syndrome’ (EDS) is a new category in the
WHO classification of dengue infection and includes atypical
presentations of dengue, involving neurological, hepatic,
renal, cardiac and other isolated organ involvement. These
features have been increasingly reported in Dengue
Haemorrhagic Fever (DHF) or severe dengue, and also in
dengue patients without the evidence of plasma leakage.

34

These unusual manifestations may be associated with
co-infections, co-morbidities or complications of prolonged
shock.1,15 Often, EDS may present with severe disease,
requiring exhaustive investigations1,15 and demanding
multi-disciplinary supports for aggressive and effective
measures. Table 3 enlists the recognized conditions of EDS,
but a number of sporadically reported features (e.g. acute
colonic pseudo-obstruction,16,17 spontaneous muscle
haematoma,18-20 spontaneous haemothorax,21,22
thyrotoxicosis23,24 etc) associated with DHF/severe dengue are
there also.
Pathogenesis
The mechanisms that lead to severe life-threatening
manifestations of dengue viral infection are not completely
understood. A number of hypotheses have been proposed,
namely, viral tropism to cell and organ systems, viral load and
virulence, complement activation, transient autoimmunity,
host factors, neutralizing and non-neutralizing antibodies,
T-cell response, and soluble mediators etc, but pathogenesis is
likely to be multi-factorial.25 Detailed discussion of
pathogenesis is beyond the scope of this review, but in
summary, it is evident that platelets and the vascular
endothelium are the two end-organs affected, leading to
bleeding manifestation and plasma leakage, respectively,
leading to shock/DHF and organ dysfunction/EDS.14,25
Gastro-Intestinal System manifestations of Expanded
Dengue Syndrome
• Acute abdomen
Abdominal pain is a feature of severe dengue.10 Although
abdominal pain may present with other EDS, there are reports
of uncommon presentation with acute abdomen only.26 Some
of these patients even required surgical exploration for
exclusion of other presumptive differential diagnoses.
Mechanism for acute abdomen in EDS is not known, but
presumed to be non-specific peritonitis. Usually, conservative
measures are all that patient requires. 26,27
• Acute acalculous cholecystitis
Fig. 1: Ultrasound showing grossly thickened edematous gall
bladder, with no evidence of calculi.
Acute acalculous cholecystitis is usually manifested with right
upper quadrant pain. Altered liver function tests are usually
present. Thickened (>3.5 mm) edematous gall-bladder wall
[Fig. 1] with no stone, and positive sonographic Murphy’s
sign (maximum tenderness of sonographically localized
gall-bladder) is diagnostic for acute acalculous cholecystitis.
The exact pathogenesis of acalculous cholecystitis is poorly
understood. However, in DHF, direct viral invasion with
plasma leakage and serous effusion from increased vascular
Bangladesh Crit Care J March 2018; 6 (1): 34-39
permeability are thought to result in thickening of the
gallbladder wall. Acute acalculous cholecystitis in DHF is
self-limiting; usually no intervention is required.14,28-30
Surgical intervention is reserved for patients with diffuse
peritonitis.12
• Acute pancreatitis
Fig. 2: Ultrasound showing swollen pancreas.
Acute pancreatitis in dengue infection presents with similar
features as with other causes. The exact pathogenesis is poorly
understood, but has been postulated to result either from direct
invasion by the virus itself, causing inflammation and
destruction of pancreatic acinar cells; or pancreatic damage
due to dengue shock syndrome (grades III and IV of DHF); or
acute viral infection causing an autoimmune response to
pancreatic islet cells and development of oedema of the
ampulla of Vater with obstruction to the outflow of pancreatic
fluid. Raised pancreatic enzymes and edematous pancreas
[Fig. 2] on ultrasound is evident.12,21,30 Though mortality is
high in other aetiogy, acute pancreatitis as EDS usually runs a
benign course.15
• Spontaneous splenic rupture
Fig. 3: Plain CT-scan of abdomen showing splenic rupture
with haematoma in the spleen and haemoperitoneum
Spontaneous splenic rupture is termed when non-traumatic
splenic rupture occurs in a histologically proven normal
spleen15,32,33 It is a very rare and potentially fatal form of
EDS.15,32 It can occur in both acute and recovery phase of
DHF.34 The spleen, frequently being congestive, bears sub
capsular hematomas in 15% of cases.12,35 Left upper quadrant
pain and shock is the usual manifestation.33 The exact
mechanism is yet to understand completely, but hypothesised
as 1) increased intrasplenic tension caused by cellular
hyperplasia and engorgement, 2) compression by abdominal
35
Bangladesh Crit Care J March 2018; 6 (1): 34-39
muscles during sneezing, coughing or defecation, and 3) traumatic factors can alter the autonomic regulation of colonic
vascular occlusion causing thrombosis and infarction, function, causing colonic atony and pseudo-obstruction.42
interstitial and sub-capsular bleed, stripping of the capsule Nausea, vomiting, abdominal distension, and pain are
and finally capsular rupture. In dengue, it is thought to be due common symptoms at presentation. On examination, the
to a combination of coagulation factors and severe abdomen is tympanic, and bowel sounds are typically present.
thrombocytopenia, but again, the mechanism is not fully The most severe complication is caecal perforation, when the
clear.32,33,36 Imaging (USG, MRI or CT) of the abdomen can distension is greater than 9 cm radiographically. Supportive
easily identify this condition [Fig. 3].33,35 Splenic rupture management is usually the mainstay of successful therapy in
needs a high index of suspicion for diagnosis. It can occur in patients not exhibiting signs of perforation.42,43 The exact
both uncomplicated and complicated/severe dengue. Early cause of the syndrome in dengue infection is not completely
surgical intervention (splenectomy) and appropriate understood, but may be associated with post-viral
supportive management is required for successful outcome of dysautonomia. Hyponatraemia might also be the cause for the
patient.32,33,36 acute intestinal pseudoobstruction.16
• Splenic necrosis
This is another extremely rare EDS, reported only once till
date, that presented with left upper quadrant pain. The cause
remains unknown. Ultrasonography and Doppler findings of
splenomegaly with hypoechoic periphery and no colour flow
wass suggestive of splenic necrosis in the background of
DHF. No specific treatment was required.37
• Acute appendicitis
Although dengue fever itself can mimic acute appendicitis,
thought to be due to lymphoid hyperplasia and mesenteric
adenitis, DHF can occur concurrently with acute
appendicitis.38 The diagnosis is mainly based on clinical
grounds, i.e features of persistent right iliac fossa pain,
evidence of localized peritonism like guarding, and persistent
fever.38,39 Perforation of the inflamed appendix is potentially
fatal and can be complicated by the formation of an
appendicular mass.38 The patients need for careful evaluation,
including ultrasonography, even when the diagnosis of
dengue infection is confirmed. Delay in the diagnosis of
dengue infection can cause dengue shock syndrome or even Fig. 4: Abdominal radiograph showing dilated colon
death. Likewise, delaying or missing the diagnosis of acute Conclusion
appendicitis can result in serious complications.40 There is no
identified cause for acute appendicitis presenting EDS.41 Although reports of Expanded Dengue Syndrome are on the
rise, they are still under-recognized and under-reported. Only
• Acute colonic pseudo-obstruction a clinician with up-to-date information and high degree of
Few cases of acute colonic pseudo-obstruction (commonly suspicion can identify a case of EDS and take appropriate
known as Ogilvie’s Syndrome) has been reported.16,17 measures, prevent complications and avoid unnecessary
Ogilvie’s syndrome is a clinical condition with the symptoms, procedures. We should keep our eyes and mind open for such
signs, and radiographic appearance of acute large bowel unusual features of DHF and let others be aware of it, for the
obstruction [Fig. 4], without evidence of a mechanical ultimate benefit of patients and mankind.
cause.42,43 Infectious, metabolic, pharmacological, or Competing interests: None declared.

Table 1: Laboratory investigations for dengue10

Method Interpretation Serum collection time
Viral isolation Virus isolated At 1-5 days of fever
Genome detection Positive RT-PCR
(Reverse Transcriptase Polymerase Chain Reaction)
Antigen detection Positive NS1 Antigen
IgM seroconversion From negative IgM to positive IgM in paired sera Acute serum (days 1–5) and
convalescent serum (15–21 days
IgG seroconversion From negative IgG to positive IgG in paired sera or
after first serum)
4-fold increase IgG levels among paired sera

36
 Bangladesh Crit Care J March 2018; 6 (1): 34-39
Table 2: WHO classification of dengue infection 1

Class Clinical Features Haemogram

Dengue fever Fever with two of the following: • WBC ≤5000 cells/mm3
• Headache/Retro-orbital pain. • Platelet count <150 000 cells/mm3
• Myalgia/Arthtralgia/bone pain. • Rising haematocrit (5% – 10% )
• Rash.
• Haemorrhagic manifestations.
• No evidence of plasma leakage

DHF I Fever and haemorrhagic manifestation (positive tourniquet • Platelet count <100 000 cells/mm3
test) and evidence of plasma leakage • HCT rise ≥20%

DHF II Grade I plus • Platelet count <100 000 cells/mm3

Spontaneous bleeding. • HCT rise ≥20%

DHF III Grade I or II plus • Platelet count <100 000 cells/mm3

(Dengue Shock Circulatory failure (weak pulse, narrow pulse • HCT rise ≥20%
Syndrome) pressure (≤20 mmHg), hypotension, restlessness).

DHF IV Grade III plus • Platelet count <100 000 cells/mm3

(Dengue Shock Profound shock with undetectable BP and pulse • HCT rise ≥20%
Syndrome)

Table 3: Atypical manifestations of dengue infection (EDS)1,11

System Involved Atypical Manifestation
Neurological • Febrile seizures in young children
• Encephalopathy
• Encephalitis/aseptic meningitis
• Intracranial haemorrhages/thrombosis
• Subdural effusions
• Mononeuropathies/polyneuropathies/Guillane-Barre Syndrome
• Transverse myelitis

Gastrointestinal/hepatic • Hepatitis/fulminant hepatic failure

• Acalculous cholecystitis
• Acute pancreatitis
• Hyperplasia of Peyer’s patches
• Acute parotitis

Renal • Acute renal failure

• Hemolytic uremic syndrome

37
Bangladesh Crit Care J March 2018; 6 (1): 34-39

Cardiac • Conduction abnormalities

• Myocarditis
• Pericarditis

Respiratory • Acute respiratory distress syndrome

• Pulmonary haemorrhage

Musculoskeletal • Myositis with raised creatine phosphokinase (CPK)

• Rhabdomyolysis

Lymphoreticular/bone marrow • Infection associated haemophagocytic syndrome.

• Haemophagocytic lymphohistiocytosis (HLH)
• Idiopathic Thrombocytopenic Purura (ITP)
• Spontaneous splenic rupture
• Lymph node infarction

Eye • Macular haemorrhage

• Impaired visual acuity
• Optic neuritis

Others • Post-infectious fatigue syndrome

• Depression
• Hallucinations
• Psychosis
• Alopecia

References:
1. World Health Organization. Comprehensive Guidelines for
Prevention and Control of Dengue and Dengue Haemorrhagic
Fever. Revised and Expanded Edition. New Delhi: World Health
Organization, Regional Office for South-East Asia, 2011.
2. Guzman MG, Harris E. Dengue. Lancet 2015;385:453-465.
3. Simmons CP, Farrar JJ, Chau NV, Wills B. Current Concepts:
Dengue. N Engl J Med 2012;366:1423-32.
4. Guzman MG, Gubler DJ, Izquierdo A, Martinez E, Halstead SB.
Dengue Infection. Nat Rev Dis Primers 2016; 2:16055.
5. Sharmin S, Glass K, Viennet E, Harley D. Interaction of Mean
Temperature and Daily Fluctuation Influences Dengue Incidence in
Dhaka, Bangladesh. PLoS Negl Trop Dis 2015;9: e0003901.
6. World Health Organization. Global Strategy for Dengue Prevention
and Control 2012-2020. Geneva, Switzerland: World Health
Organization, 2012.
7. Bhatt S, Gething PW, Brady OJ, Messina JP, Farlow AW, Moyes CL
et.al. The Global Distribution and Burden of Dengue. Nature
2013;496:504–7.
8. Brady OJ, Gething PW, Bhatt S, Messina JP, Brownstein JS, Hoen
AG et al. Refining the global spatial limits of dengue virus
transmission by evidence-based consensus. PLoS Negl Trop Dis
2012;6:e1760.
9. Dhar-Chowdhury P, Paul KK, Haque CE, Hossain S, Lindsay LR,
Dibernardo A, et al. Dengue Seroprevalence, Seroconversion and
Risk Factors in Dhaka, Bangladesh. PLoS Negl Trop Dis
2017;11:e0005475.
10. World Health Organization. Handbook for Clinical Management of
Dengue. World Health Organization, Geneva, Switzerland, 2012.
11. Anam AM, Rabbani R, Shumy F. Expanded Dengue Syndrome:
Three Concomitant Uncommon Presentations in the Same Patient.
Trop Doct 2017;47:167-70.
12. Gulati S, Maheshwari A. Atypical Manifestations of Dengue. Trop
Med Int Health 2007;12:1087-95.
13. Pawaria A, Mishra D, Juneja M, Meena J. Atypical Manifestations
of Dengue Fever. Indian Pediatr 2014;51:495-6.
14. Nimmagadda SS, Mahabala C, Boloor A, Raghuram PM, Nayak
UA. Atypical Manifestations of Dengue Fever (DF) - Where Do We
Stand Today? J Clin Diagn Res 2014;8:71-3.

38

15. Kadam DB, Salvi S, Chandanwale A. Expanded Dengue. J Assoc
Physicians India 2016;64:59-63.
16. Anam AM, Rabbani R. Ogilvie’s Syndrome in Severe Dengue.
Lancet 2013;381:698.
17. Liew ZH. Severe Dengue with Ogilvie’s Syndrome. Journal of
Microbiology, Immunology and Infection 2015;48:S184.
18. Anam AM, Rabbani R, Shumy F. Spontaneous Calf Haematoma in
Severe Dengue. BMJ Case Rep 2018. Published online first: 9
January 2018. pii: bcr-2017-222932.
19. Kumar A, Mondal S, Sethi P, et al. Spontaneous Iliopsoas
Haematoma in a Patient with Dengue Haemorrhagic Fever (DHF):
A Case Report. J Vector Borne Dis 2017;54:103–5.
20. Bhat KJ, Shovkat R, Samoon HJ. Abdominal Haematomas and
Dengue Fever: Two Different Cases of Spontaneous Psoas Muscle
Haematoma and Bilateral Rectus Sheath Haematoma Complicating
Dengue Haemorrhagic Fever. J Vector Borne Dis 2015;52:339–41.
21. Anam AM, Rabbani R, Shumy F, Polash MM. Subsequent
Pancreatitis and Haemothorax in a Patient of Expanded Dengue
Syndrome. Trop Doct 2016;46:40-2.
22. Karanth SS, Gupta A, Prabhu M. Unilateral Massive Hemothorax in
Dengue Hemorrhagic Fever: A Unique Presentation. Asian Pac J
Trop Med 2012;5:753–4.
23. Assir MZ, Jawa A, Ahmed HI. Expanded Dengue Syndrome:
Subacute Thyroiditis and Intracerebral Hemorrhage. BMC Infect
Dis 2012;12:240.
24. Talib SH, Rahul S, Chordiya A. Expanded Dengue Syndrome:
Presenting as Overt Thyrotoxicosis without Stigmata of Grave’s
Disease (A Case Report). IOSR Journal of Dental and Medical
Sciences 2013;5:4-6.
25. Martina BE, Koraka P, Osterhaus AD. Dengue Virus Pathogenesis:
An Integrated View. Clin Microbiol Rev 2009;22:564-81.
26. Al-Araimi H, Al-Jabri A, Mehmoud A, Al-Abri S. Dengue
Haemorrhagic Fever Presenting as Acute Abdomen. Sultan Qaboos
Univ Med J 2011;1:265-8.
27. Khor BS, Liu JW, Lee IK, Yang KD. Dengue Hemorrhagic Fever
Patients with Acute Abdomen: Clinical Experience of 14 Cases. Am
J Trop Med Hyg 2006;74(5):901-4.
28. Wu KL, Changchien CS, Kuo CM, Chuah SK, Lu SN, Eng HL, et
al. Dengue Fever with Acute Acalculous Cholecystitis. Am J Trop
Med Hyg 2003;68:657-60.
29. Bhatty S, Shaikh NA, Fatima M, Sumbhuani AK. Acute Acalculous
Cholecystitis in Dengue Fever. J Pak Med Assoc 2009;59:519-21.
View publication stats
Bangladesh Crit Care J March 2018; 6 (1): 34-39
30. Anam AM, Rabbani R, Shumy F. Expanded Dengue Syndrome:
Three Concomitant Uncommon Presentations in the Same Patient.
Trop Doct 2017;47:167-70.
31. Seetharam P, Rodrigues G. Dengue Fever Presenting as Acute
Pancreatitis. Eurasian J Med 2010;42:151-2
32. Bhaskar E, Moorthy S. Spontaneous Splenic Rupture in Dengue
Fever with Non-fatal Outcome in an Adult. J Infect Dev Ctries
2012;6:369-72.
33. Anam AM, Polash MMI, Islam MM, Bhuiyan MMR, Nooruzzaman
ARM, Uddin MN. Spontaneous Splenic Rupture in Severe Dengue.
Bangladesh Crit Care J 2013:1:59-62.
34. de Silva WTT, Gunasekera M. Spontaneous splenic rupture during
the recovery phase of dengue fever. BMC Res Notes 2015; 8:286.
35. de Moura Mendonça LS, de Moura Mendonça ML, Parrode N,
Barbosa M, Cardoso RM, de Araújo-Filho JA. Splenic Rupture in
Dengue Hemorrhagic Fever: Report of a Case and Review. Jpn J
Infect Dis 2011;64:330-2.
36. Gedic E, Girgin S, Aldemir M, Keles C, Tuncer MC, Aktas A.
Non-traumatic Splenic Rupture: Report of Seven Cases and Review
of the Literature. World J Gastroenterol 2008;14:6711-6.
37. Mahmood NS, Suresh HB, D'Souza S. Splenic Necrosis as a Rare
Complication of Dengue Fever. J Clin Ultrasound 2009;37:527
38. Low YN, Cheong BM. Appendicular Mass Complicating Acute
Appendicitis in a Patient with Dengue Fever. Med J Malaysia
2016;71:83-4.
39. Kumar L, Singh M, Saxena A, Kolhe Y, Karande SK, Singh N, et al.
Unusual Presentation of Dengue Fever Leading to Unnecessary
Appendectomy. Case Rep Infect Dis 2015;2015:465238.
40. Senanayake MP, Samarasinghe M. Acute Appendicitis Complicated
by Mass Formation Occurring Simultaneously with Serologically
Proven Dengue Fever: A Case Report. J Med Case Rep 2014;8:116.
41. McFarlane ME, Plummer JM, Leake PA, Powell L, Chand V, Chung
S, et al. Dengue Fever Mimicking Acute Appendicitis: A Case
Report. Int J Surg Case Rep 2013;4:1032-4.
42. Saunders MD, Kimmey MB. Ogilvie’s Syndrome. In: McDonald
JWD, Burroughs AK, Feagan, BG, eds. Evidence-based
Gastroenterology and Hepatology, 2nd edn. London: BMJ Books;
2005: 303–9.
43. Maloney N, Vargas HD. Acute Intestinal Pseudo-obstruction
(Ogilvie’s Syndrome). Clin Colon Rectal Surg 2005; 18: 96–101.
39