PARAPLEGIA IN PATIENT WITH DENGUE

Mohammed Ashwaque1, Kavina Fernandes2.

Affiliations
1- Resident, 2- Associate Professor, Department of General Medicine , Father
Mullers Medical College, Mangalore.

Abstract
Dengue a rapidly spreading mosquito borne viral disease can present in varied forms
and variations.

The incidence of dengue has grown dramatically around the world in recent
decades. The actual numbers of dengue cases are under reported and many cases
are misclassified. One recent estimate indicates 390 million dengue infections per
year (95% credible interval 284–528 million), of which 96 million (67–136
million) manifest clinically (with any severity of disease).1

Today, severe dengue affects most Asian and Latin American countries and has
become a leading cause of hospitalization and death among children and adults in
these regions.

Based on the data of National Vector Borne Disease Control Program (NVBDCP),
the number of cases reported in India in 2013 was about 74 454 for dengue with 167
deaths.In 2015, Delhi, India, recorded its worst outbreak since 2006 with over 15 000
cases.2

Dengue fever can cause systemic complications like hepatits, acute renal injury and
renal failure, ARDS, myocarditis. Although dengue is considered a non-neurotropic
virus, neurological complications have been reported in dengue cases. The
neurological manifestations of dengue infection can vary from myositis,
meningo-encephalitis to Guilliane-Barre syndrome.3,4

CASE REPORT

A 65 year old male patient presented with history of fever and loose stools 2 weeks
ago. Fever was low grade, continuous, and was not associated with chills and rigors.
The patient noticed skin lesions over his fore arm and abdomen over the course of
fever. On the 3rd day of the fever the patient visited a local hospital and was tested
positive for dengue. The patient was admitted in the hospital and the patient
developed back pain over the course of the fever. The patient had progressive
thrombocytopenia and the platelet count readings were 116000, 77000, 46000, 41000
respectively. The patient was discharged subsequently as the fever subsided. At the
time of discharge the platelet count was 48,000.

On the 8th day of the fever the patient had severe back pain which was gradually
progressive and radiating to the right thigh, for which he was taken to the local
hospital and was given an injection on his right gluteal region. At this time the patient
required one person’s support to walk, but he was able to grip his slippers.

On the same day at night the patient felt heaviness in his right lower limb. The next
day morning the patient realized he had weakness of both lower limbs which was
more in the right lower limb. The patient could sit up but could not get up on his own.
The patient noticed buckling of his knees when he attempted to get up. The patient
also noticed loss of sensation in both the lower limbs from the level of his thighs.
However the patient could appreciate his clothes. The patient also complained of
bowel and bladder incontinence.

The patient was brought to our hospital on the same day. On examination the patient
was found to have areflexia in both the lower limbs. Bilateral plantar reflex was
present. The power of the right lower limb at the level of hip and knee joint was 3.
The power of left lower limb was 4 minus at the level of hip and knee joint. The
patient could not dorsiflex both his lower limbs. There was hypotonia of both the
lower limbs. There was asymmetric loss of proprioception and vibration in both the
lower limbs. There was no head lag and single breath count was normal. The tone,
power and reflexes of both the upper limbs were normal. The symptoms pointed
towards Cauda equina but could not be considered for diagnosis in view of early
bladder involvement. The patient was considered to have Guillain -Barre but due to
early involvement of the bladder the diagnosis could not be considered. Lab
investigations revealed anemia of Hb 7.8g% and thrombocytopenia.The platelet
count was 20,000. The patient was positive for anti dengue virus IgM and IgG
antibodies. NCS was done which revealed severe sensory motor neuropathy. For
further evaluation MRI SPINE was done which revealed epidural hematoma from L1
to L3. The patient underwent emergency surgery for evacuation and decompression
of the hematoma. The patient’s condition improved with subsequent improvement in
power and return of bowel-bladder continence.

DISCUSSION

This case highlights probabilty of occurrence of epidural hemorrhages while the

platelet count is not very low.
The Dengue virus is well known to cause hemorrhagic manifestations.Minor
bleeding manifestations, most commonly skin petechiae or bruising are apparent in
many patients with dengue hemorrhagic fever (DHF). But major hemorrhage is
unusual. If severe bleeding does occur, it is almost invariably in patients with
profound or protracted shock who also have evidence of multiple-organ failure

Patient’s history and symptoms pointed to atypical presentations of cauda equina

syndrome and Guilliane-Barre syndrome.Dengue infection was confirmed by
positive Dengue IgM serology.Development of paraparesis and bowel bladder
involvement pointed to a LMN lesion and was confirmed by MRI spine which
revealed epidural hematoma.Occurrence of epidural hemorrhages when platelet
count was 48,000 without multi organ failure or disseminated intravascular
coagulation was an atypical presentation. High index of clinical suspicion lead to
early diagnosis and initiation of relevant management. Instituting a surgical
procedure with thrombocytopenia in a patient with spinal cord compression was a
challenging decision to make.Following platelet transfusions patients’s platelet count
improved to over 1 lakh and was taken up for surgery as adviced by Spine Surgeon.

CONCLUSION

This case elaborates some rare and debilitating complications of a common

infection.It is important to have a high degree of clinical suspicion when a patient
presents with atypical symptoms, to diagnose rare complications. Prompt diagnosis
and intervention of such complications can alter the clinical course as well as the
outcome of the disease.

REFERENCES

1 Bhatt S, Gething PW, Brady OJ, Messina JP, Farlow AW, Moyes CL et.al. The
global distribution and burden of dengue. Nature;496:504-507.

2.Cecilia D. Current status of dengue and chikungunya in India. WHO South-East

Asia J Public Health 2014; 3(1): 22–27.

3.Murthy J. Neurological complications of dengue infection. Neurol India.

2010;58:581–4.

4.Verma R, Sharma P, Mehrotra H. Neurological complications of dengue fever:

Experience from a tertiary centre of north India. Ann Indian Acad Neurol. 2011;14(4):
272–278.