Case Presentation:
A 27 year‐old with ADHD presented with 4 days of fever and chills associated with diffuse myalgias, arthralgias, and headache. Following fever onset, she developed an erythematous morbilliform rash beginning on her back and spreading to her arms, neck and face. Further history revealed that she had recently traveled 3 weeks throughout Thailand. She saw a Thai physician prior to an early return because of her symptoms. Blood testing was done, but results were not available at the time of her evaluation. She did not receive prophylactic medications and no travel companions had similar symptoms. Vital signs were stable and a faint macular rash was seen on her back, arms, and neck. Musculoskeletal tenderness was noted on palpation. Laboratory findings demonstrated transaminitis (AST 157 units/L and ALT 97 units/L) and thrombocytopenia (platelets 124 K/cumm). Infectious Disease was consulted. A lumbar puncture, malaria smear, HIV antibody screen with viral load, herpes simplex 2 antibody and hepatitis panels were negative. Epstein‐Barr serology suggested past infection. Dengue fever titers were sent. The Thai physician was contacted and confirmed that previous testing demonstrated Dengue NS1 antigen. Symptoms improved and she was discharged with a diagnosis of Dengue fever on hospital day 2. She returned 3 days later with abdominal pain, nausea, and emesis. Laboratory evaluation demonstrated persistent transaminitis (AST 374 units/L and ALT 291 units/L). Lipase and amylase were 857 and 436 units/L respectively (normal <100 units/L for both). Pancreatitis was diagnosed requiring a second hospital admission. Symptoms improved and she was discharged the next day. Dengue IgM returned elevated at 9.94 (normal <0.9).
Discussion:
Dengue Hemorrhagic Fever (DHF) caused by the Dengue virus is transmitted to humans from mosquitos. It remains a significant cause of illness and death in the tropics and subtropics with up to 100 million people infected yearly. There is no vaccine. The only preventive measure is mosquito protection. Our patient had the commonly associated symptoms including headache, fever, rash, and muscle pain. Although abdominal symptoms are frequent, acute pancreatitis remains a rarely reported complication. A 2011 case report by Guido et al noted only 9 reported cases of DHF associated pancreatitis from 1998 to 2009 as defined by a lipase 3 fold greater than the upper limit of normal. However a 2012 analysis by Majumdar et al reports that pancreatitis may be under‐reported and have a higher complication rate making early diagnosis and hospitalization essential to improving patient condition and survival.
Conclusions:
This case reminds hospitalists that pancreatitis is a rare but important complication of Dengue fever. Its early consideration in patients presenting with abdominal pain associated with symptoms or diagnosis of dengue fever may avoid more severe and possibly fatal complications.