Case Presentation: A 46-year-old female with a medical history of type 2 diabetes, asthma, obesity, and anxiety presented to the emergency department with a five-day history of fever, myalgias, and headache. Additionally, she experienced intermittent episodes of epistaxis and gingival bleeding while brushing her teeth for the past week. She had recently returned from a two-week trip to Mexico. She reported being exposed to mosquitoes and a family pet dog during her trip. She denied other animal exposure, swimming in lakes or rivers, history of IV drug use, ingesting contaminated water, or any known tick bites. On presentation, the patient was afebrile with stable vital signs. Skin exam revealed scattered petechiae bilaterally from the ankles to the upper shins, while the rest of exam was normal. Complete blood count (CBC) revealed a normal hemoglobin level of 13.7 g/dL, severe thrombocytopenia with a platelet count of 20 x 10^3/μL, and mild leukopenia with a white blood cell count of 3.5 x 10^3/μL. Hepatic function panel (HFP) showed markedly elevated transaminases (alanine transaminase of 196 U/L, aspartate aminotransferase of 378 U/L), low albumin (2.8 g/dL), and low total protein (5.6 g/dL). Renal function was stable with a creatinine of 0.57 mg/dL. CT of the abdomen and pelvis revealed periportal edema and small perihepatic ascites. Infectious Disease was consulted. A broad infectious workup was initiated, including tests for Dengue, Chikungunya, Zika, CMV, tick-borne illnesses, viral hepatitis, and HIV. Dengue non-structural antigen 1 (NS1) was positive, and dengue IgG was positive, while IgM was equivocal. Dengue virus PCR was positive, while other infectious tests returned negative. Based on these findings and the patient’s clinical presentation, including signs of increased vascular permeability, mucocutaneous bleeding, and severe thrombocytopenia with leukopenia, she was diagnosed with dengue hemorrhagic fever. The positive IgG result confirmed prior exposure to dengue virus. Management included intravenous fluids to maintain euvolemia and ensure adequate urine output. By hospital day 5, the patient had remained afebrile and platelet count had significantly improved to 125 × 10^3/μL. She was discharged home in stable condition. At a one-week outpatient follow-up, the patient reported feeling well and repeat CBC and HFP were within normal limits.
Discussion: Dengue fever is a mosquito-borne illness which has become increasingly prevalent int he United States over the last several years. Our patient presented at the time of defervescence, which is the most critical phase of dengue, and typically occurs on days 3 to 7 of the illness. Warning signs of severe infection as seen in this patient include plasma leakage characterized by elevated hematocrit, low albumin/protein levels, or pleural effusion/ascites as well as severe thrombocytopenia with mucosal bleeding. Severe dengue infection is characterized by shock, severe bleeding, or severe organ dysfunction. Inpatient management includes antipyretics for fever, intravascular volume repletion to maintain goal urine output, and close hemodynamic and laboratory monitoring for signs of shock.
Conclusions: Here we present a case of dengue hemorrhagic fever. Dengue should be considered for patients presenting with acute fevers and recent travel history. Inpatient management is warranted for patients who present with warning signs of severe dengue infection.