Case Presentation: An 8-year-old fully vaccinated female developed fever, abdominal pain, sore throat, and vomiting 6 days prior to admission. When seen by her pediatrician 4 days prior, she had an erythematous oropharynx and was treated with amoxicillin for streptococcus pharyngitis. The following day, she developed blood-streaked emesis and was seen in a local Emergency Department. She had a normal complete metabolic panel (CMP), received a normal saline bolus and was discharged home with a diagnosis of viral gastroenteritis. Her symptoms evolved to include worsening myalgias, episodes of nosebleeds with hematemesis, and a retro-orbital headache. She presented again to the Emergency Department with poor oral intake and concern for dehydration. At that time, physical examination revealed an ill-appearing girl with dry mucous membranes and multiple 1 mm raised erythematous and pruritic skin lesions. She was febrile to 102.1F with otherwise normal vital signs. Labs revealed leukopenia to 2.7×103/uL and thrombocytopenia to 109×103/uL with normal hemoglobin and CMP. Her erythrocyte sedimentation rate was elevated to 57 mm/hr.Further history revealed recent travel to southern Mexico where a dengue outbreak was occurring. Her additional evaluation included a malaria smear, Epstein-Barr virus serology, adenovirus polymerase chain reaction (PCR), Zika virus and Chikungunya testing, all of which were negative. Dengue fever virus IgM and PCR were positive, confirming the diagnosis of dengue. With appropriate fluid management, the patient did well and was discharged home on day 9 of illness.
Discussion: Dengue is one of the most rapidly spreading mosquito-borne diseases in the world with an estimated 50 million cases per year. It can mimic common diagnoses like streptococcus pharyngitis and viral gastroenteritis because it initially presents with mild, non-specific symptoms such as headache, abdominal pain, fever, and vomiting. However, dengue can also evolve into life-threatening distributive shock during the “critical phase,” occurring between 3-7 days after symptoms onset. Patients should be monitored for capillary leakage with frequent CBCs to evaluate for a rise in hematocrit indicating leakage of fluid from the capillaries and for edema and respiratory distress. Children pose a larger risk for dengue shock due to decreased ability to compensate for capillary leakage. Therefore timely diagnosis is extremely important for management. Dengue fever virus is transmitted via the Aedes mosquito, commonly found in tropical and subtropical climates. With global temperatures on the rise, Aedes mosquitos are rapidly expanding their territory, and thus the spread of disease. Multiple countries are experiencing a substantial increase in the number of dengue cases, with many documenting their worst dengue outbreaks in history. It should be no surprise then, that there have been over 600 cases of dengue reported in the United States. Most importantly, 5 cases in the United States have met criteria for the dengue shock.
Conclusions: The role of the hospitalist in recognizing cases of dengue is a crucial contribution to the knowledge-base necessary to combat the disease on an epidemiological level. Hospitalists need to be familiar with the warning signs and the inpatient management of this life-threatening condition. With our current global landscape, physicians must elicit accurate travel histories, as it may prove vital to the differential diagnosis and timely management of tropical diseases like dengue.