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Revista da Sociedade Brasileira de Medicina Tropical

Print version ISSN 0037-8682On-line version ISSN 1678-9849

Rev. Soc. Bras. Med. Trop. vol.49 no.5 Uberaba Sept./Oct. 2016

http://dx.doi.org/10.1590/0037-8682-0145-2016 

Cases Reports

Acute pancreatitis complicating dengue hemorrhagic fever

Kalenahalli Jagadish Kumar1 

Anitha Chandrashekar1 

Chetak Kadabasal Basavaraja1 

Halasahalli Chowdegowda Krishna Kumar1 

1Department of Pediatrics, Jagadguru Sri Shivarathreeswara Medical College, Jagadguru Sri Shivarathreeswara University, Mysore, India.


Abstract

Dengue infection can have spectrum of manifestations, often with an unpredictable clinical progression and outcome. There have been increasing reports of atypical manifestations. Abdominal pain or tenderness and persistent vomiting (warning signs) are present in the majority of cases with severe dengue prior to clinical deterioration. We report a 10-year-old child who presented with fever, persistent vomiting, and abdominal pain. A diagnosis of acute pancreatitis was made. This is a very infrequently reported complication of dengue hemorrhagic fever.

Keywords: Dengue hemorrhagic fever; Acute pancreatitis; Persistent vomiting.

INTRODUCTION

Dengue infection is a disease entity that can have different clinical presentations and often demonstrates an unpredictable clinical progression and outcome. There have been increasing reports of dengue fever (DF) and dengue hemorrhagic fever (DHF) with atypical manifestations due to involvement of liver, kidneys, heart, or nervous system (expanded dengue syndrome)1. These atypical manifestations may be potentially serious and may result in increased rates of morbidity and mortality. Therefore, clinicians should be aware of these atypical manifestations. Acute pancreatitis is a rare complication of DF2. We report a case of acute pancreatitis complicating DHF; this is a very infrequently reported complication.

CASE REPORT

A 10-year-old girl, known with autoimmune hemolytic anemia, presented with a one-day history of fever, vomiting, and body aches. On examination, her vital signs were stable. Abdominal examination revealed a 2cm hepatomegaly and a palpable spleen. Examination of other systems was unremarkable. The investigations and the course of her illness are depicted in Table 1 and Figure 1. She developed persistent vomiting with abdominal pain. A diagnosis was made of acute pancreatitis complicating DHF. She was managed conservatively and was discharged in a stable condition after 19 days of hospitalization.

TABLE 1 Investigation chart. 

Blood culture and urine culture: sterile; dengue serology: NS1 antigen positive, IgM positive, IgG negative; Peripheral smear for malarial parasite, Widal test, Weil-Felix test, Typhidot-M, and HIV test: all negative; serology for hepatotrophic viruses (hepatitis A, B, C, E): negative. On day 7, echocardiogram: normal. Arterial blood gas: pH 7.30, pCO2 32mmHg, pO2 52.8mmHg, HCO3 15.5mmol/L; kidney function tests (urea, creatinine, Na + , K + ): normal on days 1, 3, 7 and 8. Total proteins and albumin: normal On day 8: PT=16.9 (control=14.2) seconds; APTT=33 (control=29) seconds; INR=1.24. Hb: hemoglobin; TLC: total leucocyte count; AST: aspartate transaminase; ALT: alanine transaminase; N: neutrophils; L: lymphocytes; NS1: nonstructural protein 1; IgM: immunoglobulin M; IgG: Immunoglobulin G; HIV: Human immunodeficiency virus; PT: prothrombin time; APTT: Activated partial thromboplastin time; INR: International normalised ratio.

FIGURE 1 Sequence of events after admission 

DISCUSSION

In DF, abdominal and gastrointestinal symptoms are common3) (4. Presentation with an acute abdomen in DF may pose a diagnostic dilemma and is a challenge for the treating clinician. In DHF, up to 40% of patients may present with abdominal pain3. Abdominal pain or tenderness and persistent vomiting are classified as warning signs1. These symptoms (abdominal pain and vomiting) have been noted in the majority of patients with severe dengue infection prior to clinical deterioration5. Hence, there is a need for close monitoring of children with DF who display such warning signs. In a retrospective review of 8,559 patients with DF, 67% had abdominal and gastrointestinal symptoms. The most common symptom was nausea (52%), followed by abdominal pain (36%), and vomiting (29%)4. In dengue infection, the causes of abdominal pain include hepatitis, pancreatitis, acalculous cholecystitis, and peptic ulcer disease3. Acute pancreatitis is a rare complication of DF2. In a study of DF by Khanna et al., the various causes of abdominal pain were reported to include acute hepatitis [n = 20 (36.4%)], acalculous cholecystitis [n = 9 (16.4%)], acute pancreatitis [n = 8 (14.5%)], appendicitis [n = 3 (5.5%)], spontaneous bacterial peritonitis [n = 2 (3.6%)], enteritis [n = 8 (14.5%)], peptic ulcer disease [n = 2 (3.6%)], and gastric erosions [n = 3 (5.5%)]3.

Acute pancreatitis in children is associated with significant morbidity and mortality6. It was reported that of 589 cases of acute pancreatitis in children, viral infections accounted for 10%6. In a study by Setiawan et al., 29% (43/148) of children with DHF who experienced epigastric pain had an enlarged pancreas. However, serum levels of amylase and lipase were measured in only 20 children. The authors noticed slight increase in 6 (75%) of 8 patients with mild DHF and in 10 (83%) of 12 patients with severe DHF. All children with mild DHF had a normal-sized pancreas and in all 10 severe cases children with increased serum levels of amylase and lipase had an enlarged pancreas7.

In a previous study, 14 out of 328 cases of DHF/dengue shock syndrome (DSS) had an acute abdomen; causes included acute cholecystitis (n = 10), nonspecific peritonitis (n = 3), and acute appendicitis (n = 1); none had acute pancreatitis8. In a study conducted in Pakistan, however, 43 (12%) out of 357 patients with DF had an acute abdomen and three (0.8%) had acute pancreatitis. All three patients with acute pancreatitis developed acute respiratory distress syndrome, and two died9. In our patient, DHF was diagnosed according to the World Health Organization's (WHO) criteria. She presented with fever, a bleeding tendency, thrombocytopenia (platelets <100 × 109/L), and ascites, and her serology results were positive for nonstructural protein 1 (NS1) antigen and dengue immunoglobulin M (IgM) antibodies. She had continuous persistent vomiting that started one day prior to admission and stopped three days before discharge. Her initial abdominal sonogram and liver enzymes levels were normal. Given that the child's epigastric pain and associated persistent vomiting were not relieved by parenteral pantoprazole, and that she was hypotensive, we suspected acute pancreatitis and ordered serum amylase and lipase testing, and a repeat abdominal ultrasound. We diagnosed acute pancreatitis in view of clinical symptoms (abdominal pain and vomiting), hypotension, enlargement of the pancreas on ultrasound examination without features of hepatobiliary disorders, and increased serum amylase and lipase levels. We started antibiotics empirically for pneumonia and acute pancreatitis. Serum amylase and lipase levels decreased after one week. In DHF, the involvement of the pancreas may be due to direct viral invasion, secondary to host immune reactivity, or due to hypotension2.

Like septic shock, acute pancreatitis can be fatal10. As such, DHF/DSS can also cause mortality if not treated. Therefore, acute pancreatitis as a complication of DHF is dangerous, and clinicians should know when to suspect in patients with DF. Acute pancreatitis as a complication of DHF may be underdiagnosed due to lack of awareness10. Hence, clinicians might not request serum amylase or lipase investigation, despite abdominal pain and vomiting. Lee et al. compared 14 patients with hyperlipasemia (one with additional hyperamylasemia) and 57 without hyperlipasemia/hyperamylasemia among 71 DHF patients who presented with abdominal pain. They found that three patients in the hyperlipasemia group had pancreatitis, all of whom had enzyme elevation > 3 times the of normal11. In acute pancreatitis, serum amylase usually rises within a few hours of the onset of symptoms and return to normal values within 3-5 days. However, because of sensitivity, specificity, and positive and negative predictive value limitations, serum amylase alone cannot reliably be used to diagnose acute pancreatitis; the more specific serum lipase test is preferred. Serum lipase remains increased for a longer period than amylase after disease presentation12. Abdominal pain and vomiting are common in DF, especially in severe DF. Even though important common causes include acute gastritis, hepatitis, and acalculous cholecystitis, acute pancreatitis should be kept in mind as one of the causes. Simple investigations like serum lipase, amylase (levels more than 3 times the upper limit of normal), and abdominal ultrasound will establish the diagnosis. In a patient with dengue illness who has abdominal pain, it is probably justified to estimate and monitor serum lipase and amylase levels and to perform serial abdominal sonography.

To conclude, clinicians should be alert when there are warning symptoms (abdominal pain and persistent vomiting) in patients with DF, and should order testing of serum lipase and amylase levels along with abdominal sonography. Even though acute pancreatitis is a rare complication, early diagnosis and prompt treatment is necessary to prevent morbidity and mortality.

References

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2. Wijekoon CN, Wijekoon PW. Dengue hemorrhagic fever presenting with acute pancreatitis. Southeast Asian J Trop Med Public Health 2010; 41:864-866. [ Links ]

3. Khanna S, Vij JC, Kumar A, Singal D, Tandon R. Etiology of abdominal pain in dengue fever. Dengue Bull 2005; 29:85-88. [ Links ]

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7. Setiawan MW, Samsi TK, Wulur H, Sugianto D, Pool TN. Epigastric pain and sonographic assessment of the pancreas in dengue hemorrhagic fever. J Clin Ultrasound 1998; 26:257-259. [ Links ]

8. 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; 74:901-904. [ Links ]

9. Shamim M. Frequency, pattern and management of acute abdomen in dengue fever in Karachi, Pakistan. Asian J Surg 2010; 33:107-113. [ Links ]

10. Simadibrata M. Acute pancreatitis in dengue hemorrhagic fever. Acta Med Indones 2012; 44:57-61. [ Links ]

11. Lee IK, Khor BS, Kee KM, Yang KD, Liu JW. Hyperlipasemia/pancreatitis in adults with dengue haemorrhagic fever. Pancreas 2007; 35:381-382. [ Links ]

12. Tenner S, Baillie J, DeWitt J, Vege SS. Management of acute pcreatitis. Am J Gastroenterol 2013; 108:1400-1415. [ Links ]

Received: April 28, 2016; Accepted: July 12, 2016

Corresponding author: Dr. K. Jagadish Kumar. e-mail: jagdishmandya@gmail.com

The authors declare that there is no conflict of interest

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