Case report: spontaneous rupture of the spleen due to dengue fever

CASE REPORTS

Case report: spontaneous rupture of the spleen due to dengue fever

L.E.C. Miranda^{I, II}; S.J.C. Miranda^II; M. Rolland^II

^IRibeirão Preto Medical School, São Paulo University, São Paulo, SP

^IIUnimed Recife Hospital, Recife, PE, Brazil

^{Correspondence}

ABSTRACT

Spontaneous rupture of the spleen has been described in cases of hematologic, neoplasic and infectious diseases, or resulting from pancreatitis. We report a rare case of spontaneous splenic rupture, and favorable evolution after splenectomy, in a patient with dengue fever, which occurred during the last outbreak of dengue fever in Brazil.

Key Word: Spleen, rupture, dengue fever.

Dengue fever has become a public health concern in Brazil since 1976, when Aedes aegypti, the arthropod vector of the causative virus, was again found in the country. The first epidemic was registered in Roraima, a state in the Amazon, in 1981 and 1982. Rio de Janeiro, which has the second largest Brazilian urban area, suffered its first outbreak in 1986 [1]. A patient infected by a second serotype may present dengue hemorrhagic fever, which can be lethal. Last summer there was a huge outbreak in Rio de Janeiro, with hundreds of patients presenting the hemorrhagic form and about 40 confirmed deaths. We report a case of dengue fever with splenic rupture, which occurred during the last dengue fever outbreak in Brazil.

Case Report

A 52-year-old married woman, living in Recife, the capital of Pernambuco, a state in north east Brazil, sought the emergency room in February, 2002, due to a two-day feverish acute illness, generalized myalgias and headache. She had been using NPH insulin for diabetes mellitus during 15 years, ramipril for hypertension, and cloxazolan for anxiety. There were no abdominal trauma antecedents, nor did she use acetyl salicylic acid. She had smoked two packets of cigarettes/day, for 32 years. The patient received a diagnosis of dengue fever. Paracetamol was prescribed and the patient was discharged. On the sixth day of illness, she developed sudden, severe abdominal pain. She had pallid skin and mucosa, filiform pulses, low arterial blood pressure, globus abdomen with tenderness, defense and mild rebound. Laboratory tests demonstrated lowered hematocrit, hemoglobin and platelets, with normal amylase (Table 1). A CT scan of the abdomen revealed diffuse ascites and a large splenic hemorrhage (Figure 1). An exploratory laparotomy revealed massive hemoperitoneum and splenic rupture, with perisplenic hemorrhage. Splenectomy was performed. Anatomo-pathological examination showed a normal spleen, with no evidence of malignancy or granulomas or splenic capsule rupture. Dengue fever serology (ELISA, with IgM search) was positive. After surgery the patient's recovery was complete.

Figure 2

Discussion

The clinical spectrum of dengue fever ranges from asymptomatic infection, through severe illness (dengue hemorrhagic fever/dengue shock syndrome -DHF/DSS), the characteristic feature of which is increased capillary permeability, resulting in shock [2]. The pathogenesis of DHF is not well understood. Bleeding can occur in any organ. The spleen, which is frequently congestive, bears subcapsular hematomas in 15% of cases [3]. Although up to 100 million cases of dengue fever are registered per year, there are only two previously reported cases of spleen rupture in patients with dengue fever: a 35-year-old white man with dengue fever was submitted to splenectomy in French Polynesia and had favorable clinical evolution [4]; a 23-year-old female who lived in Venezuela had severe illness and died after splenectomy, with Gram-negative sepsis and multiorgan failure. In the former and in the present case, spleen rupture developed in patients without the classical symptoms of DHF/DSS [5]. Most of the world population lives in areas infested with the dengue vector [2] and the number of sick people may be very high during outbreaks of dengue fever. A case of spleen rupture may be misdiagnosed due to misinterpretation of the shock syndrome as in a case of DHF/DSS. In spite of being a rare condition, dengue fever with spontaneous splenic rupture can be a fatal complication if not quickly and correctly diagnosed. Splenectomy can be curative.

Received on 08 April 2003

revised 04 August 2003

• 1. Marzochi K.B.F. Dengue in Brazil Situation, transmission and control A proposal for ecological control. Mem Inst Oswaldo Cruz 1994;88(2):235-45.
• 2. Gubler D.J. Dengue and Dengue Hemorragic Fever. Clin Microbiol Rev. 1998;11(3):480-96.
• 3. Bhamarapravati N., Tuchinda P., Boonyapaknavik V. Pathology of Thailand haemorrhagic fever. A study of 100 autopsy cases. Ann Trop Med Parasitol 1967;61:500-10.
• 4 Imbert P., Sordet D., Hovette P., Touze J.E. Spleen rupture in a patient with dengue fever. Trop Med Parasitol 1993;44:327-8.
• 5. Redondo M.C, Ríos A., Cohen R., et al. Hemorrhagic dengue with spontaneous splenic rupture. Clin Infect Dis 1997;25:1262-3.

Publication Dates

• Publication in this collection
  01 Mar 2004
• Date of issue
  Dec 2003

History

• Accepted
  04 Aug 2003
• Received
  08 Apr 2003