Indian Journal for the Practising Doctor

Case Report

ISSN No: 0973-516X

Pankaj Beniwal, Sachin Kumar, Sameer Gulati, Sandeep Garg

Pankaj Beniwal, Sachin Kumar, Sameer Gulati, and Sandeep Garg are from the Department of Medicine, MAULANA AZAD MEDICAL COLLEGE, NEW DELHI- 110002.

Corresponding Author: PANKAJ BENIWAL, 68 PG MENS’ HOSTEL, MAULANA AZAD MEDICAL COLLEGE, NEW DELHI – 110002. (PHONE NO.: 9811661976).
Email: [email protected]

Abstract:

Dengue fever is endemic in India and is responsible for frequent outbreaks in the region. Normally dengue fever is a self limited illness, however, hemorrhage and shock are the 2 dreaded complications. Various atypical manifestations of dengue virus infection have been reported during recent years. We report a rare case of dengue fever presenting with acute cholecystitis. Adequate hydration, antipyretics and close monitoring for signs of shock and perforation is adequate in cases of dengue fever presenting with acalulous cholecystitis. Surgical intervention should be reserved for cases with perforation and peritonitis. We recommend routine use of abdominal ultrasosnography in cases of dengue fever which may help both in diagnosis and early detection of complications.

Key-words: dengue, cholecystitis, ultrasonography

Case History:

A 17 year old male presented with a 5 day history of high grade fever with chills, malaise, muscle pain and joint pains. On the third day of his illness he also developed pain abdomen which was localized to right hypochondrium, was non-colicky and associated with nausea and vomiting. It had no specific aggravating or relieving factors. There was no history of any rash or bleeding from any site. There was no significant past medical history. Examination revealed a febrile patient (temperature 102°F) who was conscious and oriented. His heart rate was 110/min and he had a blood pressure of 110/80 mm Hg. His cardiovascular examination was unremarkable.

Respiratory examination revealed reduced air entry over the right lung base. Per abdomen examination revealed tenderness, guarding and rigidity in the right hypochondrium. Murphy’s sign was positive. Liver was just palpable below the costal margin and there was no splenomeagaly.

Investigations revealed a hemoglobin of 12.3 gm%, a total leukocyte count of 3,400/mm3 with 64 % neutrophils and 32% lymphocytes. He had a platelet count of 56,000/mm3 and a hematocrit of 60%. The patients total bilirubin was 1.3 mg, serum aspartate aminotransferase level of 213 IU/L (reference value <40 IU/L) and alanine aminotransferase level of 171 IU/L (reference value lt;40 IU/L). Serum alkaline phosphatase was 11 kA/L (reference value:3-13) and INR was 1.29. Patients’ kidney function tests and serum amylase levels were normal. Chest X ray revealed minimal right-sided pleural effusion. His blood cultures and serum Widal for enteric fever were negative. His dengue serology (by ELISA) was positive for IgG as well as IgM antibodies.

Abdominal ultrasound (Images: 1 and 2) done revealed a thickened gallbladder wall of 5.2 mm with pericholecystic fluid collection, echo-free lumen and a positive sonographic Murphy’s sign. There was minimal free fluid in the peritoneal cavity.

Image 1

Image 2

Patient was managed conservatively with intravenous fluids and antibiotics. His clinical symptoms improved over 3-5 days with normalization of platelets and hematocrit values.

Discussion

Dengue fever (DF) is a mosquitoborne viral disease caused by a flavivirus and is endemic in large areas of the Southeast Asia¹. In India, more than 50 outbreaks have been reported by the National Institute of Communicable diseases, New Delhi since 1963². The clinical picture of classic dengue begins with a high grade fever, intense headache and myalgia, prostration, nausea, vomiting and arthralgia. Various atypical manifestations of dengue virus infection, including fulminant hepatitis, encephalopathy, cardiomyopathy, acute pancreatitis, and acalculous cholecystitis have been reported during recent years^3-5. Frequent sonographic findings in a case of dengue include a thickened gallbladder wall with pericholecystic fluid, ascites, splenomegaly, and pleural effusion which is commonly right-sided^6-8. Gallbladder edema is found to be more common in cases of secondary dengue and there is a tendency for gallbladder edema to be associated with higher increase of hematocrit⁹ and greater severity of illness¹⁰. The main pathophysiologic change in DF could be increased vascular permeability, causing plasma leakage and serous effusion with high protein content which induces thickening of the gallbladder wall. Acalculus cholecystitis though described is rarely seen in Indian patients. A Chinese study reported an incidence as high as 7.6%¹¹ which has not been reported by others.

Key Messages: It is important to recognise the complications of dengue fever and their course. Gall bladder wall edema and pericholecystic fliud collection in dengue fever are well known. Acalculus cholecystitis in dengue fever is rarely seen and has to be managed conservatively unless there are signs of perforation.

Acalculous cholecystitis is associated with burns, trauma, vasculitis, post-surgical conditions, and certain infections such as salmonellosis. The mortality rate of acute acalculous cholecystitis is very high, ranging from 10% to 50%¹². The rapid progression of acute acalculous cholecystitis to gangrene and perforation has been reported¹³.Therefore; prompt, early recognition and intervention are required¹³.

However, our patient was managed conservatively with intravenous fluids and antibiotics. A surgical consultation was nevertheless taken but he was not considered for intervention on account of thrombocytopenia and poor general condition. He improved completely by the 5th day of his admission and was discharged thereafter.

Acalculous cholecystitis should be suspected in a case of DF presenting with abdominal pain, fever, a positive Murphy’s sign, mild elevation of transaminases and a thickened gallbladder wall without stones on ultrasonography. In DF patients with acute acalculous cholecystitis, the course of DF could be self-limiting and the gallbladder wall could return to normal after several days. Cholecystectomy in a case of dengue fever complicated by acalculous cholecystitis is rarely required and hence the patient should be closely observed for signs of perforation. Adequate hydration, antipyretics and platelet-transfusion in cases with severe thrombocytopenia may be all they need. There have been numerous studies^6-10 supporting the role of ultrasonography in a case of dengue fever. Abdominal ultrasonography should be made a routine in cases of dengue fever as it may help in the clinical diagnosis as well as early detection of complications as in our case.

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