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Table of Contents
LETTER TO EDITOR  
Year : 2011  |  Volume : 14  |  Issue : 2  |  Page : 155-156
Dengue fever in a patient recovering from coronary artery bypass grafting


Institute of Critical Care and Anaesthesiology,Cardiac Critical Care and Anaesthesiology, Medanta the Medicity, Haryana, India

Click here for correspondence address and email

Date of Web Publication25-May-2011
 

How to cite this article:
Rawat S, Mehta Y, Juneja R, Trehan N. Dengue fever in a patient recovering from coronary artery bypass grafting. Ann Card Anaesth 2011;14:155-6

How to cite this URL:
Rawat S, Mehta Y, Juneja R, Trehan N. Dengue fever in a patient recovering from coronary artery bypass grafting. Ann Card Anaesth [serial online] 2011 [cited 2019 Oct 19];14:155-6. Available from: http://www.annals.in/text.asp?2011/14/2/155/81575


The Editor

Dengue fever is the most common and widespread arbovirus infection worldwide. It is endemic in the tropical and subtropical areas of the world especially in Southeast Asia, the Pacific, East and West Africa, the Caribbean and the Americas with cyclical epidemics in these areas. [1],[2] Dengue fever can manifest as mild, undifferentiated fever or a more severe form of the disease called dengue hemorrhagic fever (DHF: grades I-IV). The most critical phase of this viral infection is defervescent when the fever subsides but the patient develops life-threatening thrombocytopenia due to complement activation by viral antigens binding to the platelets. We describe the case of a 62 year old hypertensive men who was operated for triple-vessel left main coronary artery disease. Preoperative echocardiography did not show any regional wall motion abnormalities and the ejection fraction was 60%. He underwent uneventful Off Pump CABG (OPCABG)technique The patient was transferred to the ICU and trachea was extubated 6 hours after surgery. On the second post-operative day, the patient was transferred to the ward. The laboratory values that time were: hemoglobin 10.6 G/dL, total white cell count 5,600/dL; and the platelet count 1,26,000/dL. He was afebrile and all the other investigations were normal. On the third post operative day, the patient developed high-grade fever (39-40 o C). On investigation, his hemoglobin was 9.1gm/dL; total white cell count 3,900/dL and the platelet count was 77,000/dL. He appeared swollen and had swelling of the body, arms, legs; pedal edema and pleural effusion. In view of the high-grade fever and decrease of platelet count the dengue serology was sent to the lab, which showed a positive dengue IgM antibody. subsequently, his platelet count decreased to 16,000/dL. He was again transferred to the ICU and transfused with platelet apheresis and the symptomatic treatment for fever was undertaken. The next day, the patient was afebrile and his platelet count started increasing up, to 57,000/dL. The patient had no petechiae and evidence of bleeding disorder till then. After the increasing trend of the platelet count was observed and with the patient was afebrile,, the patient was transferred back to the ward. He was discharged from the hospital on the ninth post operative day.

Dengue infection is transmitted by Aedes aegypti mosquito, which acquies the virus after biting a human infected by dengue fever. The incubation period varies from 5 to 8 days. The clinical fever can vary from mild, self-limited febrile syndrome (classical dengue) to dengue hemorrhagic fever characterized by thrombocytopenia (platelet count, <100Χ-10 3 dL) hemorrhagic manifestation and increased vascular permeability, [3] to dengue shock syndrome characterized by cardiovascular instability.

The critical phase of the disease is on the third to fifth day of the illness, when thrombocytopenia and hemoconcentration due to plasma leakage in the interstitium and pleural and abdominal spaces occurs. According to World Health Organization guidelines, mild-to-moderate dengue fever needs to be managed with intravenous fluid therapy for 24 to 48 hours and careful observation of the patient for progression of the disease process. [4] Although, no separate guidelines are available for surgical patients, those who continue to demonstrate thrombocytopenia and petechiae should be hospitalized and observed carefully for impending circulatory shock. During the pahse of thrombocytopenia, removal of the indwelling vascular catheters may cause hemorrhage due to the possible coagulopathy. There may be chances of profuse bleeding from the surgical sites, which should be kept in mind. Although in the reported patient the removal of indwelling catheter had already been done prior to the development of thrombocytopenia, anticipatory platelets transfusion is not warranted in all surgical patients, as low platelet counts do not necessarily predict a high chance of bleeding in dengue fever.

During the rainy season, the incidence of dengue fever increases significantly in India. In any postoperative patient with unexplained thrombocytopenia, this etiology should also be kept in mind; specific antigen/antibody tests should be performed, and the patient should be managed in the ICU if the patient develops DHF or dengue septic shock.

 
   References Top

1.Rigau-Pérez JG, Clark GG, Gubler DJ, Reiter P, Sanders EJ, Vorndam AV. Dengue and Dengue Haemorrhagic fever. Lancet 1998;352:971-7.  Back to cited text no. 1
    
2.Murray PR, Rosenthal KS, Kobayashi GS. Medical Microbiology. St. Louis: Mosby; 2002. p. 557-68.  Back to cited text no. 2
    
3.Worl Health Organization. Guidelines for treatment of dengue fever/ Dengue hemorrhagic fever in small hospitals. Regional office of South East Asia. New Delhi: WHO; 1999.  Back to cited text no. 3
    
4.Krishnamurti C, Kalayanarooj S, Cutting MA, Peat RA, Rothwell SW, Reid TJ, et al. Mechanisms of hemorrhagic in dengue without circulatory collapse. Am J Trop Med Hyg 2001;65:840-7.  Back to cited text no. 4
    

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Correspondence Address:
Yatin Mehta
Medanta Institute of Critical Care and Anaesthesiology,Sector 38, Gurgaon, Haryana - 122 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.81575

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