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160 Lymphedema in Dengue Fever – an Unreported Case Downloaded from www.medrech.com “Lymphedema in dengue fever – An unreported case” Medrech ISSN No. 2394-3971 Case Report LYMPHEDEMA IN DENGUE FEVER – AN UNREPORTED CASE Ching Soong Khoo 1* , Wan Yi Leong 1, Rosaida Md Said 1, Suguna Raman 2, Pushpagandy Ramanathan 2, Petrick Periyasamy 3 1. Department of Internal Medicine/ Ampang Hospital/ Jalan Mewah Utara, Taman Pandan Mewah, 68000 Ampang, Selangor, Malaysia 2. Department of Radiology/ Ampang Hospital/ Jalan Mewah Utara, Taman Pandan Mewah, 68000 Ampang, Selangor, Malaysia 3. University Kebangsaan Malaysia Medical Centre/ Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia Submitted on: October 2015 Accepted on: October 2015 For Correspondence Email ID: Abstract Dengue fever is a neglected tropical disease, which is rearing its ugly head in increasing numbers of both morbidities and mortalities in Malaysia. As of August 18, 2015, a total of 76819 dengue cases and 212 dengue deaths have been reported for 2015 according to Malaysian health officials [1]. Atypical presentations of dengue fever are also on the rise, which are underreported or unrecognized due to lack of awareness [2,3,4]. Lymphedema complicating dengue fever has not been reported in any literature. We detail this case to highlight the varied manifestations of dengue fever. Keywords: Dengue fever, lymphedema Introduction Case Report According to the World Health Organization A 38-year-old Nepalese gentleman (WHO), dengue fever is most commonly an presented to the Emergency Department acute febrile illness defined by the presence with fever for three days, arthralgia, of fever and two or more of the following, myalgia, persistent vomiting, epigastric pain retro-orbital or ocular pain, headache, rash, and productive coughs. He had been in myalgia, arthralgia, leukopenia, or Malaysia for ten months and worked as a hemorrhagic manifestations. It is a systemic security guard. He stayed in a dengue-prone ronicles, 2015 and dynamic disease [5] . Dengue fever is a area. Upon arrival, he was alert, conscious, vector-borne disease transmitted by several and not tachypneic. His height and weight Ch species of mosquito within the genus Aedes , were 1.67m and 65kg respectively. He was principally A. aegypti . Treatment of dengue febrile at 38.4 degrees Celsius. Otherwise, fever is mainly supportive and there is no his other vital signs were stable. He had search vaccine available at present. bibasal crackles and widespread expiratory Re rhonchi on respiratory examination. ico Cardiovasular examination revealed no Med Khoo C. S. et al , Med. Res. Chron., 2015, 2 (5), 687-692 687 Downloaded from www.medrech.com “Lymphedema in dengue fever – An unreported case” murmurs and no signs of pulmonary heaviness, making ambulation difficult. hypertension. Other system examination was Clinical examination revealed non-pitting unremarkable and he did not have any signs edema up to bilateral knees. They were of plasma leakage. His blood investigations neither tense nor tender. No skin changes, upon arrival were as follows: positive ulcerations or varicose veins were found on dengue non-structural protein-1 (NS1 clinical examination. Femoral, popliteal, antigen) on Dengue Combo Rapid Test Kit, posterior tibial and dorsalis pedis pulses hemoglobin 13.5g/dL, hematocrit 35.1%, were well felt. There was no edema in other white blood cell 4.1 x 10 9/L, platelet 139 x body parts. He claimed that the swollen legs 10 9/L, albumin 39g/L, alanine trasaminase occurred on day six of illness (critical phase) (ALT) 44U/L, aspartate transaminase and this had never happened previously. (AST) 91U/L, activated partial There was no recent history of fall or trauma thromboplastin time (APTT) 45.8 seconds, to the legs. He had no symptoms of heart urea 2.8mmol/L, creatinine 112 µmol/L. failure prior to admission. His creatinine Dengue IgM was detected on day five of was normalized at 70µmol/L. ALT and AST illness and blood films for malarial parasites peaked at 93U/L and 118U/L respectively. were repeatedly negative. Electrocardiogram He was not hyperglycemic in the ward with showed sinus rhythm. His chest film was HbA1c 5.5%. His thyroid function test was normal. He was then admitted with dengue normal. Microfilariae were not detected on fever in febrile phase with warning blood films. He had no proteinuria. Results symptoms (persistent vomiting and of serological testing for HIV, syphilis, abdominal pain) and acute bronchitis. He hepatitis B and hepatitis C were negative. was managed with intravenous fluids, Ultrasound revealed minimal right pleural Augmentin and nebulised Combivent. effusion with no pericardial effusion. There He had an uneventful stay in the ward till he were no abdominal mass and ascites too. reached critical phase on day six of illness. ECHO was normal with ejection fraction Apart from tachycardia, he was tachypneic 70%. requiring nasal prong oxygen support. Ultrasound Doppler of both lower limbs Plasma lactate crept up to 3.2mmol/L. We revealed no evidence of deep vein also noticed non-pitting edema in his lower thrombosis. However, there were bilateral limbs since the day before (day five of enlarged inguinal lymph nodes and illness). Breath sound was reduced on the subcutaneous edema of both lower limbs right base. He was subsequently transferred (Figure 1 & 2). The edema was found from to the High Dependency Ward (HDU) for bilateral feet up to thighs. We managed him compensated dengue shock syndrome with with compressive bandage and leg elevation right pleural effusion and pneumonia. in the ward. Five days later, he ambulated Antibiotics were upgraded to ceftriaxone well and repeated ultrasound was normal (no and azithromycin. more enlarged lymph nodes and This gentleman remained stable with nasal subcutaneous edema). Calf and thigh were ronicles, 2015 prong oxygen at the HDU. He was not measured at 32cm (from 38cm) and 42cm Ch transfused and was not on any vasopressors. (from 52cm) respectively upon discharge. On day nine of illness (recovery phase), he He remained well and had no more leg was transferred back to the dengue ward. He swelling two months later in the clinic for search was stable and had no warning symptoms. follow-up. His chief concern was the leg swelling and Re ico ico Med Khoo C. S. et al , Med. Res. Chron., 2015, 2 (5), 687-692 688 Downloaded from www.medrech.com “Lymphedema in dengue fever – An unreported case” Figure 1. Subcutaneous edema in the right proximal thigh. ronicles, 2015 Ch search Re ico Figure 2. Subcutaneous edema in the left calf. Med Khoo C. S. et al , Med. Res. Chron., 2015, 2 (5), 687-692 689 Downloaded from www.medrech.com “Lymphedema in dengue fever – An unreported case” Discussion is classified as primary (genetic) or With rapid population growth, tremendous secondary (acquired) lymphedema [9] . urbanization and inappropriate sanitary Primary lymphedema can further be measures, incidences of dengue fever have classified into congenital, precox and tarda increased exponentially over the years. As [10] . Primary lymphedema is caused by either of August 1, 2015, the number of dengue congenital hypoplasia or aplasia of the cases is 28.6% higher compared with the peripheral lymphatics; or valvular same reporting period of 2014 in Malaysia incompetence. In secondary lymphedema, according to the Dengue Situation Update the lymphatic failure is caused by either by the World Health Organization (WHO). acquired blockade of the lymph nodes or Dengue fever poses a substantial economic disruption of the lymphatic channels. Its and disease burden particularly in Malaysia, causes are summarized in table 1 [10] . which is an endemic country [6] . In filariasis, the adult worms cause damage One of the problems that clinicians are to the lymph vessels either by dilating them facing now in treating dengue fever is the or inhibiting their contractility [11] . The increasingly atypical manifestations and common etiological agents for lymphatic complications. Non-pitting edema filariasis are Wuchereria bancrofti, followed complicating dengue fever, to our best by Brugia malayi and Brugia timori . knowledge, has not been reported in medical Recurrent skin infections, such as cellulitis literature. Non-pitting edema is defined and erysipelas cause lymphedema via when indentation does not persist after lymphangitis and lymphadenitis [12] . applying pressure to the swollen area. Its Lymphedema, mainly in the acral causes include lymphedema, myxedema and distribution, is seen in chikungunya fever lipedema [7] . [13] . Herpes simplex virus type 2 has been Our patient developed bilateral leg swelling found to be associated with lymphedema on day five of illness (entering critical [14,15] . phase) and resolved nine days later. Dengue fever can cause generalized Common causes of edema have been ruled lymphadenopathy [16] . Lymphadenopathy is out in our case such as heart failure, liver common [17] and Halstead SB et al. reported failure, nephrotic syndrome, deep vein 26-50% of lymphadenopathy in dengue thrombosis and filariasis [8] . He was not fever. Our patient developed bilateral obese with body mass index 23.3. He did not inguinal lymphadenopathy as evidenced by ingest any drugs known to cause edema. ultrasound. We believe that lymphedema in There were no features suggestive of venous this case is due to the obstruction from the insufficiency. His thyroid function was enlarged inguinal lymph nodes. Subsequent normal. His hepatitis, syphilis and HIV ultrasound did not reveal any more enlarged
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