A 14-y-old boy was admitted with high fever since 8 d, vomiting, pain in abdomen and decreased urine output since 1 d. On admission, the systolic blood pressure was 70 mm Hg with poor perfusion requiring fluid rescusitation and inotropic support. Relevant investigations were done. Hematocrit was very high – Hb 20.7 g % , PCV 61.5 and platelet count was 110 × 103/mm3. Dengue IgG was strongly positive, IgM was negative and blood bactec was negative. Radiograph chest revealed right pleural effusion.
Clinical picture and investigations suggested diagnosis of dengue shock syndrome. Patient was electively intubated and ventilated in view of poor perfusion and unstable hemodynamics. Patient required multiple fluid boluses and upward titration of inotrope and vasopressor support. Serial monitoring of PCV was done.PCV values were as follows: 61.5 at admission, 54.8 at 8 h, 50 at 10 h and 37 at 14 h of admission.
At 10 h of admission, patient had poor perfusion, cold peripheries, oliguria and severe hypertension with BP of 150/120 mm Hg suggestive of severe vasoconstriction. Also, abdomen felt very firm and rigid. Clinical picture suggested abdominal compartment syndrome. Ascitic tap was done and continuous ascitic drain was kept. Also, milrinone drip was started and adrenalin drip reduced to decrease vasoconstriction. Ascitic fluid drainage was continued. Patient responded well with improvement in perfusion and subsidence of severe hypertension. Approximately 2.7 l of ascitic fluid was drained, following which abdomen became soft. Patient was extubated after 24 h of ventilation and thereafter made an uneventful recovery.
An 8-y-old girl was referred to the authors’ hospital with history of fever since 6 d and one episode of hemoptysis following which she became breathless. On admission, she was cyanosed, restless with laboured breathing and therefore, was intubated and ventilated. On ET suctioning, fresh blood and blood stained secretions were suctioned. High ventilator settings were required to maintain adequate oxygen saturation (>90%). Radiograph chest done was suggestive of ARDS. Patient required PRBC, FFP and platelet transfusions. She also required fluids, dopamine and nor-adrenalin infusion to maintain adequate blood pressure and perfusion. PT/ PTT sent prior to giving any blood products was normal and platelet count was 87000/mm3. Dengue IgG was strongly positive whereas Dengue IgM was negative. Clinical picture and lab investigations suggested diagnosis of dengue shock syndrome. Inotropes were omitted on day 4 and patient could be weaned from ventilator on day 5 of admission.
Post extubation, child was doing well and had normal sensorium. However, 12 h post extubation, she had 2 episodes of generalised tonic clonic seizure. CBC and metabolic work up done were normal. Sensorium remained normal and loading dose of phenytoin was given. Next day, patient had multiple episodes of convulsions following which sensorium became altered with drowsiness, aggressive behaviour and hallucinations. Loading dose of phenobarbitone and IV valparin were given. Patient remained afebrile during these events.
CT scan of the brain was done which suggested bilateral frontal and occipital lobe hypodensities in the white matter suggested of demyelination. Pediatric neurologist’s opinion was taken. In view of clinical picture and CT brain findings, diagnosis of ADEM was made. She was started on pulse dose intravenous methylprednisolone 30 mg/kg once a day for 3 d. She showed dramatic improvement and was completely normal neurologically after 2nd pulse dose of methylprednisolone. After 3 pulse doses of methylprednisolone, oral prednisolone was started in the dose of 2 mg/kg/day and given for a total of 14 d in a tapering dose. She was discharged after 15 d of hospitalization and was neurologically normal at discharge.