Case history
Case history #1
A 21-year-old man presents with a 3-day history of a continuous high fever. He reports generalised aches and pains that originate in the lower back, a headache that is more severe in the front of the head, and retro-orbital pain that gets worse with eye movement. He has a reduced appetite, but is able to tolerate liquids and reports no other significant symptoms. He lives in a suburb in the US where many cases of dengue fever have been reported recently. On examination, he has a temperature of 38.3°C (101°F), blood pressure of 110/80 mmHg, and a radial pulse rate of 92 bpm. It is noted that he has a generalised skin flush over his body that is more noticeable on his face, ears, and lips, and that blanches with finger pressure. His hands and feet are warm, and capillary refill time is <2 seconds. He is breathing normally and his tongue is a little dry.
Case history #2
A 13-year-old girl presents with a 5-day history of a high fever. She also reports severe retro-orbital pain, bone and joint pain, nausea, constipation, and upper abdominal pain. She has vomited twice and complains of vaginal bleeding, which she attributes to menstruation. She feels dizzy and as if she is going to faint when she tries to get up. She passed urine only twice on the previous day. On examination, she is febrile and looks ill and dehydrated. A rubelliform rash with dusky red blotches and petechiae is seen on her limbs. Her hands and feet are cold to the touch and have a bluish tint. Capillary refill time is >3 seconds, respiratory rate is 22 breaths per minute, pulse rate is 108 bpm, and supine blood pressure is 90/80 mmHg with a postural drop of 30 mmHg. Her abdomen is mildly distended, the epigastrium is tender to palpation, and there is flank dullness.
Other presentations
Other manifestations are less common but should be considered. Encephalopathy should be considered if the patient develops altered levels of consciousness. Specifically, hepatic encephalopathy should be considered in patients presenting with jaundice or asterixis (liver flap or flapping tremor). Encephalitis should be considered in patients with seizures. Myocarditis should be considered in patients with excessive or unusual tiredness, chest discomfort, hypoxia, tachycardia or bradycardia, or ECG changes (including T-wave inversion or bundle-branch blocks). Acalculous cholecystitis, hepatitis, acute pancreatitis, or acute appendicitis should be considered in patients with prominent gastrointestinal manifestations (e.g., watery diarrhoea, right upper or lower quadrant pain). Rhabdomyolysis, persistent thrombocytopenia, and haemophagocytic syndrome may also occur.[1] Rarely, dengue infections may be accompanied by concurrent bacteraemia. Risk factors may include severe dengue infection, older age, and the presence of comorbidities.[4]
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