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LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 5  |  Page : 541-543

Spinal epidural hematoma with myelitis and brainstem hemorrhage: An unusual complication of dengue fever


1 Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
2 Department of Neuroanaesthesia, All India Institute of Medical Sciences, New Delhi, India

Date of Submission14-Jul-2013
Date of Decision20-Jul-2013
Date of Acceptance13-Oct-2013
Date of Web Publication22-Nov-2013

Correspondence Address:
Pankaj Kumar Singh
Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.121946

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How to cite this article:
Singh M, Garg K, Bisht A, Sharma BS, Singh PK, Pandia M, Mahapatra A. Spinal epidural hematoma with myelitis and brainstem hemorrhage: An unusual complication of dengue fever. Neurol India 2013;61:541-3

How to cite this URL:
Singh M, Garg K, Bisht A, Sharma BS, Singh PK, Pandia M, Mahapatra A. Spinal epidural hematoma with myelitis and brainstem hemorrhage: An unusual complication of dengue fever. Neurol India [serial online] 2013 [cited 2019 Aug 23];61:541-3. Available from: http://www.neurologyindia.com/text.asp?2013/61/5/541/121946


Sir,

Dengue fever is the commonest arboviral disease. [1] The common neurologic complications include encephalitis and encephalopathy. Hemorrhagic complications due to thrombocytopenia can affect a part of the neuroaxis. We report a case of dengue fever with a dorsal spinal epidural hematoma and brainstem hemorrhage.

A 45-year-old male had moderate grade intermittent fever (102 F) with myalgia and headache for 7 days. On day 4 of the illness he developed urinary retention, which required catheterization. This was followed by rapid onset weakness and reduced sensation in both lower limbs, which progressed to complete paraplegia over 3-4 hours. Magnetic resonance imaging (MRI) of spine revealed an epidural hematoma with severe cord compression at T9-11 level [Figure 1], for which he was managed conservatively at a district hospital. On day 6 of his illness he started developing weakness in both upper limbs. He presented to us on day 7 of illness and had flaccid quadriplegia with total sensory loss below C4. He required mechanical ventilation. MRI of spine and brain revealed cord expansion and signal changes in whole cord in addition to a T9-11 epidural hematoma [Figure 2]. Screening MRI of the brain was normal. His coagulation parameters were within normal limits. Patient underwent T9-11 laminectomy and evacuation of the epidural hematoma. He had diffuse bleeding from the entire operative field and lost 4,000 ml of blood in surgery. He developed thrombocytopenia in postoperative period. Dengue serology was done in view of intraoperative bleeding and low platelet counts, and history of fever, and immunoglobulin M (IgM) for dengue was found to be positive. He required multiple blood and platelet transfusions. There was no improvement in his weakness. He had recurrent episodes of bradycardia in postoperative period. On day 10 of surgery, his Glasgow coma scale was E1VetM1 and non-contrast computed tomography (CT) brain revealed brain stem hemorrhage [Figure 3]. The patient died on the day 18 of illness.
Figure 1: Sagittal T2 magnetic resonance imaging (MRI) showing dorsal epidural hematoma at time of paraplegia

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Figure 2: Saggital T2 MRI showing dorsal haematoma with holocord signal changes at stage of quadriplegia, holocord signal change with cord expansion

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Figure 3: Axial brain non contrast CT scan 15/10/11 showing medullary bleed

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The first episode of dengue fever is usually self-limiting. Subsequent infection with a heterologous dengue virus serotype is the main factor for severe dengue via 'antibody dependent enhancement'. [2] The bleeding tendency seen in dengue is due to thrombocytopenia, capillary leakage, coagulation abnormalities, and hepatic dysfunction. Central nervous system (CNS) involvement in dengue is rare with the reported rates varying from 0.88 to 5.4%. The CNS involvement may be due to direct invasion (encephalitis, meningitis, and myelitis), secondary to systemic complications (encephalopathy and hypokalemia paralysis) or post-infectious acute disseminated enecephalomyelitis (ADEM). The involvement of the CNS may also be secondary to coagulopathy induced bleeding. [3],[4] Our patient in the course of the illness developed quadriparesis and MRI showed cord swelling and diffuse cord signal changes. The possible explanations for these findings could be dengue myelitis or related to cord ischemia. However, it would be difficult to clearly define what would be the pathology. A case of myelitis due to direct viral infection with MRI abnormalities limited to the gray matter has been documented. [5] The management of dengue fever and its complications consists of supportive care and treatment of complications.

 
  References Top

1.Jha S, Ansari MK. Dengue infection causing acute hypokalemic quadriparesis. Neurol India 2010;58:592-4.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.Dey AB, Chaudhury D, Mohapatra AK, Nagarkar KM, Malhotra OP. Fever, mucocutaneous haemorrhage, and severe headache during an epidemic of haemorrhagic fever. Postgrad Med J 1998;74:433-5.  Back to cited text no. 2
[PUBMED]    
3.World Health Organization: Dengue. Guidelines for diagnosis, treatment, prevention, and control, New edition. Geneva: WHO; 2007.  Back to cited text no. 3
    
4.Schmidt AC. Response to dengue fever-the good, the bad and the ugly. N Engl J Med 2010;363:484-7.  Back to cited text no. 4
[PUBMED]    
5.Kunishige M, Mitsui T, Tan BH, Leong HN, Takasaki T, Kurane I, et al. Preferential gray matter involvement in dengue myelitis. Neurology 2004;63:1980-1.  Back to cited text no. 5
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]

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