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NI FEATURE: FACING ADVERSITY…TOMORROW IS ANOTHER DAY! - LETTERS TO EDITOR
Year : 2019  |  Volume : 67  |  Issue : 2  |  Page : 530-531

A report of quadriparesis in dengue fever due to hematomyelia


Department of General Medicine, Vijaya Hospital, Chennai, Tamil Nadu, India

Date of Web Publication13-May-2019

Correspondence Address:
Dr. M Senthil Kumar
S1, Second Floor, Subham Villa, Thirunagar First Main Road, Vadapalani, Chennai - 600 026, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.258054

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How to cite this article:
Kumar M S, Srinanthini K R, Gopal S. A report of quadriparesis in dengue fever due to hematomyelia. Neurol India 2019;67:530-1

How to cite this URL:
Kumar M S, Srinanthini K R, Gopal S. A report of quadriparesis in dengue fever due to hematomyelia. Neurol India [serial online] 2019 [cited 2019 May 24];67:530-1. Available from: http://www.neurologyindia.com/text.asp?2019/67/2/530/258054




Sir,

Dengue fever, a common tropical infection in India, can present with neurological manifestations in 0.5%–20% of cases.[1] We report a case of quadriparesis in a patient with dengue hemorrhagic fever causing hematomyelia, that is, bleeding within the cord substance. A thorough literature search revealed that there has been no case of hematomyelia reported due to thrombocytopenia or dengue fever till date.

A 66-year old female patient with no known medical comorbidities was admitted in November 2017 with complaints of melena and back pain for 3 days and with sudden-onset weakness of bilateral upper and lower limbs. She had a history of fever lasting for 1 week which settled 3 days prior to admission. She was catheterized in an outside hospital in view of acute retention of urine. At the time of presentation, her power was 1/5 in upper limbs, 0/5 in lower limbs, and 1/5 in neck muscles. Deep tendon reflexes were absent with a mute plantar reflex. Sensory examination was normal. Her illness occurred during the dengue outbreak in South India during the months of September to December 2017. Her electrocardiogram showed QTc prolongation with a U-wave. The blood investigations revealed thrombocytopenia, with normal prothrombin time/international normalized ratio and activated partial thromboplastin time values as well as hypokalemia.

A provisional diagnosis of hypokalemic paralysis was made due to possible dengue fever and the patient was treated with intravenous potassium supplementation. Fresh frozen plasma and single-donor platelet transfusion was done to correct the bleeding manifestations, but there was no improvement in the weakness. Potassium levels also reached a normal stage. Her dengue serology was positive for nonstructural protein 1 antigen (NS1Ag), immunoglobulin M (IgM), and immunoglobulin G (IgG) indicating a secondary dengue fever. Ultrasound of the lower chest and abdomen revealed bilateral pleural effusion and acute acalculous cholecystitis with ascites. The patient did not show any sign of improvement in her neuromuscular weakness. Hence, intravenous immunoglobulin (IVIg) therapy was started suspecting the possibility of Guillain–Barre syndrome (GBS). It was given at the dosage for 0.4 g/kg/day. On day 3, the patient developed respiratory paralysis with worsening of Glasgow coma scale (GCS) and had to be intubated for providing mechanical ventilation. Despite the administration of IVIg and potassium supplementation, the patient did not show any sign of improvement, hence a magnetic resonance imaging (MRI) scan of the brain with MRI of the spine were done. MRI of the brain showed the presence of an acute subarachnoid hemorrhage with intraventricular hemorrhage [Figure 1], and MRI of the spine showed the presence of an acute subarachnoid hemorrhage in the cervical and dorsal regions with hemorrhage in intramedullary segments of cervical and dorsal spinal cord with cord edema [Figure 2] and [Figure 3].
Figure 1: MRI brain, T2 FLAIR sequence showing the subarachnoid hemorrhage with intraventricular hemorrhage

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Figure 2: T2 sequence at the cervical level showing the subarachnoid hemorrhage with intramedullary hemorrhage (hematomyelia), indicated by dotted arrow, with cord edema and a hematoma compressing the posterior aspect of brainstem, cerebellum, and cord at the level of foramen magnum, indicated by the solid arrow

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Figure 3: T2-weighted image at the thoracic and lumbar level with intramedullary hemorrhage extending upto T9 segment and the presence of subarachnoid hemorrhage

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The patient had a drop in her hemoglobin and platelet levels, for which packed cells and platelet transfusion were done. She did not have any improvement in her GCS and it remained E1VTM1. She had recurrent episodes of bradycardia. Echocardiogram showed global hypokinesia of the left ventricle and troponin I was positive indicating the presence of dengue myocarditis. Her chest X-ray showed bilateral infiltrates. The endotracheal secretion culture grew Acinetobacter baumannii, and blood cultures grew Burkholderia cepaciae. She did not have a spontaneous respiration since the 5th day of admission and eventually succumbed on her 6th day of admission, that is, the 13th day of illness.

The neurological manifestations of dengue can be due to the neurotrophic effects of the virus causing encephalitis and meningitis, systemic complications of dengue infection, and postinfectious complications such as GBS or acute disseminated encephalomyelitis.[2] Quadriparesis in dengue fever is most often due to hypokalemic paralysis,[3] myositis,[4] myelitis,[2] or GBS.[5] An occasional case of compressive myelopathy due to cervical epidural hematoma[6],[9] has also been reported. Hematomyelia or intramedullary spinal cord hemorrhage is a rare neurological disorder that often leads to permanent disability. The causes can be traumatic or atraumatic. The atraumatic causes include the presence of a spinal arteriovenous malformation, spinal tumor, anticoagulant usage, and bleeding diathesis. There has been no case of hematomyelia secondary to thrombocytopenia reported so far.[7],[8] There was a case report of quadriparesis in dengue secondary to longitudinal extensive transverse myelitis with a cervical epidural hematoma, which improved after IVIg administration and plasmapharesis.[9] Although the common causes of quadriparesis in a case of dengue include hypokalemic paralysis, myositis, myelitis, and GBS,[2],[3],[4],[5] the suspicion of hematomyelia is also warranted as a bleeding tendency secondary to thrombocytopenia and platelet dysfunction is an important element in the pathogenesis of the disease. As there are no clear guidelines for the management of acute hematomyelia, its treatment varies from person to person. However, many surgeons advocate the evacuation of a spinal cord hematoma to minimize cord injury. High-dose methyl prednisolone has been tried in one case, but enough evidence to argue for or against this intervention is missing.[7] In the presence of thrombocytopenia, a surgical evacuation in a case of dengue fever is a challenging task. An early diagnosis and a prompt supportive care can be tried in cases; however, a good prognosis cannot be guaranteed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Li GH, Ning ZJ, Liu YM, Li XH. Neurological manifestations of dengue infection. Front Cell Infect Microbiol 2017;7:449:1-13.  Back to cited text no. 1
    
2.
Murthy JM. Neurological complications of dengue Infection. Neurol India 2010;58:581-4.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Jha S, Ansari MK. Dengue infection causing acute hypokalemic quadriparesis. Neurol India 2010;58:592-4.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Kalita J, Misra UK, Mahadevan A, Shankar SK. Acute pure motor quadriplegia: Is it dengue myositis? Electromyogr Clin Neurophysiol 2005;45:357-61.  Back to cited text no. 4
    
5.
Kumar S, Prabhakar S. Guillain-Barre syndrome occurring in the course of dengue fever. Neurol India 2005;53:250-1.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Verma SP, Himanshu D, Tripathi AK, Vaish AK, Jain N. An atypical case of dengue haemorrhagic fever presenting as quadriparesis due to compressive myelopathy. BMJ Case Reppii: bcr1020103421. doi: 2011;10.1136/bcr.10.2010.3421.  Back to cited text no. 6
    
7.
Leep Hunderfund AN, Wijdicks EF. Intramedullary spinal cord hemorrhage (hematomyelia). Rev Neurol Dis 2009;6:E54-61.  Back to cited text no. 7
    
8.
Shaban A, Moritani T, Al Kasab S, Sheharyar A, Limaye KS, Adams HP Jr. Spinal cord Hemorrhage. J Stroke Cerebrovasc Dis 2018;27:1435-46.  Back to cited text no. 8
    
9.
Fong CY, Hlaing CS, Tay CG, Kadir KA, Goh KJ, Ong LC. Longitudinal extensive transverse myelitis with cervical epidural haematoma following dengue virus infection. Eur J Paediatr Neurol 2016;20:449-53.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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