Dengue Fever Outbreak in Surgical Patients: Diagnostic Challenges and Outcome Impact, 2014

Dengue fever has re-emerged as a major arboviral infection in tropical countries [1]. It is a mosquito borne disease transmitted by Aedes aegypti [1]. There are five serotypes [2]. Clinical presentation varies from subclinical infection to high grade fever and even hemorrhagic shock [3]. Diagnosis of dengue is challenging when it presents with acute abdomen [1]. Dengue has been described during pregnancy [4] and after organ transplantation [5]. It adds to the morbidity in these conditions. Dengue fever complicating surgical gastroenterology patients has not yet been described. It is a diagnostic dilemma in this group, especially in post-operative period. Through this report, we intend to share our experience of managing peri-operative dengue fever.


Introduction
Dengue fever has re-emerged as a major arboviral infection in tropical countries [1]. It is a mosquito borne disease transmitted by Aedes aegypti [1]. There are five serotypes [2]. Clinical presentation varies from subclinical infection to high grade fever and even hemorrhagic shock [3]. Diagnosis of dengue is challenging when it presents with acute abdomen [1]. Dengue has been described during pregnancy [4] and after organ transplantation [5]. It adds to the morbidity in these conditions. Dengue fever complicating surgical gastroenterology patients has not yet been described. It is a diagnostic dilemma in this group, especially in post-operative period. Through this report, we intend to share our experience of managing peri-operative dengue fever.

Method
Six inpatients were diagnosed with Dengue fever in October and November 2014. The diagnosis was sought on high index of suspicion for unexplained fever or bleeding episodes with thrombocytopenia. All the patients underwent Dengue serology (IgM) using ELISA kit for confirmation. Details of the hospital stay, morbidity, outcome and mortality were recorded.

Case History
During the study period, six patients were diagnosed with dengue fever. All of them had fever, thrombocytopenia and positive dengue serology. Three patients (50%) developed bleeding manifestations and two of them succumbed to the illness (Table 1).

Open Access Journal of Surgery
Hospital stay was prolonged in rest of the four. The details of these patients are as follows: a) A 22 year female admitted as a case of adhesive obstruction underwent laparotomy. On postoperative day (POD) 3, she developed high grade fever. Complete blood count (CBC) revealed thrombocytopenia. Non-steroidal anti-inflammatory drugs (NSAIDs) were stopped immediately. She developed increased drain output, bleeding from the surgical wound and generalized itching on day 4 of fever. Dengue serology turned out to be positive. She was managed with intravenous fluids, paracetamol and component transfusion. Platelet levels recovered after day 6 of fever. She responded to conservative management and was discharged on POD 12. b) A 65 year male underwent CBD exploration for failed endoscopic clearance. He was planned for discharge when he developed high grade fever, followed by bleeding from surgical wound. His investigations revealed thrombocytopenia and positive dengue serology. Patient developed seizures on day 3 and finally succumbed to the illness. c) Another case of carcinoma stomach (45 year female) developed high grade fever during hospital stay. Her dengue serology was positive. On day 5 of fever, she developed hematemesis, melena and petechiae. Gastroduodenoscopy revealed multiple hemorrhagic spots in stomach oozing actively. She was transfused single donor platelet (SDP) and blood, but finally went into hemorrhagic shock and expired. d) Another 30 year male patient was admitted with diagnosis of acute enterocolitis. He also developed high grade fever on day 5 of admission. Diagnosis of dengue was confirmed on serology. He recovered on conservative management. e) An elderly male (74 years), being evaluated for high grade dysplasia esophagus, developed high grade fever. He was ELISA positive for dengue. He recovered over next 10 days and required SDP. The definitive surgery was delayed by one month.

f)
Similarly, definitive treatment was delayed in a patient of gall-bladder cancer who suffered from dengue fever with one episode of seizure.

Discussion
Dengue fever is an important public health problem. Majority of the patients respond to resuscitative measures, but a few that land up in hemorrhagic manifestations, require aggressive support. Early suspicion and diagnosis becomes more important in the post surgical patients, who are usually on NSAIDs for pain control. An added insult on thrombocytes by dengue can prove deleterious. Moreover, in a surgical ward, dengue is not the first suspicion of new onset fever. Bleeding as a complication thus becomes a more common presentation. In our report 50% patients had a bleeding manifestation; otherwise the reported incidence is 5-30%3. The increased incidence of dengue hemorrhagic fever in surgical patients reflects as increased mortality, as in our report (33%, 2/6).
One patient, who was recovering after CBD exploration, had received 4 days of NSAIDs post-operatively. The other patient had a malignant ulcer in the stomach which bled to death due to thrombocytopenia. Taking lessons from the two mortalities, we shifted to opiates for pain control in all our patients during the outbreak.
Dengue fever delayed the definitive management of two patients and prolonged the hospital stay in others. This adds to the total cost of treatment. A delay of 3-4 weeks in surgery may render malignant diseases unresectable. One should be vigilant enough and suspect dengue as an important cause of fever in a surgical ward, especially in patients with increased drain output or surgical site bleeding. Early diagnosis is the key to decrease morbidity and mortality.

Conclusion
Dengue fever should be suspected in all patients with perioperative rise of temperature, particularly in endemic regions. During an outburst of Dengue, a clinician should refrain from using non steroidal anti-inflammatory drugs (NSAIDs) for pain control.