Indian Pediatr 2011;48: 737
Persistent Thrombocytopenia in Dengue
GP Prashanth and Shrinath B Mugali,
SDM College of Medical Sciences and Hospital, Dharwad;
and Sneh Children’s Nursing Home
and Research Center, Hubli, Karnataka, India.
A five-year-old previously healthy, male child from Hubli presented with
confirmed dengue hemorrhagic fever on seventh day of illness. At
admission, his total leucocyte count was 8500/cmm, hematocrit 40% and
platelet count 50,000/cmm. Liver function test was normal. There was no
proteinuria or hematuria. On Day 3 of admission, he developed acute
respiratory distress syndrome(ARDS) and was ventilated for next fifteen
days (he later had ventilator-associated-pneumonia). Meanwhile, platelet
count dropped to as low as 7,000/cmm requiring alternate day SDP (single
donor platelets) transfusions. For next four weeks, he had persisting
intermittent fever spikes without any focus of infection. He received a
total of 10 units of SDP to maintain the platelet counts above 20,000/cmm,
without bleeding manifestation. Bone marrow aspirate on fifth week of
illness was normal. The patient received intravenous immunoglobulins (IVIg)
and later, anti-D immune globulin (250IU/kg) intravenously; platelets
transiently went up to 35,000/cmm. On day 44, the child suddenly developed
features of raised intracranial tension and had massive pulmonary
hemorrhage. He died of intractable hypovolemic shock. Just before death,
platelet count was 12,000/cmm, confirmed by peripheral smear examination.
DIC profile was normal. Autopsy findings suggested massive cerebral
intraparenchymal hemorrhage along with pulmonary and gastric mucosal
It is well known that thrombocytopenia is short-lived
in dengue illness and platelet counts recover with clinical improvement.
Primary post-dengue immune thrombocytopenic purpura (ITP) responds to
steroid therapy . Though we did not go for anti platelet-associated
antibody (PAIg) assay, thrombocytopenia caused by such antibodies is
transient . Alloimmunization to multiple platelet transfusions is less
likely as we used single donor platelets (SDP). In our case, Anti-D
immunoglobulin failed to improve platelet counts. Lack of response to IVIg
was similar to the observation by Dimaano et al. .
Dengue virus is known to induce aberrant immune
activation and cytokine (IL-6) overproduction leading to enhanced
production of anti-platelet and anti-NS1 (nonstructural protein-1 antigen)
antibodies cross-reacting with human platelets . However, none of the
recent findings suggest any mechanism that can explain persistence of
thrombocytopenia following dengue infection. Immune clearance of platelets
by macrophages may not be the primary mechanism in this disease .
In view of possibility of intercurrent illness in ICU
and sepsis delaying recovery from thrombocytopenia, we had blood and urine
samples cultures twice which showed no growth of bacteria and fungal
elements. We also considered the possibility of co-existing rickettsial
infection and malaria and treated appropriately. Atypical evolution of
dengue hemorrhagic fever can cause prolonged fever in dengue illness .
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