Fatal Fulminant Hepatic Failure in a Diabetic with Primary Dengue

We report a 49-year-old diabetic with dengue hemorrhagic fever who developed fulminant hepatitis, severe coagulopathy, shock, and refractory metabolic acidosis and died on the eighth day of illness. This is the only second report of an adult with fatal fulminant hepatic failure due to dengue, and the first case arising from a primary dengue infection. 1. Introduction Dengue is an arboviral illness caused by four serotypes (DEN-V 1 to 4) and is transmitted by the bite of an infected Aedes mosquito with an incubation period varying from 3 to 14 days [1]. Hepatic failure in dengue has been frequently reported in the pediatric population and is rare in adults [2]. Fulminant hepatic failure has been reported only in six adults as of 2007, one of whom, a Bangladeshi immigrant to England, had had a fatal illness with secondary dengue [3]. We report a case of fulminant hepatic failure arising from a primary dengue infection in a middle-aged diabetic that ended in his death. 2. Case Report This 49-year-old bus driver was admitted with complaints of fever, headache, bodyaches, nausea, and fatigue for 5 days prior to admission. He had been on oral hypoglycemic agents for the previous three years and did not smoke and was a teetotaler. Examination revealed a temperature of 100°F, tachycardia (105/min), normotension, and tachypnea (28/minute) in a tired and drowsy looking obese man (BMI-32？kg/m2). He had a palpable liver of 5？cm and right-sided pleural effusion (Figure 1). Pending reports, he was instituted on intravenous ceftriaxone and artesunate and oral doxycycline. Investigations showed hemoconcentration, thrombocytopenia, direct hyperbilirubinemia, transaminases elevation (aspartate transaminase/alanine transaminase (AST/ALT) = 2.3), prolonged activated partial thromboplastin time (aPTT) and prothrombin time, and prerenal azotemia with hyperkalemia (Table 1). Dengue IgM and NS1 antigen were positive, while malarial smear and scrub IgM ELISA were negative. Hepatitis panel and HIV were negative. Serum ceruloplasmin was normal. An abdominal ultrasonogram (day 2) revealed hepatomegaly, gall bladder edema, moderate ascites, and bilateral pleural effusion. Table 1: Laboratory values. Figure 1: Chest radiograph on day 1 with right-sided pleural effusion. An internal jugular central venous access was secured following platelet transfusion, and intravenous fluids (dextrose saline), fresh frozen plasma (FFP), intravenous vitamin K and thiamine, lactulose, and oral metronidazole were administered. Six hours after admission, he was intubated and mechanically ventilated