Dengue Viral Myositis Complicated with Rhabdomyolysis and Superinfection of Methicillin-Resistant Staphylococcus aureus

Dengue is endemic in Sri Lanka and the physician should be aware of different and unusual presentation of the illness. Rhabdomyolysis is a well-known complication following many viral and bacterial infections; however, only a few cases have been reported with dengue viral infections. Further occurrence of coinfection by dengue and bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) has been underestimated, and few reports have been published so far. This case describes a 17-year-old boy who presented with prolonged severe myalgia, dark red urine, and a febrile illness that was diagnosed as having dengue viral myositis, dark red urine, and a febrile illness that was diagnosed as having dengue viral myositis complicated with rhabdomyolysis and superinfection of MRSA. Despite intensive care management, he died due to multiorgan failure. Autopsy and serological studies confirmed the diagnosis. This case stresses that red-coloured urine in dengue patients is not always due to haematuria, and if a patient’s vital signs do not respond to appropriate fluid management in DHF, sepsis from a secondary pathogen including MRSA should be suspected. 1. Introduction Dengue is endemic in Sri Lanka, and the diagnosis of dengue fever or dengue haemorrhagic fever (DHF) is not usually a challenge to the physician. However, the diagnosis of dengue fever with super infection and additional pathology is a diagnostic challenge as there can be atypical presentations, and if the diagnosis is delayed, the risk of morbidity and mortality increases. This paper describes a rare presentation of dengue fever. 2. Case Report A 17-year-old boy was transferred to a tertiary centre with an acute febrile illness from a primary care facility on the 4th day of the illness. He had fever with severe myalgia for 4 days. He also had a productive cough with yellowish sputum, but there was no haemoptysis. Three days, he had watery diarrhoea, and during the latter part of his stay at primary care center, he developed oliguria and the urine became red in colour. He denied substance abuse, self-ingestion of antipsychotic medications, or heavy manual exertion prior to the illness. He was not exposed to muddy water or paddy fields. On examination, he was alert with an GCS of 15/15, but looked unwell and had a temperature of 38.4°C. He had generalized muscle tenderness with restricted movements due to muscle pain. He had a regular, low-volume pulse of 102 beats per minute. His supine blood pressure was 100/80？mm？Hg. Chest auscultation detected a dual rhythm with no murmurs, and both lung