CASE REPORT

Hemoperitoneum in Dengue Fever with Normal Coagulation Profile

Nagesh Kumar Talakad Chandrashekar, Rashmi Krishnappa1, Chandra Sekara Reddy,
Arun Narayan
Departments of Internal Medicine and 1Pathology, MS Ramaiah Medical College and Teaching Hospital, Bengaluru,
Karnataka, India

ABSTRACT
A 43-year-old male living in Bengaluru sought emergency services due to high-grade fever, headache, myalgia, abdominal pain
and distension. Platelet count (except the first-96,000/mm3) and coagulation profile was in normal limits. The dengue serology
was positive for IgM and Ig G (immunoglobulin M and G) antibodies. Ultrasound abdomen showed gross ascites, mild bilateral
pleural effusion and hepatosplenomegaly. The patient continued to have abdominal pain and progressive distention Ascitic tap was
hemorrhagic. Later laparoscopy showed 1.5 liters peritoneal fluid with blood clots and mild diffuse congestion of the peritoneum.
Liver, spleen and blood vessels were normal. Then what would be the possible mechanism to explain hemoperitoneum, is it the
increased vascular permeability caused by the virus? India being endemic for dengue illness, it is an interesting and rare case
presentation.

Key words: Coagulation profile, Dengue, Hemoperitoneum, Laparoscopy, Ultrasound

INTRODUCTION secondary to spontaneous rupture of the spleen.[4-6] We

report an interesting case of serologically confirmed

T wo-thirds of the world’s population lives in areas

infested with dengue vectors, mainly Aedes aegypti.[1]
The dengue virus was first isolated in India in Kolkata
dengue-positive patient with hemoperitoneum.

in 1945. Dengue illness is caused by four distinct dengue
virus types, 1, 2, 3 and 4 belonging to the genus flavivirus of
family togaviridae and all four types are prevalent in India.[1]
Dengue illness is clinically characterized by sudden
onset of fever, intense headache, retro-orbital pain,
myalgia, maculopapular rash, generalized erythema, and
minor bleeding manifestation like petechial rashes, gum
bleeding, subconjunctival hemorrhage; severe hemorrhagic
manifestations like epistaxis, hematemesis, hematuria
and hemoperitoneum are also observed.[2] Hemorrhagic
manifestations are observed at every stage of the illness
and are probably the summation of the ill-understood
viral pathogenesis as well as host factors that result in the
incompetence of the vascular endothelium.[3] There are
few case reports of dengue illness with hemoperitoneum
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CASE REPORT
A male aged 43 years, residing in Bengaluru sought
emergency services in July 2010. He presented with
high-grade fever since four days and headache, myalgia,
abdominal pain with distension since two days. He was
a known diabetic (blood sugars were under control
throughout the course, was on oral hypoglycemic
agents) and was a social drinker (occasional alcohol
consumption). Patient did not have any history of trauma.
On examination he was febrile, anicteric, without any rash
or lymphadenopathy. The complete blood count (CBC)
showed total leukocyte count–6100 cells/mm3, differential
count–neutrophils-50%, lymphocytes–45%, platelet
count–96,000 cells/mm3 and packed cell volume–30%.
The dengue serology was positive for both IgM and
IgG antibodies (immunochromatography) serological
test and peripheral smear for malaria was negative.
The titers (ELISA) of dengue immunoglobulins was
IgM : IgG = 4:1 and 14 days later IgM : Ig G = 5:2. With
rising titers new dengue illness was diagnosed. The blood

DOI: Address for correspondence:

10.4103/0974-777X.107172 Dr. Nagesh Kumar Talakad Chandrashekar,
E-mail: tcnk_861@yahoo.com

Journal of Global Infectious Diseases / Jan-Mar 2013 / Vol-5 / Issue-1 29

 Chandrashekar et al.: Profile of H1N1 infected patients in ICU and their outcome in tertiary care center
culture was sterile and ultrasound abdomen reported
gross ascites, bilateral minimal pleural efflusion and
borderline hepatosplenomegaly. We supposed the ascites
is transudative and a part of the viral illness and as self-
limiting. But the abdominal distension and pain continued
to bother the patient so peritoneal tap was planned.
Simultaneously, patient developed progressive pallor with
drop in hemoglobin (from 9.6 gm/dl to 6.9 gm/dl) and
hematocrit (from 30 to 23%), for which patient underwent
blood transfusion (twice-packed red blood cells). During
the initial two attempts of peritoneal tap, 500 ml of
hemorrhagic ascitic fluid was drained. Even after drainage
the abdominal pain and distention persisted with drop in
hemoglobin, so laparoscopy was planned. Laparoscopic
exploration showed 1.5 liters of peritoneal fluid with blood
clots in the peritoneal cavity and mild diffuse congestion
of the peritoneum. Liver, spleen, bladder and blood vessels
were normal. His coagulation profile was within normal
limits throughout the course (Prothrombin time (PT)-15.9
sec, Activated Patial thromboplastin time(APTT)-29 sec,
International Normalized Ratio(INR)-1.48). Patient
underwent blood transfusion (two packed red blood
cells) again. The histopathological examination of the
peritoneum showed mild hyperemia. Peritoneal drain was
there for two days, abdominal discomfort and distention
reduced over a week and hemoglobin improved and
repeat ultrasound showed that the peritoneum was free
of collection. Patient was discharged on oral hypoglycemic
agents. The patient was asked to follow up with repeat
hemoglobin, fasting and post-prandial blood sugar. During
follow-up he is doing fine.
DISCUSSION
The clinical spectrum of dengue illness can range from
asymptomatic infection to life-threatening dengue
hemorrhagic fever (DHF) and dengue shock syndrome
(DSS). There are various theories of the pathogenesis
of DHF/DSS, such as increase in vascular permeability,
perivascular edema, vascular endothelial injury and
parenchymal necrosis with splenic hyperplasia.[5] Bleeding
manifestations in dengue illness are multifactorial. A
combination of (a) increased prothrombin time, (b)
hemoconcentration, (c) platelet count of less than
50,000 cells/ mm3 and (d) elevated alanine transaminase
(ALT) is known to be predictive for spontaneous
bleeding manifestations.[7] Studies across the world have
documented various bleeding manifestations in dengue
illness, most common being gum bleeding, bleeding into
internal organs, hemorrhagia and bleeding into serous
cavities. Hemoperitoneum in dengue fever though rare
30 Journal of Global Infectious Diseases / Jan-Mar 2013 / Vol-5 / Issue-1
can be life-threatening if not recognized early. Previous
case reports on hemoperitoneum in dengue illness have
been commonly associated with spontaneous rupture
of the spleen.[4-6] However, our case had an unusual
presentation of hemoperitoneum with normal abdominal
viscera and coagulation. The patient came with high-grade
fever, later found to be positive for dengue on serology.
The hemoperitoneum was suspected after hemorrhagic
parecentesis and associated decrease in hematocrit.
However, the coagulation profile was normal and platelet
count remained normal. The ultrasound abdomen showed
fluid collection with normal spleen, liver, and major vessels.
Although up to 100 million cases of dengue fever are
registered per year only a few reports of hemoperitoneum
are seen in the literature.[5]
CONCLUSION
The dengue illness is endemic in India and Southeast Asia, so
are hemorrhagic complications due to thrombocytopenia.
In our case there was spontaneous peritoneal bleeding
with significant drop in hemoglobin without dengue
hemorrhagic fever or dengue shock syndrome. By
ultrasound abdomen it is difficult to differentiate between
hemoperitoneum and transudative ascites. So regular
monitoring of vital signs, regular hemoglobin estimation,
apart from platelet count monitoring are important in
dengue illness, for early detection of internal bleeding and
associated complications. As per our knowledge this is the
only case report of dengue fever with hemoperitoneum
with normal spleen, liver, blood vessels and normal
coagulation profiles.
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How to cite this article: Chandrashekar NT, Krishnappa R, Reddy CS,
Narayan A. Hemoperitoneum in dengue fever with normal coagulation
profile. J Global Infect Dis 2013;5:29-30.
Source of Support: Nil. Conflict of Interest: None declared.
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