Dengue Hemorrhagic Fever and Non Immune Hemolytic Anemia: Two Recherche in Alliance

Case Report

J Blood Disord. 2022; 9(1): 1066.

Dengue Hemorrhagic Fever and Non Immune Hemolytic Anemia: Two Recherché in Alliance

Gomes RR*

Associate Professor, Medicine, Ad-din Women’s Medical College Hospital, Dhaka, Bangladesh

*Corresponding author: Richmond Ronald Gomes, Associate Professor, Medicine, Ad-din Women’s Medical College Hospital, Dhaka, Bangladesh

Received: March 14, 2022; Accepted: April 06, 2022; Published: April 13, 2022


Dengue is a prevalent arthropod-borne viral disease in tropical and subtropical areas of the globe. Dengue clinical manifestations include asymptomatic infections; undifferentiated fever; dengue fever, which is characterized by fever, headache, retro orbital pain, myalgia, and arthralgia; and a severe form of the disease denominated dengue hemorrhagic fever/dengue shock syndrome, characterized by hemoconcentration, thrombocytopenia, and bleeding tendency. However, atypical manifestations, such as liver, central nervous system, and cardiac involvement, have been increasingly reported called expanded dengue syndrome. We report a 42 years old lady with atypical and rare presentation of dengue disease marked by non immune hemolysis following the critical phase of infection. Condition improved after conservative treatment. Hematological complications in dengue are now increasingly observed with the most common case is cytopenias and bleeding. Non immune hemolytic anemia in dengue is self-limiting in almost all cases. The main mechanism of hemolysis is still unknown though both direct viral infection and immune mediated damage have been suggested to be the cause. To avoid otherwise preventable morbidity and mortality, physicians should have a high index of suspicion for hematological complications in patients with dengue illness and should manage this accordingly.

Keywords: Non immune hemolysis; Thrombocytopenia; Expanded dengue syndrome; Dengue fever


Dengue, an arthropod-borne viral infection of humans, is endemic to tropical and subtropical regions of the world and represents an important public health problem. Dengue viruses are transmitted by the bite of the Aedes aegypti mosquito infected by the one of the four dengue virus serotypes: dengue-1, -2, -3, and -4. More recently, dengue disease has spread geographically to many previously unaffected areas and, as travelling around the world has become more accessible, physicians in temperate areas are more likely to see returning travelers with dengue infection [1,2].

World Health Organization (WHO) classification of symptomatic dengue infection, continuously evolved, first in 1997 it divided into dengue fever (DF), dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). In 2009 it improved into dengue with or without warning signs and severe dengue [3]. However, in 2011, WHO Regional Office for South East Asia (SEARO) revised and further improving the classification, divided into DF, DHF without shock or with shock (DSS) characterized by increased vascular permeability, thrombocytopenia (platelets <100,000), bleeding tendency, and, in a small percentage of patients, circulatory shock [4-7] and expanded dengue syndrome [8].

Expanded dengue syndrome is a new entity added to the classification system to incorporate a wide spectrum of unusual manifestations of dengue infection affecting various organ systems that had been reported including gastrointestinal, hepatic, neurological, cardiac, pulmonary and renal systems [8]. Patients with comorbid, pregnancy, infants, elderly, and immunocompromised are more prone to developing EDS conditions [9,10]. Hemolytic anemia is a rare complication of EDS where the mechanism of association has not been widely reported.

Unlike other viral infections, non immune hemolysis determined by dengue infection is a rare complication. We describe a 42 years old Bangladeshi lady diagnosed with non immune hemolysis caused by oligosymptomatic dengue infection.

Case Presentation

A 42 years old pleasant lady, from Dhaka, Bangladesh, not known to have any diabetes mellitus, hypertension, bronchial asthma or epilepsy presented to us with the history of high grade, intermittent fever, severe headache, body ache and retro orbital pain for 4 days, vomiting for several times for the same duration. Previously, she went to the primary care facility and was given antibiotics (Azithromycin) and acetaminophen. The patient had no history of dengue fever. She denied any cough, chest pain, palpitation, shortness of breath, abdominal pain or distension, burning micturition, joint pain. She had no recent history of travel of late. She lives in 2nd floor of her apartment and have hobby of gardening. His elder brother just recovered from dengue 1 week prior his illness. On examination, she was compos mentis (GCS 15), febrile (temperature 103oF), with pulse 110beats/min, with normal rhythm and volume, blood pressure was 90/70 mm of Hg. There was diffuse blanching erythema, more prominent over trunk but there were no other signs of active bleeding. Other systematic examination revealed no abnormalities.

She was started treatment with intravenous fluids, anti-emetics, anti-pyretic. He became afebrile the next day but considering her newly developed abdominal discomfort, USG of whole abdomen was done which revealed thickened edematous gall bladder, moderate ascites and bilateral pleural effusion suggestive of dengue hemorrhagic fever. Serial blood count monitoring was done which showed progressive improvement of her white cell and platelet counts and volume replacement was done accordingly. With conservative management he showed dramatic improvement in following 4 days with reduced headache, vomiting and general well being. But she complained of worsening weakness. Repeat clinical examination showed severe pallor and icterus. As there was no bleeding with stable hemodynamic and presence of jaundice, work up for hemolytic anemia was undertaken and she was found to have non immune hemolytic anemia. No active management was given apart from regular close monitoring of her blood counts and vital signs. She was discharged on the eleventh day of illness with complete recovery and was found to be well on follow-up after 1-week.

Citation: Gomes RR. Dengue Hemorrhagic Fever and Non Immune Hemolytic Anemia: Two Recherché in Alliance. J Blood Disord. 2022; 9(1): 1066.