Department of Pediatric Surgery, National University of Hospital, Singapore
Correspondence and offprint requests to: Felicia Li-Sher Tan, Department of Pediatric Surgery, National University of Hospital, Singapore. Email: feliciates{at}hotmail.com
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Introduction |
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Case report |
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On the 5th post-operative day, he spiked a temperature of 39°C. He was asymptomatic and physical examination did not reveal a source of infection. In view of a previous history of dengue infection in the donor, blood was analysed for dengue virus using real-time polymerase chain reaction (RT-PCR). This was positive for Dengue virus Serotype 1.
Over the next week, he continued to spike high temperatures with a fall in platelet count and a deterioration of his general clinical condition. On the 12th post-operative day, he developed upper gastrointestinal bleeding, gross haematuria and tachycardia. Investigations revealed that his haemoglobin had dropped to 4.6 g/dl, leucocyte count was 0.86 x 109/l, platelet count was 71 x 109/l, serum lactate dehydrogenase was 1322 U/l (normal: 300700 U/l) and albumin was 14 g/l (normal: 3849 g/l). His mycophenolate mofetil dose was discontinued and granulocyte-colony stimulating factor was commenced for his profound leucopenia. He required multiple packed cell and platelet transfusions. Chest X-ray revealed a right sided pleural effusion. On the 15th post-operative day, he complained of left flank pain and abdominal distension. One litre of blood was drained from his Tenckoff catheter. Computed tomography of his abdomen revealed a large retroperitoneal haematoma arising from the bed of the transplanted kidney. Emergency laparotomy was undertaken for surgical haemostasis and evacuation of the haematoma. Intra-operatively, 1.5 l of blood was drained from the retroperitoneal space. A generalized ooze was seen from the tissue bed of the allograft and this was treated with packing. There was a perforation seen in the peritoneum, which allowed communication between the retroperitoneal and intraperitoneal spaces. The transplanted kidney appeared healthy. A repeat dengue RT-PCR was negative.
Post-operative recovery was uneventful with resolution of fever and recovery of thrombocytopenia within the next week. Haemorrhagic tendencies ceased spontaneously with resolution of haemetemesis and haematuria. His graft function remained excellent. Figure 1 depicts the course and progression of his illness.
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Discussion |
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Having lived in a dengue-endemic region, our patient may have been infected previously but was asymptomatic or had subclinical infection. A large proportion of the adult population in Singapore have been exposed to dengue as reflected by a high prevalence of dengue seropositivity (45%) [3]. Transplantation of the dengue-infected allograft can cause secondary infection and development of DHF. It is not known whether donor organs remain infected after apparent resolution of viraemia. Alternatively, secondary transmission could have been via the usual route, the bite of a mosquito. However, there was no active transmission of dengue in our area during this period, making hospital-acquired infection less likely.
Clinical presentation and course of the illness in this immunosuppressed patient is similar to that in the immunocompetent, except for a longer period of illness. Our patient experienced a prolonged course of illness (19 days) as well as prolonged duration of thrombocytopenia (12 days). The mean duration of illness is 27 days and duration of thrombocytopenia 3.6 days (±1.6 days) [4]. The critical stage in DHF is usually around the time of defervescence, with circulatory failure of haemorrhagic manifestations occurring about 24 h before to 24 h after the temperature falls to normal or below. This was the case for our patient with shock and haemoperitoneum occurring on the same day as defervescence of fever (Figure 1).
DHF occurring early post-operatively poses a potential danger to the transplant patient. Bleeding diathesis resulting from thrombocytopenia, dysfunctional surviving platelets and increased fibrinolysis result in persistent haemorrhage especially from cut tissue surfaces. In our patient, profuse, persistent bleeding from the tissue bed of the transplanted kidney led to circulatory collapse and a need for surgical drainage of haematoma and haemostasis. In addition, he also had other haemorrhagic manifestations with gastrointestinal bleeding and haematuria. Hypovolaemia poses a risk of damage to the allograft. Hypoalbuminaemia secondary to leakage of plasma aggravates the problem of poor wound healing in the immunosuppressed transplant recipient. No specific therapy or vaccine exists for DHF. Management is supportive, with correction of hypovolaemia and coagulation abnormalities.
This case illustrates the severity of DHF after renal transplantation of an infected allograft. In dengue-endemic regions, clinicians should have a high index of suspicion for DHF in patients with viral haemorrhagic fevers. Screening donors of organs and blood products may be beneficial, although sensitivity, feasibility and cost benefits of screening need to be assessed.
Conflict of interest statement. None declared.
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