dengue is an arboviral disease endemic in most of the tropical countries with recurrent epidemics . although dengue is known to cause hepatic involvement commonly , it only occasionally results in fulminant liver failure ( flf ) , which has a high mortality . n - acetyl cysteine ( nac ) , a precursor of glutathione , is an effective antioxidant scavenging for oh radicals have shown to be effective mainly in acetaminophen and even in non - acetaminophen - induced flf . activated recombinant factor vii ( rfviia ) was initially developed to overcome the limitations of existing treatments for patients with congenital hemophilia and inhibitors . clinical success in this arena led to experimental use in other coagulopathies as well . to the best of our knowledge , this is the first reported case of dengue hemorrhagic fever complicated by fulminant liver failure and massive hemorrhage successfully managed with nac and rfviia . a 37-year - old previously healthy man who was a teetotaler admitted with fever , repeated vomiting , body aches , and fatigue for four days . examination revealed a temperature of 100f , tachycardia ( 106/min ) , normotension , and tachypnea ( 28/minute ) . investigations showed leukocyte count ; 5.1  10/l ( neutrophils 53% , lymphocytes 41% ) , and platelets ; 60  10/l , hemoglobin ; 14.1 g / dl with hematocrit of 43.4% , aspartate aminotransferase ( ast ) ; 220 u / l , alanine aminotransferase ( alt ) ; 157 u / l on admission . presumptive diagnosis of dhf was made considering the clinical picture and prevailing outbreak in the country . close monitoring with replacement of maintenance volume of fluids was started in both oral and intravenous means . during next 36 hours , he had clinical and hematological evidence of ongoing plasma leakage but remained hemodynamically stable . next day , he was shifted to intensive care unit due to agitation and drowsiness . platelet count dropped to less than 10  10/l during day 5 and 6 of the illness and subsequently started rising gradually . u / l ) in seventh day of illness with prolongation of prothrombin time of 19.8s ( inr ; 1.7 ) activated partial thromboplastin time ( 89s ) , and elevated serum bilirubin . chest x - ray and ultrasonography of abdomen showed bilateral pleural effusions and moderate ascites . liver failure treatments started with intravenous vitamin k , thiamine , lactulose , and oral metronidazole . in the same day , worsening agitation and sensorium ( grade iii hepatic encephalopathy ) necessitated elective intubation and mechanical ventilation . blood sugar was monitored , and his serum sodium levels maintained at 145 - 150 mmol / l range . an internal jugular central venous access was secured following transfusion of platelets and fresh frozen plasma ( ffp ) . twenty percent manitol infusion was administered 12 hourly for 48 hours , and nac intravenous infusion was continued for 72 hours . bleeding was difficult to control with transfusion of platelets , fresh frozen plasma , and pack red cells alone . this prompted us to administer him with 3 doses of rfviia following transfusion of cryoprecipitate to replenish fibrinogen levels in serum . patient 's central venous pressure started rising ( 24 - 29 cmh2o ) by ninth day with of illness necessitating a considerable dose of frusemide to achieve a safe level of cvp ( 8 - 12 cmh2o ) . dengue igm and igg ( elisa ) were positive , while malarial smear , hepatitis panel , leptospira serology , and hiv elisa became negative . however , the course of his illness was complicated initially by ventilator - associated pneumonia with acenetobacter and later by pseudomonas , necessitating antibiotic cover with netilmycine and ceftazidime . he was extubated following 7 days of ventilatory support and managed to be discharged after 18 days of hospital stay . dengue hemorrhagic fever is defined as the presence of fever , thrombocytopenia , and evidence of capillary leak with serological evidence of acute infection by dengue virus . current management of dhf is mainly focused on meticulous fluid management during leakage phase of the illness . in dhf , an antibody - dependent immune mechanism is in play , by which non - neutralizing antibodies of previous dengue infection complexes with the new infecting serotype enhancing its uptake . liver damage is due to viral replication in hepatocytes , cytokine - related damage , and partly due to ischemic hepatitis . fulminant liver failure is defined as rapid onset of acute encephalopathy and coagulopathy ( inr 1.5 ) in the setting of liver failure less than 6 weeks duration . since the liver is capable of regenerating to a large extent as underlying cause of hepatocyte injury is controlled with supportive medical therapy , fhf in principle sustains potential for a complete recovery . fulminant liver failure due to dengue infection with subsequent complete recovery has been reported rarely . flf may be associated with changes in systemic hemodynamic , i.e. , tissue hypoxia , which contributes to multiple - organ failure . recent studies have shown that nac administered to patients with flf ( non - paracetamol - induced ) increases oxygen delivery and improves survival . morbidity and mortality in dhf is mainly associated with either prolonged shock or fluid overload . activated recombinant factor vii is a coagulation protein that induces hemostasis by directly activating factor x. there were some evidences on safety and efficacy of rfviia for controlling hemorrhage in patients without hemophilia . since inadvertent administration of blood products would worsen the fluid overload in dhf , the place for rfviia seems to be invaluable to arrest life - threatening bleeding as in our patient . so far , there was no clear information about the prophylactic or therapeutic use of rfviia in dhf . the use of nac and rfviia despite limited evidence presumably had a greater impact on recovery of our patient . therefore , this case highlights the potential use of rfviia and nac along with aggressive supportive measures in cases of near - fatal dhf for a successful outcome . prevention of ischemic injury of liver by meticulous fluid resuscitation during the leakage phase of dengue fever is of paramount importance . dengue may occasionally lead to flf , has to be treated promptly with aggressive supportive measures . indication of rfviia to arrest uncontrolled internal bleeding and the place of nac in non - acetaminophen - induced flf in complicated dhf is a platform for discussion .