Hemoperitoneum in Dengue Fever with Normal Coagulation Profile
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 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.