Atypical Dengue Meningitis in Makkah, Saudi Arabia with Slow Resolving, Prominent Migraine like Headache, Phobia, and Arrhythmia
A 27-year-old Saudi female, living in Makkah, was referred from ophthalmology clinic, with severe retro-orbital headache and neck pain started 3 days before admission. There was no myalgia, arthralgia, bleeding manifestation, cutaneous rash, or any similar or significant past medical history. On examination, she was in pain, febrile with a temperature of 38.3°C, respiratory rate of 20/min, heart rate of 112/min, and blood pressure 116/63 mmHg. Her chest, cardiovascular, abdomen, and neurological examinations including fundus were unremarkable, except of mild neck rigidity. She was admitted with professional diagnosis of acute meningitis and started on intravenous dexamethasone, vancomycin, ceftriaxone, and acyclovir with good hydration. Brain CT scan was normal. CSF was normal except of pleocytosis (85% lymphocytes). The complete blood count was as follows: WBC 4.5 cell/mm3, 60% lymphocytic, Hb 12.1 gm/dL, platelets count 135/mm3. The blood tests for malaria, brucella, cytomegalovirus (CMV), Epstein-Barr virus (EBV), human immunodeficiency virus (HIV), and swine flu virus (H1N1) in the blood were negative. Dengue serology sent to Makkah central laboratory due to relative low platelets and low grade fever. Upon these result dexamethasone, vancomycin, and ceftriaxone were stopped on the next day and the patient was kept on intravenous acyclovir only. Throughout the 7 days admission period, the patient was almost afebrile but showed bizarre headache appearing as persistent diffuse headache with attacks of severe retro-orbital pain, eye tearing, and blurring vision mainly on left eye that respond only to pethidine intravenous injection in spite of trial of multi analgesic and neuropathic medication including amitriptyline, topiramate, pregabaline, and tramadol. The headache attacks predominantly appeared between 3 and 11 pm, associated with anxiety and fear of death in addition to episodes of arrhythmia range between bradycardia down to 45/min and supraventicular tachycardia up to 180/min, that required many cardiology and psychiatry on call review. On 4th day of admission, serum dengue IgM reported to be positive. To further strengthen the diagnosis, we repeated the CSF test for dengue IgM. On the 7th day, the patient was so much upset and asked discharge against medical advice to seek abroad management. 20 days later, the patient was seen in neurology out-patient clinic complaining of persistence migraine like headache and the CSF test for dengue IgM was found to be positive. Over several months later, the patient was on amitriptyline and tramadol on need. Then gradually and slowly, headache attacks diminished in frequency and severity, resolving almost completely 4 months after onset.