Atypical Dengue Meningitis in Makkah, Saudi Arabia with Slow Resolving, Prominent Migraine like Headache, Phobia, and Arrhythmia
A 48-year-old Egyptian obese woman, not known to have any medical illness before, was referred by ENT specialist as possible central dizziness with history of severe dizziness, nausea, and vomiting associated with blurring of vision and headache 1 day before. On examination, she was looking ill, with a temperature of 38.4°C, respiratory rate of 21/min, heart rate of 124/min, and blood pressure of 167/93 mmHg. Her chest, cardiovascular, abdomen, and neurological examination were unremarkable, except of mild early bilateral papilledema, neck rigidity, and ataxic gait. A CT scan of brain done with/without contrast in emergency department showed possible left sigmoid sinus partial occlusion. She was admitted and started on heparin infusion and ceftriaxone with good hydration plus amitriptyline, betahistine, cinnarizine, and heparin 5000 IU 6 hourly sc injections. Next day, MRI/MRV of brain was done and reported to be normal, but the platelet count dropped to 109/mm3, and GPT raised to 87 compared to normal result on baseline admission result; this supports stopping heparin therapy. On the third day afternoon, she was suffering from severe diffuse burning quality headache mainly on right tempro-occipital with severe central scalp scratching and pressing like pain last several hours and aborted only on pethidine intravenous injection. On the 4th day, lumbar puncture was done and the CSF was normal. The blood tests for CV, EBV, HIV, and H1N1 were also negative but serum dengue IgM was positive. A CSF sample for dengue IgM sent to private lab reported as positive. Throughout the 23 days admission period, the patient was almost afebrile but showed significant fatigue with bizarre headache appearing as persistent diffuse pressure like headache with attacks of severe bilateral temproparietal burning and central scratching pain associated with nausea, vomiting, dizziness, phonophobia, photophobia, anxiety, and near death phobia and bradycardia (4060) that required many cardiology and psychiatry on call review. On the 22nd day, the patient was discharged after showing reduction of headache attacks severity and frequency with normal blood count and liver enzymes. Then patient was on weekly out-patient neurology clinic follow up for several months using amitriptyline, respridone, and tramadol on need. Then gradually and slowly, headache attacks diminished in frequency and severity, resolving completely about 3 months after onset.