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Article history: INTRODUCTION: Dengue fever is an acute viral disease, which usually presents as a mild febrile illness.
Received 2 July 2013 Patients with severe disease present with dengue haemorrhagic fever or dengue toxic shock syndrome.
Received in revised form 22 August 2013 Rarely, it presents with abdominal symptoms mimicking acute appendicitis. We present a case of a male
Accepted 29 August 2013
patient presenting with right iliac fossa pain and suspected acute appendicitis that was later diagnosed
Available online 8 September 2013
with dengue fever following a negative appendicectomy.
PRESENTATION OF CASE: A 13-year old male patient presented with fever, localized right-sided abdominal
Keywords:
pain and vomiting. Abdominal ultrasound was not helpful and appendicectomy was performed due to
Dengue fever
Acute appendicitis
worsening abdominal signs and an elevated temperature. A normal appendix with enlarged mesenteric
Acute abdomen nodes was found at surgery. Complete blood count showed thrombocytopenia with leucopenia. Dengue
Leucopenia fever was now suspected and confirmed by IgM enzyme-linked immunosorbent assay against dengue
virus.
DISCUSSION: This unusual presentation of dengue fever mimicking acute appendicitis should be suspected
during viral outbreaks and in patients with atypical symptoms and cytopenias on blood evaluation in
order to prevent unnecessary surgery.
CONCLUSION: This case highlights the occurrence of abdominal symptoms and complications that may
accompany dengue fever. Early recognition of dengue fever mimicking acute appendicitis will avoid non-
therapeutic operation and the diagnosis may be aided by blood investigations indicating a leucopenia,
which is uncommon in patients with suppurative acute appendicitis.
© 2013 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd.
Open access under CC BY license.
2210-2612 © 2013 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. Open access under CC BY license.
http://dx.doi.org/10.1016/j.ijscr.2013.08.017
CASE REPORT – OPEN ACCESS
M.E.C. Mcfarlane et al. / International Journal of Surgery Case Reports 4 (2013) 1032–1034 1033
The patient was observed for 24 h in hospital and was noted to serous fluid collection and oedema may result in the inflamma-
have worsening right iliac fossa pain and leucopenia on the second tory changes identified in patients with acalculous cholecystitis
day. Examination at that time revealed marked right iliac fossa ten- and acute appendicitis. Spasms of the cystic duct, gall bladder dis-
derness in keeping with a diagnosis of acute appendicitis. Because tension and cholestasis have been suggested as possible causes
the signs were thought to be typical of appendicitis diagnostic of acalculous cholecystitis. Enlarged mesenteric lymph nodes as
laparoscopy was not deemed necessary and an appendicectomy was found in our patient may explain the acute right iliac fossa
performed via a Lanz incision, at which time a normal appendix pain mimicking acute appendicitis similar to the presentation in
was found with multiple enlarged mesenteric lymph nodes. Lymph patients with mesenteric adenitis. Reviews of the literature have
node biopsy was not done. failed to identify any specific aetiological agent or features on
Repeat blood investigations again showed bicytopenia with pathological analysis that can account for this presentation.15
platelet count of 99 × 106 mm−3 and a white cell count of In a series of patient reported by Shamim et al.14 all patients with
2.3 × 106 mm−3 . acute abdominal pain had complications of dengue fever namely
Dengue fever was suspected and was confirmed with a positive dengue haemorrrhagic fever or dengue shock syndrome. Other the-
IgG and IgM enzyme-linked immmunoabsorbent assay. ories proposed to explain acute abdominal pain in patients with
The histology of the appendix showed no gross abnormality. The dengue fever include plasma leakage and serious effusions contain-
patient received supportive care, which included analgesics, bed ing high protein content together with lymphocytic infiltrations in
rest and fluid therapy and made an uneventful recovery. Repeat patients presenting with acute appendicitis, pancreatitis and acal-
blood investigations one week later were normal. culous cholecystitis.12,15
The patient was seen one year later in the outpatients depart-
ment at which time blood results were repeated and were normal. 4. Conclusions
10. Derycke T, Levy P, Genelle B, Ruszniewski P, Merzeau C. Acute pancreati- 13. Premaratna R, Bailey MS, Ratnasena BG, de Silva HJ. Dengue fever mimicking
tis secondary to dengue. Gastroenterologie Clinique et Biologique 2005;29(1, acute appendicitis. Transactions of the Royal Society of Tropical Medicine and
January):85–6. Hygiene 2007;101(7, July):683–5. Epub 2007 Mar 21.
11. Goh BK, Tan SG. Case of dengue virus infection presenting with acute acalculous 14. Shamim M. Frequency, pattern and management of acute abdomen in dengue
cholecystitis. Journal of Gastroenterology and Hepatology 2006;21(5, May):923–4. fever in Karachi, Pakistan. Asian Journal of Surgery 2010;33(3, July):107–13.
12. Khor BS, Liu JW, Lee IK, Yang KD. Dengue hemorrhagic fever patients with acute 15. Wu KL, Changchien CS, Kuo CM, Chuah SK, Lu SN, Eng HL, Kuo CH. Dengue fever
abdomen: clinical experience of 14 cases. American Journal of Tropical Medicine with acute acalculous cholecystitis. American Journal of Tropical Medicine and
and Hygiene 2006;74(5, May):901–4. Hygiene 2003;68(6, June):657–60.