Acute Pancreatitis in Dengue Hemorrhagic Fever

CASE REPORT
Acute Pancreatitis in Dengue Hemorrhagic Fever
Marcellus Simadibrata
Department of Internal Medicine, Faculty of Medicine, University of Indonesia - dr. Cipto Mangunkusumo
Hospital. Jl. Diponegoro no. 71, Jakarta Pusat 10430, Indonesia. Correspondence mail: cgono@indosat.net.id.
ABSTRAK
Kami melaporkan sebuah kasus pankreatitis akut sebagai komplikasi demam berdarah dengue (DBD).
Komplikasi ini dapat menyebabkan kondisi yang lebih fatal, dan kesulitan dalam pengobatan, meskipun jarang.
Demam berdarah dengue (DBD) merupakan salah satu penyakit endemik dan sering timbul sebagai suatu
wabah di Asia Tenggara termasuk Indonesia. Demam berdarah dengue (DBD) merupakan masalah kesehatan
masyarakat global, karena sampai saat ini belum ada obat untuk membasmi virus dengue, belum ada vaksin
Dengue dan sulit memberantas nyamuk sebagai vektor penularan. Diagnosis dan pengobatan pankreatitis akut
sedini mungkin penting untuk meningkatkan kondisi pasien dan kelangsungan hidup. Pasien adalah seorang
laki-laki 59 tahun yang telah ditatalaksana secara konservatif. Pasien dirawat di rumah sakit, dipuasakan oral
sampai hari keempat, diberikan nutrisi parenteral total, obat-obatan antibiotik intravena dan lainnya. Makanan
cair oral awal diberikan pada hari kelima dan lalu diit diubah secara bertahap sesuai dengan kondisi. Pasien
itu kemudian menyembuh dan keluar dari rumah sakit dalam keadaan baik.
Kata kunci: pankreatitis akut, demam berdarah dengue, komplikasi.
ABSTRACT
We reported a case of acute pancreatitis as the complication of dengue hemorrhagic fever (DHF). This
complication can cause more severe fatal condition, and difficulties in treatment, although it is rare. Dengue
hemorrhagic fever (DHF) is one of the endemic diseases and often come as an outbreak event in South East Asia
including Indonesia. Dengue hemorrhagic fever (DHF) is a global public health problem, because until now there
has been no medicine to eradicate the dengue virus, no dengue vaccine and difficult to eradicate the mosquitoes as
the contagious vector. Diagnosis and treatment of acute pancreatitis as early as possible is important to improve
the patient’s condition and survival. The patient was a 59 year old male and had been treated conservatively. The
patient was admitted to the hospital, oral fasting until the fourth day, given parenteral nutrition, antibiotic and other
intravenous medicines. Initial oral liquid diet was given on the fifth day of hospitalization and changed gradually
according to the condition. The patient was then improved and discharged from the hospital.
Key words: acute pancreatitis, dengue hemorrhagic fever, complication.
INTRODUCTION
Dengue hemorrhagic fever (DHF) is one
of the endemic diseases and often comes as an
outbreak event in South East Asia including
Indonesia. 1-9 The dengue hemorrhagic fever
(DHF) is a global public health problem,
because until now there has been no medicine
to eradicate the dengue virus, no dengue
vaccine and difficult to eradicate the mosquito
as the contagious vector. Until now 4 serotypes
of Dengue virus have been documented i.e.
DEN-1, DEN-2, DEN-3 and DEN-4. 8,9 The
incidence of DHF in Indonesia in the year 2001
was 17.2/100.000 people and in the year 2004
27.8/100.000 people. The case fatality rate (CFR)
in the year 2004 was around 1.1%.1,2 Indonesia
as one of the developing countries is still lack
of funds and facilities to cut the contagious
Acta Medica Indonesiana - The Indonesian Journal of Internal Medicine
57
Marcellus Simadibrata
chain of dengue fever/dengue hemorrhagic
fever. Dengue infection or dengue hemorrhagic
fever has a lot of complications i.e. acute organ
bleeding, shock(DSS), acute hepatitis, acalculous
cholecystitis, acute pancreatitis, gastritis, enteritis
etc.3-6,10-18
Dengue hemorrhagic fever has the risk
to cause severe or fatal disease, especially in
dengue shock syndrome stage. Acute pancreatitis
itself can also cause severe-fatal diseases like
septic shock etc. According to those reasons,
the acute pancreatitis complication can cause
more severe condition in dengue hemorrhagic
disease. This report is made to demonstrate acute
pancreatitis as one of the complications of dengue
hemorrhagic fever.
Acta Med Indones-Indones J Intern Med
Figure 1. Ultrasonographic picture of the pancreas and liver
on the 1st day of admission
CASE ILLUSTRATION
A 59 year old male patient came to the
emergency ward of one private hospital with
chief complaint of epigastric pain and abdominal
bloating since 1 day before admission. Since 4
days before the patient had been complaining
of high fever, malaise, bodyache and headache.
The patient went to a doctor and got antibiotic
and antipyretic, but there was no improvement.
Since 1 day before admission the patient had been
complaining of epigastric pain, bloating, nausea
and vomiting. The patient also complained of
difficulty in defication and abdominal bloating.
Physical examination showed that the
general appearances were moderately ill,
consciousness alert, blood pressure 130/80
mmHg, heart rate=pulse=100/m, temperature
39oC and respiration rate 20x/m. Heart and lung
within normal limit. The abdomen was bloating,
meteoristic, bowel sound +, epigastric pain (+).
Extremities within normal limit.
Laboratory: hemoglobin 13g%, leukocyte
13.200/mm3, hematrocrit 56 vol%, thrombocyte
120.000/mm3. AST 80 U/l, ALT 90 U/l, amylase
654 U/l, lipase 780 U/l. Ureum 50 mg/dl,
creatinine 1.6 mg/dl, IgM dengue (+), IgG
dengue (+).
Ultrasound examination on the 1st day of
admission showed mild to moderate fatty liver,
normal gall bladder and spleen, normal pancreas
and kidney, and there were minimal ascites within
the area of spleen. (Figure 1 and 2)
Problems of this patient were acute
pancreatitis, dengue hemorrhagic fever (DHF)
and renal insufficiency.
58
Figure 2. Ultrasonographic picture of the abdomen showed
ascites
The management for the patient were oral
fasting, nasogastric tube placement to collect the
gastric secretion every 24 hours, total parenteral
nutrition: Ringer lactate infusion + Triofusin E
1000 infusion + Aminosteril 10% in 24 hours,
and antibiotic: Ceftriaxone 2 x 1 gr/day.
On the 2nd day of admission: The general
appearances of the patient were moderately ill,
consciousness alert (compos mentis), blood
pressure 120/70 mmHg, heart rate=pulse= 102/m,
temperature 37.8oC, and respiration rate 20/m.
The abdomen was still bloating, meteoristic (+)
and the bowel sound was weak. Laboratory:
hemoglobin 12 g%, leukocyte 11.200/mm3,
hematocrit 56 vol%, thrombocyte 40.000/mm3.
Abdominal CT-scan showed fatty liver, no
tumor, the pancreas was prominent and enlarged
showed pancreatitis, no tumor. The common
bile duct was not enlarged. There were still
minimal ascites perisplenic. Right and left pleural
effusion was positive. There was no lymph node
enlargement.
Vol 44 • Number 1 • January 2012
On the 5th day of admission: Initial oral
liquid diet was given and changed gradually
according to the condition.
On the 6th day of admission: The General
appearances of the patient were moderately ill,
better, consciousness alert (compos mentis),
blood pressure 130/80 mmHg, heart rate=99/m,
temperature 37oC, and respiration rate 18/m.
The abdomen was not bloating, meteoristic+,
and the bowel sound was normal. The laboratory
showed hemoglobin 13g%, leukocyte 8800/mm3,
hematocrit 48 vol%, and thrombocyte 74,000/
mm3.
Repeated ultrasonography showed fatty
Liver, acute pancreatitis still positive, minimal
ascites around the spleen and left pleural effusion
still positive.
On the 10th day of admission: The general
appearances of the patient were mildly ill, better,
consciousness alert, blood pressure 120/80
mmHg, heart rate=82/m, temperature 36.8oC, and
respiration rate 18/m. The abdomen was normal,
no more meteorismus and the bowel sound was
normal. Laboratory findings showed hemoglobin
12.8 g%, leukocyte 8200/mm3, hematocrit 46
vol%, thrombocyte 99,000/mm3, serum amylase
48 U/l and serum lipase 66 U/l.
Repeated ultrasound result compared
to the last ultrasound examination showed
improvement, no ascites, minimal left pleural
effusion, and the other organs within normal
limit. (Figure 3)
Figure 3. Ultrasonographic picture of the pancreas on day10th admission
On the 11th day of admission the patient was
discharged from the hospital.
DISCUSSION
South East Asia including Indonesia, is the
place where Dengue hemorrhagic fever is still
Acute Pancreatitis in Dengue Hemorrhagic Fever
prevalent and endemic. Sometime there is an
outbreak of Dengue hemorrhagic fever and this
condition needs good management including
prevention and treatment.1,2,7,19,20 This Dengue
Hemorrhagic Fever is caused by Dengue virus
infection which transmitted by specific mosquito
such as Aedes aegypti or Aedes albopictus.
Basically we know that dengue virus infection
can cause complications such as acute pancreatitis
and other abdominal abnormalities.3,4,6,8,9,13-18 In
this case report we have already shown that
the acute pancreatitis complication occurs
in dengue hemorrhagic fever. The dengue
hemorrhagic fever diagnosis was made according
to the WHO criteria, fever 3-5 days, bleeding
tendencies, thrombocytopenia below 100.000/
mm3, with positive IgM Dengue result. Acute
pancreatitis diagnosis was made upon the clinical
symptoms, epigastric pain, vomiting, fever,
bloating, epigastric tenderness, enlargement
of the pancreas on ultrasound examination
without hepatobiliary disorders, increased serum
amylase-lipase 3x normal.
Freguently the acute pancreatitis complication
is underdiagnosed due to the lack of awareness
about the complications of dengue hemorrhagic
fever or dengue virus infection. We knew that
not all of the dengue fever cases will get acute
pancreatitis complication, so it is unusual to
check pancreatic function test such as serum
amylase-lipase. Because there is a risk to develop
acute pancreatitis complication every doctor
must be aware of this DHF’s complication. If the
medical doctors do not diagnose the pancreatic
complication as early as possible, the patient will
have more severe and fatal condition.3-7,9 This
acute pancreatitis might increase the severity of
dengue virus infection.
Mild renal insufficiency that occurred in the
patient was caused by dehydration. The renal
insufficiency was then improved after rehydration
and patient’s improvement.
The ascites that occurred in this patient were
caused by fluid extravasation from intravascular
to extravascular due to Dengue virus infection or
could be caused by the acute pancreatitis. When
the Dengue Hemorrhagic Fever improved, the
fluid extravasation process stopped and then the
ascites also disappered.1,7,9,12,18-20 If the ascites
were caused by the acute pancreatitis, and if the
pancreatic inflammation improved, the ascites
will also dissapear.6,10,16, 21,22
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Marcellus Simadibrata
The ultrasonography examination on day
1 admission could only detect abdominal
ascites, but could not detect the pancreatic
enlargement and inflammation. This result was
in line with literature and studies which showed
that ultrasonography examination on acute
pancreatitis frequently will have normal pancreas
result.16,21,22-25 Ascites found in ultrasonography
examination could be the specific sign in Dengue
hemorrhagic fever or could be the sign of acute
pancreatitis. This finding is in line with literature
and study that reported that ascites can be found
in patients with Dengue hemorrhagic fever or
acute pancreatitis.19-25
In this case, the inflammation of the pancreas
was very active so we gave total parenteral
nutrition with optimum fluid-electrolyte to
prevent the intravascular plasma leakage. The
fluid-electrolyte and nutrition treatment of these
patients were given according to the requirement,
underlying disease and body weight. Every day
the patient must be monitored and followed up
regularly to know the effects or side effects of
the fluid-electrolyte-nutrition treatment. From
many studies it was shown that enteral nutrition
via nasojejunal tube is better than total parenteral
nutrition.4,5,23 In our patients in Indonesia, we have
not done the enteral nutrition with nasojejunal
tube due to lack of facilities. We do not have
the nasojejunal tube available in the market in
Indonesia, so we still use total parenteral nutrition
in 5-7 days of acute pancreatitis then we change
gradually to enteral nutrition or oral nutrition
when the pancreatic function is normal.
Antibiotic is given in both of the patients
above to prevent secondary bacterial infection
due to intestinal bacterial translocation. In the
second case, the antibiotic is given also for
the indication of pneumonia. This antibiotic
therapy is given in line with the treatment
recommendation for acute pancreatitis, although
in our patients the cause of acute pancreatitis is
dengue virus.4,5
The length of stay for this case was 11 days.
The length of stay for this case is longer than
the general length of stay for acute pancreatitis
or dengue hemorrhagic fever cases. The length
of stay for mild acute pancreatitis according to
literatures is between 5-7 days.24,25 The length of
stay of Dengue hemorrhagic fever usually also
need 5-7 days.19-22 The length of stay is varied
according to the disease severity. Logically, if
60
Acta Med Indones-Indones J Intern Med
there are 2 diseases in one patient, the length of
stay for the patient will be longer than for one
disease only.
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