DENGUE HEMORRHAGIC FEVER IN PATIENTS WITH THALASSEMIA: A CASE

REPORT
1,
Aisyah Mayang Wulan, 2, Edward Kurnia Setiawan L, 3, Florence Alexandra,
4,
Din Alfina.

1. Medical doctor, Ajibarang General Hospital, Banyumas, Central Java, Indonesia.

2. Departement of Clinical Pathology Ajibarang General Hospital, Banyumas, Central Java,
Indonesia.
3. Departement of Pediatric Ajibarang General Hospital, Banyumas, Central Java, Indonesia.
4. Departement of Pediatric Ajibarang General Hospital, Banyumas, Central Java, Indonesia.

Introduction:
Dengue viral Infection is an endemic disease in Indonesia and Southeast Asian countries,
Morbidity and mortality are high if the treatment is not given appropriately, especially in cases
with complication and comorbid. One of the comorbid is Thalassemia. Thalassemia patients with
dengue infection will be very hard to be diagnosed compared to non-thalassemia patients that
infected with dengue.
Case Description:
A girl 13 year old, came to Ajibarang Regional Hospital for a scheduled blood
transfusion. She came to the hospital only complaints for weak and look pale. She had been
diagnose as Thalassemia Intermedia since she was one year old. She does not have a fever. On
physical examination found anemic conjunctiva, scleral icterus, facies cooley,
hepatospenomegaly, and hyperpigmentation of the skin. She was planned for a 2500 cc / 12 hour
PRC transfusion. After entering half a bag of blood, the patient suddenly got a fever, so the
transfusion is stopped. She has a high fever continuously for 4 days. First day of the lab
examination, Hb 5,2 g/dl, hematocrit 15%, leukocytes 2.340 /uL, platelets 148.000 /uL. The third
day of treatment, she was given Ceftazidime injection and Gentamicin injection as a therapy for
Febrile Neutropeni. Fifth day of treatment, she has no fever, so the transfusion is continued again
until it's finished. We examined Dengue IgG and IgM, the results were reactive.

Table 1. Results of laboratory examinations of patients during treatment.

Day 1 Day 3 Day 6 Day 7 Day 8 Reference

Units
Range

Hemoglobin 5,2 7,9 7,5 10,3 11,9 12,8-16,8 g/dL

Leukocytes 2,34 0,66 1,67 1,36 1,91 4,8-10,8 10^3/ uL

Hematocrit 15 21,6 21,1 26,8 31,9 37,0-47,0 %

Erythrocytes 1,85 2,42 2,36 2,90 3,82 4,2-5,4 10^6/ uL

 Platelets 148 73 66 91 99 150-450 10^3/ uL

MCV 81,1 89,3 89,4 92,4 83,5 79,0-99,0 fl

MCH 28,1 32,6 31,8 35,5 31,2 27,0-31,0 pg

MCHC 34,7 36,6 35,5 38,4 37,3 33,0-37,0 g/dl

RDW 13,9 15,2 15,0 - 15,5 11,5-14,4 %

MPV 12,0 - - 12,9 10,3 7,2-11,1 fL

Basophils 0 0 0 0 1 0,0-1,0 %

Eosinophils 0 0 0 0 0 2,0-4,0 %

Neutrophil 0,0 0,0 0,0 0,0 0,0 2,00-5,00 %

Stems
Neutrophil 64,5 50,0 20,3 33,1 41,9 40,0-70,0 %
Segment
Lymphocytes 25 42 73 63 48 25,0-40,0 %

Monocytes 10 8 7 4 9 2,0-8,0

Dengue IgM Reactive Non

Reactive
Dengue IgG Reactive Non
Reactive

Discussion:
The clinical difference between Dengue Fever and Dengue Hemorrhagic Fever is due to
differences in pathophysiology. There was a shock in Dengue Haemorrhagic Fever caused by
plasma leakage, suspected because of the immunological process. Hemoconcentration is an
indicator of plasma leakage in patients with Dengue Haemorrhagic Fever, but Dengue
Haemorrhagic Fever in thalassemic patients present with hemolysis characterized by anemia
rather than haemoconcentration.

Conclusion:
The absence of hemoconcentration does not exclude the possibility that in this patient a
plasma leakage has occurred. Early diagnosis and proper management including red blood cell
transfusion in anemic patients can reduce morbidity and mortality in these patients.
Keywords:
Dengue Hemorrhagic Fever, thalassemia intermedia, febrile neutropenia, Anemia,
Complications.

References:

1. WHO. Handbook for clinical management of dengue. WHO Library Cataloguing

in Publication Data. 2012: 1-111

2. Pongtanakul, B., Narkbunnam, N., Veerakul , G., (2005). Dengue Hemorrhagic Fever in
Patients with Thalassemia. J Med Assoc Thai 2005; 88(Suppl 8): S80-5.
3. Natesirinilkul, R.,Tantiworawit, A., Charoenkwan, P., 2013. Clinical course of dengue in
patients with Thalassaemia. Paediatrics and International Child Health 2013 VOL. 33
NO. 1
4. Ampaiwan Chuansumrit . 2013. Commentary Thalassaemia and dengue virus infection,.
Paediatrics and International Child Health 2013 VOL. 33 NO. 1