Dengue fever is a mosquito borne, arboviral debilitat- ing disease caused by dengue virus of Flaviviridae family.
It may present as a wide spectrum of manifestations rang- ing from mild dengue fever to severe forms like dengue haemorrhagic fever (DHF) and dengue shock syndrome.
Development of severe form of dengue may be predicted early on the basis of high risk factors like older age, pres- ence of other associated infections, history of dengue fe- ver in the past, haematocrit fluctuation >20%, activated partial thromboplastin time (aPTT) >30 s etc. Though, DHF may result in bleeding from any part of the body, spontaneous large muscle haematoma is seldom reported.
In present investigation a rare case of large spontaneous iliopsoas haematoma developed in an elderly DHF patient is reported.
Case report
A 79-yr-old male resident of Delhi, and a known case of COPD and hypertension (both controlled on medica- tion) presented with complaints of moderate grade fever associated with chills and rigor for one day and gener- alised malaise for three days. He had no other localized complaints. There was no history of bleeding from any body part. On physical examination, he was found to be haemodynamically stable with mild wheeze on chest aus- cultation. The systemic examinations were normal.
Baseline haematological investigations revealed thrombocytopenia (platelet count 50,000/µl) and hae- matocrit of 40%. Biochemical parameters were normal.
Dengue IgM antibody test was positive by ELISA meth- od. Malarial antigens were not detected in serum. Ultra- sound of abdomen revealed presence of gallbladder wall oedema coherent with features seen in dengue fever.
Provisional diagnosis of dengue fever with warning signs was made and he was kept under close monitoring with conservative management. On Day 3 of admission, he complained of severe pain in left hip on left lower limb movements. Local examination of hip joint and gluteal region was unremarkable except for flexion deformity of left hip joint with painful limb movements. An immedi- ate ultrasound of left hip (in view of risk of bleeding in joint due to thrombocytopenia) was performed which did not reveal any focal abnormality. On next day, abdo- men examination revealed a firm mass in left iliac fossa region. Haematological investigation revealed a drop in haemoglobin from 12.5 to 10 g/dl and thrombocytopenia (14000/µl). These findings raised the suspicion of intra- abdominal haemorrhage. USG abdomen revealed echo- genic collection within left iliopsoas muscle. Magnetic resonance imaging (MRI) of abdomen revealed a large he- matoma in left iliopsoas muscle (Figs. 1a and b). He was managed with multiple single donor platelet transfusions, skeletal muscle relaxants (tab Thiocolchicoside 4 mg twice a day and analgesics (initially on oral paracetamol 500 mg sos (initial 2 days) to thrice a day (from Day 3 to 5 ) which was replaced with intravenous 500 mg four times a day (from Day 5 to Day 10) for five days. He was closely monitored by serial ultrasound for haematoma.
His platelet count gradually became normal by 12 days.
He was put on intermittent left leg skin traction with some weight to prevent flexion deformity. He had full range of movements at left hip joint by Day 19 of hospital stay.
He was discharged in haemodynamically stable condition with a predischarge USG showing a resolving haematoma of smaller size in left iliopsoas muscle. After discharge he was followed-up thrice. At the end of two months of Case Reports
Spontaneous iliopsoas haematoma in a patient with dengue haemorrhagic fever (DHF): A case report
Arvind Kumar
1, Saikat Mondal
1, Prayas Sethi
1, Smita Manchanda
2, Ashutosh Biswas
1&
Naveet Wig
11Department of Medicine; 2Department of Radio Diagnosis, All India Institute of Medical Sciences, New Delhi, India
Key words Dengue haemorrhagic fever; dengue shock syndrome; iliopsoas haematoma J Vector Borne Dis 54, March 2017, pp. 103–105
J Vector Borne Dis 54, March 2017 104
Fig. 1: Baseline MRI of pelvis. Axial fat suppressed T2 weighted im- age (a) and axial T1 weighted MR image (b) revealed a large heterogeneous lesion involving the left iliopsoas. This lesion is predominantly of hyperintense signal intensity on T2 WI (arrow in a) and isointense on T1 WI (arrow in b) suggestive of acute haematoma.
Fig. 2: Follow-up MRI performed two months later. Axial fat sup- pressed T2 weighted image (a) and coronal T1 weighted MR image (b) showed a small residual focal lesion in the left il- iopsoas. This lesion is hyperintense with a well defined hy- pointense rim on both T2 (arrow in a) and T1 (arrow in b) weighted images suggestive of resolving haematoma.
a
b
a
b
follow-up there was minimal residual focal lesion in left psoas muscle and his limb movements were free (Figs.
2a and b).
DISCUSSION
Though, spontaneous bleeding in body cavities (like thoracic, abdominal cavity) and joints in dengue haemor- rhagic fever has been reported, spontaneous muscle hae- matoma is a rare complication. Only a countable number of case reports have been documented in medical litera- ture. Pathogenesis of haematoma formation is not clear.
It is suggested that the secondary immune response in the host to a secondary dengue virus infection causes vas-
culopathy, thrombopathy and disseminated intravascular coagulation. The vasculopathy includes endothelial dys- function and increased vascular permeability1-2. Throm- bopathy consists of thrombocytopenia and platelet dys- function which ultimately leads to bleeding. Other risk factors like old age may be contributory. Common sites of muscle haematoma that have been reported are psoas, ilia- cus muscle and rectus sheath. Ammer et al3, Ganeshwaran et al4 and Ganu et al5 reported cases of DHF with muscle haematomas in the psoas, rectus muscle and iliopsoas, respectively.Bhat et al6, reported two different cases of spontaneous psoas muscle haematoma and bilateral rec- tus sheath haematoma further complicating dengue haem- orrhagic fever. Waseem et al7 and Sharma et al8 reported
105 Kumar et al: Dengue complicated by spontaneous iliopsoas haematoma
unusual cases of DHF with the presentation of as rectus sheath haematoma.
Because of anatomic relationship between iliacus muscle and femoral nerve and presence of tough fascia covering iliacus muscle, a haematoma under the fascia may cause compressive neuropathy of femoral nerve re- sulting in weakness in the distribution of femoral nerve and pain in the hip area. Recovery of femoral nerve in such case may need surgical evacuation of haematoma3. High clinical suspicion and close monitoring of patient are important for early diagnosis and management of such cases. Management is usually conservative and surgical intervention is rarely needed.
Conflict of interest: None.
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Correspondence to: Dr Smita Manchanda, Assistant Professor, Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi–110 029, India.
E-mail: [email protected]
Received: 21 July 2016 Accepted in revised form: 19 December 2016
