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AN ADULT WOMAN WITH FEVER, COUGH AND ABNORMAL LIVER FUNCTION

ANSWER

1. She had acute primary dengue fever. She did not have feature of dengue haemorrhagic fever (DHF) such as bleeding tendency. The presence of IgM antibody suggests she had acute dengue. Dengue IgG is often detectable even in the early phase of secondary dengue,1 which was not seen in this case.
2. Respiratory tract involvement is often thought to be uncommon in dengue fever. However, evaluation of serologically proven dengue cases has shown that cough was reported as a symptom in a significant proportion of cases in Singapore (26%),2 Thailand (26%),3 Taiwan (37.6%)4 and Vietnam (30.7-53.1%).5 Interestingly, in two studies2,5 the frequency of cough was similar in the dengue and non-dengue cases. This symptom was also found to be more common in children than in adults,3 and more in primary dengue than in secondary dengue. 5 This underlies the importance of including dengue in the differential diagnosis of febrile patient with respiratory symptoms in the primary care setting.
3. LFT is seldom performed in suspected dengue fever in the primary care setting unless there are clinical signs pointing to liver involvement (e.g. jaundice). Clinical studies showed that mild biochemical liver dysfunction is very common in dengue (>90%).6-9 Furthermore, dengue haemorrhagic fever tended to have higher liver enzymes than classical dengue fever.9,10 Although abnormal liver function test is not a good indicator of DHF, normal plasma aspartate aminotransferase had high negative predictive value for DHF.11 Perhaps  a case can be made for more frequent LFT testing in suspected dengue infection in primary care.

References

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3. Wichmann O, Hongsiriwon S, Bowonwatanuwong C, Chotivanich K, Sukthana Y, Pukrittayakamee S. Risk factors and clinical features associated with severe dengue infection in adults and children during the 2001 epidemic in Chonburi, Thailand. Trop Med Int Health. 2004; 9(9):1022-9 [PubMed]
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5. Phuong HL, de Vries PJ, Nga TT, Giao PT, Hung lQ, Binh TQ et al. Dengue as a cause of acute undifferentiated fever in Vietnam. BMC Infect Dis. 2006; 6:123 [PubMed] [Full text]
6. Itha S, Kashyap R, Krishnani N, Saraswat VA, Choudhuri G, Aggarwal R. Profile of liver involvement in dengue virus infection. Natl Med J India. 2005; 18(3):127-30 [PubMed]
7. Kuo CH, Tai DI, Chang-Chien CS, et al. Liver biochemical tests and dengue fever. Am J Trop Med Hyg. 1992; 47(3):265-70 [PubMed]
8. Pancharoen C, Rungsarannont A, Thisyakorn U. Hepatic dysfunction in dengue patients with various severity. J Med Assoc Thai. 2002;85 Suppl 1:S298-S301 [PubMed]
9. Wahid SF, Sanusi S, Zawawi MM, Ali RA. A comparison of the pattern of liver involvement in dengue hemorrhagic fever with classic dengue fever. Southeast Asian J Trop Med Public Health. 2000; 31(2):259-63 [PubMed]
10. Kalayanarooj S,Vaughn DW, Nimmannitya S, et al. Early clinical and laboratory indicators of acute dengue illness. J Infect Dis. 1997; 176:313–21 [PubMed]
11. Monath TP. Early indicators in acute dengue infection. Lancet. 1997; 350:1721-2 [PubMed]