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. 2014 Sep-Oct;56(5):459–460. doi: 10.1590/S0036-46652014000500018

AUTHORS REPLY

Beuy JOOB (1), Viroj WIWANITKIT (2)
PMCID: PMC4172123  PMID: 25229232

June 13, 2014

Sir, the recent report on “thrombocytopenic purpura and dengue” is very interesting1. AMÂNCIO et al. concluded that “DENV-4 can also result in severe forms of the disease and lead to hemorrhagic complications and death, mainly when dengue infection is associated with coexisting conditions1”. In fact, dengue is a common arboviral disease that can be seen in several tropical countries. No doubt that this infection can co-occur with other thrombohemostatic disorders. The concomitant disorder between dengue and thrombocytopenic purpura is not common and can be problematic. This problem can induce to severe bleeding as well as atypical manifestations such as angina2. To manage those cases, adding to fluid replacement therapy, steroid therapy seems to be useful6. Nevertheless, dengue can be the cause of immune thrombocytopenic purpura3,4 and it is observed for relationship to severe cardiovascular failure and shock5. In the present case, it is needed to clarify whether the observed thrombocytopenic purpura problem is the new superimposed or old problem. Since the clinical management of the dengue case with underlying thrombocytopenic purpura is different from general cases, it is the role of the physician in charge to carefully take the patient past history on personal illness.

REFERENCES

  • 1.Amâncio FF, Pereira MA, Iani FC, D'anunciação L, Almeida JL, Soares JA, et al. Fatal outcome of infection by dengue 4 in a patient with thrombocytopenic purpura as a comorbid condition in Brazil. Rev Inst Med Trop Sao Paulo. 2014;56:267–70. doi: 10.1590/S0036-46652014000300014. [DOI] [PMC free article] [PubMed] [Google Scholar]
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Rev Inst Med Trop Sao Paulo. 2014 Sep-Oct;56(5):459–460.

AUTHORS REPLY

Frederico F Amâncio (1), Maira A Pereira (2), Felipe C M Iani (2), Lorena D'anunciação (2), Jorge L C Almeida (3), Janer A S Soares (4), Marcela L Ferraz (5), Thiago C Vale (6), José R Lambertucci (1), Mariângela Carneiro (1),(7)

To the Editor

We would like to thank JOOB & WIWANITKIT for their comments on our article1. In fact, as a variety of conditions associated with dengue could explain the bleeding and thrombocytopenic picture described, it is difficult to ensure that the patient got worse by an exacerbation of immune thrombocytopenic purpura. That is why it makes difficult the use of steroids in such cases. As reported1, dengue associated with sepsis or just severe dengue with gastrointestinal bleeding are possible explanations for the described clinical picture. Despite anecdotal reports of favorable outcome in specific dengue cases who used steroids3,4, a thorough review showed no benefit from use of corticosteroids in dengue shock2. The steroids use during the early acute phase of dengue infection was also not associated with reduction in the development of shock7 and there was no benefit of using adjunctive corticosteroid therapy in term of changing the severity of thrombocytopenia5,6. We completely agree that the treatment of dengue should be personalized considering comorbidities and clinical history of the patients, however, as corticosteroids can potentially do harm, we believe that their use need to be better defined and limited to very specific dengue situations.

We wish to thank JOOB & WIWANITKIT again for their attention and observations. We enjoyed the opportunity to discuss the case reported and we hope that future studies adequately powered, designed and controlled evaluate the possible beneficial effects of steroids on the various manifestations of dengue infection.

REFERENCES

  • 1.Amâncio FF, Pereira MA, Iani FC, D'anunciação L, Almeida JL, Soares JA, et al. Fatal outcome of infection by dengue 4 in a patient with thrombocytopenic purpura as a comorbid condition in Brazil. Rev Inst Med Trop Sao Paulo. 2014;56:267–70. doi: 10.1590/S0036-46652014000300014. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Panpanich R, Sornchai P, Kanjanaratanakorn K. Corticosteroids for treating dengue shock syndrome. Cochrane Database Syst Rev. 2006;((3)):CD003488. doi: 10.1002/14651858.CD003488.pub2. [DOI] [PubMed] [Google Scholar]
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  • 5.Shashidhara KC, Murthy KA, Gowdappa HB, Bhograj A. Effect of high dose of steroid on plateletcount in acute stage of dengue fever with thrombocytopenia. J Clin Diagn Res. 2013;7:1397–400. doi: 10.7860/JCDR/2013/6135.3143. [DOI] [PMC free article] [PubMed] [Google Scholar]
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