Large hematoma over the puncture site of percutaneous transluminal coronary angioplasty as a presenting sign of severe dengue infection

Abstract

Dengue fever is a common arboviral infection all over the world. It is endemic in the tropical and subtropical areas of the world with periodic epidemics in these areas. In its severe form dengue patients may develop life-threatening bleeding manifestations. We report here a case of large hematoma formation precisely located over the puncture site of percutaneous transluminal coronary angioplasty as a presenting sign of severe dengue infection for its unusual occurrence.

<Learning objective: Severe dengue including dengue shock syndrome is a potentially life-threatening condition. Dengue virus-induced coagulopathy and thrombocytopenia may further complicate cardiological interventions like percutaneous transluminal coronary angioplasty or coronary artery bypass grafting as such patients are already on antiplatelet drugs. Performing any cardiovascular intervention in an endemic area of dengue needs proper vigilance to avoid such potentially life-threatening complications.>

Introduction

Dengue fever is one of the most common arboviral infections all over the world [1].

It is endemic in the tropical and subtropical areas of the world particularly in south east Asia, the Pacific, east and west Africa, the Caribbean, and the Americas with periodic epidemics in these areas [1]. Dengue fever may present as mild, self-limited febrile episode with constitutional symptoms [2]. On the other hand, severe dengue including dengue shock syndrome is characterized by severe capillary permeability and plasma leakage, fluid accumulation, respiratory distress, severe bleeding, and severe organ involvement (liver, central nervous system, heart, kidneys, and others) [2]. We herein report a case of large hematoma precisely located over the puncture site of percutaneous transluminal coronary angioplasty (PTCA) as a presenting sign of severe dengue infection for its unusual occurrence.

Case report

A 64-year-old man underwent PTCA and stenting in the proximal left anterior descending coronary artery with a sirolimus-eluting stent (3 mm × 28 mm) for acute coronary syndrome. The patient was put on aspirin (150 mg/day) and clopidogrel (75 mg/day) therapy. The immediate postoperative period was uneventful and the puncture site was healthy. From the first post-operative day, the patient had fever (up to 38.3 °C).

On the 4th postoperative day, the patient developed an acute onset hematoma over the right groin around the puncture site. The swelling eventually extended into the right iliac fossa, right upper thigh, and pubic region. Focal blistering and erosion were also noted on the hematoma (Fig. 1). The systemic examination revealed mild pallor, icterus, tachycardia with low volume pulse, and the left arm supine blood pressure was 90/60 mmHg. Anti-platelet therapies were stopped immediately and the patient was subsequently evaluated for hematoma and fever. The patient had low hemoglobin level (9.1 g %), very low platelet count (10,000/cmm), grossly deranged coagulation profile [activated partial thromboplastin time: >100 s (control: 23.3 s), prothrombin time: 27.5 s], hyperbilirubinimia (bilirubin: 5.8 mg/dl, direct: 2.6, indirect: 3.2), and markedly raised transaminase levels (aspartate transaminase: 8880 IU/dl, alanine transaminase: 3590 IU/dl). Table 1 shows a profile of important parameters of the patient before and after the life-threatening bleeding manifestations.

Fig. 1.

Large hematoma with erosions and superficial bullae.

Table 1.

Profile of important parameters of the patient before and after the life-threatening bleeding manifestations.

Parameters	At presentation	When bleeding complications started
Blood pressure	120/80 mmHg	90/60 mmHg
Pulse	72/min	112/min
Hemoglobin level	13 g/dl	9.1 g/dl
Platelet count	161,000/cmm	10,000/cmm
Bilirubin	1.1 mg/dl	5.8 mg/dl
Alanine transaminase	44 IU/dl	3590 IU/dl
Aspartate transaminase	46 IU/dl	8880 IU/dl
Prothrombin time	12 s	27.5 s
Activated partial thromboplastin time	21 s	>100 s

His chest X-ray was normal and ultrasonography of the abdomen was non-contributory apart from a suggestion of rectus muscle hematoma. As several people in his locality had infection with dengue virus, we further investigated to rule out the same. Enzyme-linked immunosorbent assay (ELISA) test for specific dengue NS1 antigen was positive. Subsequently IgM and IgG antibody against dengue virus, by ELISA method, was strongly positive. Based on the clinical features and laboratory investigations, a diagnosis of severe dengue was made. The patient was treated conservatively in an intensive care unit setting with supportive measures including infusions of platelet and fresh frozen plasma. Within 24 h, his sensorium was deteriorated and melena was started. Subsequently, the patient died.

Discussion

In cases of severe dengue, patients may develop life-threatening thrombocytopenia due to complement activation by viral antigens binding to the platelets [1]. Our patient was strongly positive for both IgM and IgG which signified that this was probably the second episode of dengue, which is usually more severe than the primary dengue infection. On the other hand, the incubation period of severe dengue (also known as dengue hemorrhagic fever) is approximately 4–7 days [3]. In our patient PTCA was performed on the day of the admission and the patient was afebrile at that time. He developed fever on the first postoperative day and therefore it appeared to be a community-acquired infection.

Hence, we would like to highlight that hospitals in the dengue endemic areas, offering any type of cardiac intervention, should incorporate regular dengue screening of their cases since many such patients might acquire infection before admission to hospital. These patients may also spread dengue virus in otherwise dengue-free hospitals [4]. It is also worth mentioning that fulminant hepatitis is a rare but potentially serious complication of dengue [5]. The hematoma formation in our patient was probably multifactorial in origin. We speculate that dengue virus-induced acute fulminant hepatitis with subsequent coagulopathy, dual antiplatelet-induced thrombocytopenia and/or functional disorder of platelets, and dengue-induced thrombocytopenia was instrumental in the causation of hematoma. New hematoma formation over the puncture site of angioplasty on the 4th post-operative day in an otherwise healthy person is unusual in the absence of any blood dyscrasia.

So, this observation further pointed toward the pivotal contributory role of dengue in the present case. This case also brought forward a dilemma in the management as PTCA with drug-eluting stent needed dual platelet therapy and on the other hand, we had to stop antiplatelets, in the setting of coagulopathy and thrombocytopenia. Dengue virus-induced coagulopathy has previously been reported in cases of renal transplant recipients [6], after hysterectomy [7], and following coronary artery bypass grafting [1]. However, appearance of hematoma, precisely located on the PTCA site, as a clue to the diagnosis of severe dengue was a hitherto unreported occurrence.

In this report we further sought to emphasize that performing any cardiovascular intervention in an endemic area of dengue needs proper vigilance to avoid such potentially life-threatening complications.

Conflict of interest

None.