Dengue Infections and the Surgical Patient

Abstract.

Dengue infections are increasing globally and account for significant morbidity and mortality. Severe dengue results in microvascular changes and coagulopathy that may make surgical intervention risky and the overall surgical management challenging. We outline the potential surgical manifestations and complications following dengue infections and describe the clinical, pathogenetic, diagnostic, and treatment aspects of dengue and surgical patients. The main surgical presentations were acute cholecystitis, acute pancreatitis, acute appendicitis, splenic rupture, bowel perforation, gastrointestinal bleeding, and hematomas. Dengue may also mimic an acute abdomen without any true surgical complications. A majority were treated nonoperatively. Misdiagnosis and unnecessary surgical intervention resulted in poor outcomes. Better knowledge of the potential surgical complications would help in early diagnosis, treatment, and referral to specialized centers and thus improve outcomes. A high degree of suspicion of dengue fever is necessary when patients in a dengue-epidemic area present with acute abdomen or bleeding manifestations. In endemic areas, early dengue antigen testing and abdominal imaging before surgical intervention may help in the diagnoses. Multidisciplinary team involvement with case-by-case decision-making is needed for optimal care.

INTRODUCTION

The dengue virus is a single-stranded non-segmented RNA virus, belonging to family Flaviviridae and genus Flavivirus. It consists of four serotypes. Dengue infections are increasing globally and account for significant morbidity and mortality.¹ Dengue is endemic in tropical and subtropical regions^2,3 and causes regular epidemics in countries within the tropical belt.^4,5 Dengue infections cause a wide spectrum of clinical manifestations, from an asymptomatic state to severe dengue with organ dysfunction and death.^1,6 Classical dengue fever is characterized by an acute onset of fever associated with headache, retro-orbital pain, severe arthralgia, and myalgia. The more severe forms are dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS).⁷ There has been a change in disease patterns with increasing involvement of gastrointestinal, hepatic, renal, hematological, neurological, respiratory, and cardiac systems.^8–15 Abdominal pain is a recognized feature during the critical phase of DHF.^1,7 Some patients with dengue may present with surgical complications such as gastrointestinal bleeding, acute pancreatitis, and splenic rupture, and others may mimic an acute abdomen without any true complications.^16,17

Severe dengue results in microvascular changes and coagulopathy, which may make surgical intervention risky and the overall surgical management challenging. Better knowledge of the potential surgical complications would help in early diagnosis, treatment, and referral to specialized centers and thus improve outcomes. Early identification of dengue in some patients presenting as acute abdominal emergencies to a surgical unit would help prevent unnecessary surgical interventions. We have critically analyzed the reported surgical complications following dengue and described the clinical, pathogenetic, diagnostic, and treatment aspects of dengue and surgical patients.

MATERIALS AND METHODS

An extensive search of the published literature before March 31, 2020 was carried out using PubMed, Embase, Scopus, and Google Scholar databases (Supplemental Figure S1). We used the keywords “dengue” OR “dengue viral infections” OR “dengue infections” AND “surgical complications” OR “acute abdomen,” OR “appendicitis,” OR “pancreatitis,” OR “cholecystitis,” OR “splenic rupture” OR “gastrointestinal bleeding” OR “peritonitis” OR “gastrointestinal perforation” OR “peptic ulcer” OR “abdominal wall hematoma.” Only articles published in English language were considered. Initial screening for eligibility (based on titles, abstracts, and keywords of citations from electronic databases) was performed by two investigators. The full-text articles of all relevant records were then evaluated. In doubtful situations, the opinions of senior investigators were sought. All data relating to the clinical presentation, investigation, treatment, and outcomes of dengue in the surgical patient were extracted, categorized, tabulated, and presented descriptively. The studies describing all types of acute surgical presentations were pooled and described qualitatively. Case reports of surgical manifestations in dengue were described separately.

RESULTS

Common causes of acute abdomen in dengue infections.

Abdominal pain is a known clinical manifestation of DHF. An acute abdomen is less common and may mislead the clinician assessing the patient. In general, the studies described acute abdomen as rapid onset abdominal pain and fever as the main complaint with evidence of peritonism on examination.¹⁷ Table 1 shows the case series and case reports of patients with acute abdomen and dengue.^16–38 A total of 22 studies were found; most were from South Asia (India [n = 13], Sri Lanka [n = 3], and Pakistan [n = 3]) and a few were from Taiwan (n = 3). A total of 9,365 dengue patients were studied and 1,501 (16%) presented with an acute abdomen. The patients’ age ranged from 10 to 76 years. The main causes were acute cholecystitis (45.4%, n = 681), acute pancreatitis (7.7% n = 116), acute appendicitis (2.7% n = 40), appendicular perforation (0.2% n = 3), splenic rupture (0.1% n = 2), and nonspecific peritonitis (3.1% n = 46). Twenty surgical procedures were carried out in these patients (appendectomy [n = 10], cholecystectomy [n = 6], laparotomy [n = 3], and splenectomy [n= 1]). The rest were managed conservatively using intravenous fluids, analgesics, and antibiotics. Most patients recovered, 30 died, and a prolonged hospital stay was reported in 39 patients.

Table 1.

Common causes of acute abdomen in dengue infections

Article number	Author country	Study type/study period	n/N	Age (years)	Male	Surgical presentations	Surgical interventions	Prolonged hospital stay	Deaths
1	Wu18 Taiwan	Retrospective/10 months	10/131	Mean: 48; SD: 15	4	Acute cholecystitis: 10	Cholecystectomy: 2, percutaneous drainage: 1	3	NA
2	Khanna33 India	Retrospective/4 months	20	Mean: 35.5;range: 20–67	15	Acalculous cholecystitis: 2,acute appendicitis: 1,acute pancreatitis: 5	Appendicectomy: 1	NA	NA
3	Khor19 Taiwan	Retrospective/7 months	14/328	Mean: 44; range: 15–68	4	Acute cholecystitis: 10, nonspecific peritonitis: 3, acute appendicitis: 1	Cholecystectomy: 1, appendicectomy: 1, percutaneous drainage: 1	3	NA
4	Sharma29 India	Prospective/12 months	14/27	Mean: 29.8; SD: 9.7	21	Acalculous cholecystitis: 14	None	14	1
5	Lee34 Taiwan	Retrospective/NA	71/774	Mean: 53; range: 18–76	28	Acute pancreatitis: 3	None	0	1
6	Premaratna20 Sri Lanka	Retrospective/9 months	12/NA	Mean: 28; SD: 4.6	5	Acute appendicitis: 12	Appendicectomy: 1	1	NA
7	Bhatty38 Pakistan	Retrospective/2 months	11/40	NA	8	Acute acalculous cholecystitis: 8	None	NA	0
8	Weerakoon36 Sri lanka	Retrospective/4 months	14/337	Mean: 28; range: 12–47	7	Acute cholecystitis: 5	None	NA	NA
9	Jhamb26 India	Retrospective/4 months	39/76	Mean: 28;SD: 9.6	NA	Acalculous cholecystitis: 15	None	NA	0
10	Shamim21 Pakistan	Prospective/42 months	43/357	Mean: 29.47; range: 15–72	15	Acute cholecystitis: 26, acute appendicitis: 7, nonspecific peritonitis: 7, acute pancreatitis: 3	Appendicectomy: 5, open cholecystectomy: 3	17	2
11	Chakravarti37 India	Retrospective/13 months	6/64	NA	NA	Acute cholecystitis: 6	None	NA	0
12	Majumdar35 India	Prospective/6 months	300	Range: 15–40	NA	Pancreatitis: 45,acalculous cholecystitis: 75	NA	NA	9
13	Ahmad16 Pakistan	Retrospective/33 months	121/875	Mean: 34.79;range: 18–70;SD: 12.21	NA	Acute cholecystitis: 46, acute pancreatitis: 19, acute appendicitis: 4, splenic rupture: 1	Splenectomy: 1	NA	2
14	Chatterjee25 India	Retrospective/6 months	5/180	Mean: 46.7;: 13–70	NA	Acute pancreatitis: 4,splenic rupture: 1	None	NA	7
15	Desai31 India	Three case reports/NA	3/NA	NA	NA	Appendicular perforation: 3	Exploratory laparotomy: 2, appendicectomy: 1	NA	0
16	Sreeramulu24 India	Retrospective/35 months	68/955	NA	NA	Acute acalculous cholecystitis: 68	None	NA	0
17	Pothapregada28 India	Retrospective/29 months	5/254	Mean: 6.9;SD: 3.3	NA	Acalculous cholecystitis: 2, acute pancreatitis: 1,acute appendicitis: 2	NA	NA	6
18	Jayasundara17 Sri Lanka	Retrospective/12 months	17/3,309	Range: 10–71	7	Acute appendicitis: 8, acute cholecystitis: 5, nonspecific peritonitis: 3, acute pancreatitis: 1	Appendicectomy: 1	1	1
19	Laul27 India	Retrospective/3 months	65/115	Mean: 31.36;SD: 13.17	NA	Acalculous cholecystitis: 26	None	NA	0
20	Shashirekha22 India	Retrospective/12 months	183/214	NA	NA	Acalculous cholecystitis: 122, pancreatitis: 24, appendicitis: 4, nonspecific: 33	None	NA	0
21	Chandey30 India	Prospective/5 months	309/540	Range: 16–65	NA	Acalculous cholecystitis: 210,pancreatitis: 9	None	NA	0
22	Gupta32 India	Prospective/14 months	165/501	16–72	111	Acalculous cholecystitis: 31, acute pancreatitis: 2,acute appendicitis: 1	None	NA	1

n = dengue cases with acute abdomen; N = total number of DF/DHF cases; NA = not available.

Most of the studies described a minority of dengue patients having an acute abdomen, although a few described a higher prevalence. Shashirekha et al.²² reported an acute abdomen in 85.5% of 214 dengue patients; a majority (n = 122) developed acute acalculous cholecystitis. In the study by Jayasundara et al.,¹⁷ of 3,309 dengue patients, 17 developed acute abdominal symptoms (acute appendicitis [n = 8], acute cholecystitis [n = 5], acute pancreatitis [n = 1], and nonspecific peritonitis [n = 3]). Some studies described acute cholecystitis as the only surgical complication observed in dengue patients. Seeramulu et al.²⁴ reported 68 patients presenting with acute abdomen among 955 DHF patients from India over a 35-month period; all had acute cholecystitis and were managed conservatively. Four studies from India (Jhamb et al.,²⁶ Laul et al.,²⁷ Sharma et al.,²⁹ and Chakravarti et al.³⁷) and one from Pakistan (Bhatty et al.³⁸) describe a total number of 121 dengue patients presenting with acute abdomen. All had acute acalculous cholecystitis and were managed conservatively.

Acute appendicitis associated with dengue infections.

Supplemental Table S1 outlines the reports of acute appendicitis in dengue.^39–46 Six of the eight patients were male. Common clinical presentations include fever, abdominal pain mainly in the right lower quadrant, and tenderness. Blood pressure, pulse rate, and respiratory rate were normal in all patients. On imaging, two had ultrasonic evidence suggesting appendicitis and in the others, the appendix was not visualized. Three were managed conservatively, and one had a planned interval appendectomy. One underwent reexploration 36 hours after appendicectomy because of increasing peritonism, but no bowel pathology was found. A ruptured appendicular mass was noted in another. Of the five where histology was available, two had a normal appendix and three had acute appendicitis with transmural neutrophil infiltration. All patients recovered, and the hospital stay ranged from 6 to 13 days.

Acute cholecystitis associated with dengue infections.

Supplemental Table S2 outlines the reports of acute cholecystitis in dengue.^47–60 The age of the patients was between 18 and 59 years, and 80% were female. Fever and right upper quadrant abdominal pain were seen in all, one patient was in shock, and the others were hemodynamically stable. Five had a positive Murphy’s sign, thrombocytopenia was seen in all, and alkaline phosphatase levels were high. One patient had an abnormal coagulation profile. Imaging (ultrasonography, computed tomography, or magnetic resonance imaging) showed acute acalculous cholecystitis in all. Of the 15 patients, four underwent cholecystectomy and the others were managed conservatively. One of the operated patients died after surgery following severe bleeding, and another had a perforated gall bladder at fundus/body junction. Histology showed changes of acute cholecystitis. Two of the patients were pregnant at the time of diagnosis and later went on to have successful vaginal deliveries.

Pancreatitis associated with dengue infections.

Supplemental Table S3 outlines the reports of acute pancreatitis in dengue.^61–78 Most of them were from Sri Lanka and India, age range was 10–66 years, and 12 of the 18 were male. Most had fever for > 3 days and epigastric pain, one had melena, and two had hematemesis at the time of admission. On examination, most had low blood pressure, a rapid pulse and respiratory rate, and tender epigastrium. All had low platelet counts and a raised serum amylase or lipase level or both. Liver enzymes were abnormal in most. Imaging (computed tomography, ultrasonography, or magnetic resonance imaging (MRI) scan of the abdomen) showed evidence of acute pancreatitis such as pancreatic edema and acute fluid collection in the majority. Some studies have failed to exclude/mention about other commonest causes of acute pancreatitis such as alcohol and gall stones. Nine developed complications such as bilateral massive pleural effusion, acute lung injury, gastrointestinal bleeding, and liver failure with cerebral edema. Two developed acute kidney injury, shock, and multi-organ dysfunction syndrome, and one patient died. All were managed conservatively. One needed a chest drain, and other interventions included mechanical ventilation, anti-liver failure regime, and blood product transfusion according to their need. Hospital stay ranged from 8 to 21 days.

Splenic rupture associated with dengue infections.

Supplemental Table S4 outlines the reports of splenic rupture in dengue.^79–94 A majority were from Asia, age ranged from 20 to 52 years, and 15 of 19 were male. All presented with fever for five or more days and abdominal pain, and a majority had signs of shock. Thrombocytopenia, low hemoglobin levels, and low packed cell volume were common. Liver enzymes were abnormal in five patients, and one had an abnormal clotting profile. Imaging showed a splenic hematoma or rupture. There were four deaths: three after a laparotomy and splenectomy and the other before surgical intervention (24 hours after admission). Of the other 15 patients, five were managed conservatively and ten had a laparotomy and splenectomy. There was normal splenic architecture with a capsular tear and no evidence of granuloma or malignancy. Hospital stay ranged from 7 to 30 days.

Other surgical manifestations in patients with dengue fever.

Supplemental Table S5 summarizes the other less common surgical manifestations in dengue.^{16,23,95–114} Seven studies and several case reports/series were found mainly from Asian countries. A total of 296 patients were described. Upper gastrointestinal bleeding was reported in 245 patients (82.7%), and rectal bleeding was reported in 11 patients (3.7%). A total of 147 patients had upper gastrointestinal endoscopic findings of peptic ulcer, hemorrhagic/erosive gastritis, and duodenal and esophageal ulceration. Two patients needed a laparotomy, and 25 patients were managed with endoscopic injections. Two patients with rectal bleeding needed ligation of actively bleeding hemorrhoids. Apart from surgical interventions, a majority needed blood product transfusions, intravenous crystalloids, and intravenous proton pump inhibitors, and a few needed inotropic support and intravenous antibiotics.

Seven (2.4%) patients had a hollow viscous perforation. A previous history of peptic ulcer diseases was not mentioned in these cases. Three patients had a gastric perforation, and one had ileal and two patients had jejunal perforations. Almost all of them had air fluid levels and gas under diaphragm on abdominal X-rays. All needed emergency laparotomies for repair of the perforation.

Abdominal wall hematomas, predominantly in the rectus sheath, were reported in eight patients. These were managed with percutaneous drainage (n = 1), ultrasound-guided aspiration (n = 1), and surgical repair of inferior epigastric artery leak (n = 1). The rest were managed conservatively. Three cases of retroperitoneal hematomas were reported, and one was managed with endovascular embolization under general anesthesia. Two psoas muscle hematomas were also reported, which were managed conservatively. Fourteen patients developed abscesses which were drained via an incision. Abdominal compartment syndrome was reported in two patients. Surgical wound bleeding was reported in two patients with thrombocytopenia, and one of the patients died.

DISCUSSION

Abdominal symptoms are not uncommon in dengue.¹¹⁵ A large multicenter prospective study found nausea, vomiting, diarrhea, and abdominal pain in 35%, 20%, 16%, and 15% of dengue patients, respectively.¹¹⁵ Right hypochondrial and epigastric tenderness were noted in 26% and 12% patients, respectively. Most of these abdominal symptoms were associated with severe forms of the disease.¹¹⁵ An acute abdomen in dengue has been well-described. Most are single-center reports and involve a small percentage of the total cohort of dengue patients. Most are managed nonoperatively but may have a prolonged hospital stay with complications. Diagnosis of an acute abdomen can be difficult in a critically ill dengue patient. Worsening biochemical parameters, features of edema or inflammation on imaging, clinical deterioration with abdominal guarding, and rigidity would point to the diagnosis. However, similar imaging features may occur secondary to fluid leakage. With borderline presentations, repeated assessments by a multidisciplinary team of specialists would help decide if the patient requires any invasive procedures. The risks of any invasive procedure such as bleeding, secondary infections, surgical stress, and exposure to anesthesia should be weighed against the benefits of removing the source of sepsis or stopping further bleeding. The patients’ general health, their clinical condition, and comorbidities would impact on deciding whether invasive procedures should be considered.

Dengue infections may associate with true or apparent surgical acute abdomen because of several reasons. A true acute abdomen may occur as a complication of dengue fever (e.g., ruptured splenic hematomas, upper and lower gastrointestinal bleeding, and abdominal wall hematomas due to coagulopathy associated with dengue). Dengue infections may occur with simultaneous surgical disease (i.e., dual pathology). Such dual pathologies may occur either pathophysiologically unrelated to dengue (e.g., dengue patient with a perforation of a hollow viscus) or pathophysiologically related to it (e.g., or acute acalculous cholecystitis related to dengue). Furthermore, dengue fever may mimic a surgical acute abdomen and may present to surgical specialties. Moreover, surgical complications may be iatrogenic (e.g., abdominal compartment syndrome due to overzealous fluid resuscitation or gastric perforation related to nonsteroidal anti-inflammatory drug [NSAID] use). Some complications may occur because of complications of dengue and also iatrogenically (e.g., abdominal compartment syndrome due to rectus sheath hematoma¹¹⁶ or due to excessive fluid resuscitation¹¹⁷).

A substantial number of cases of acute abdomen seen in dengue are not because of true complications of dengue or dual pathology but because of clinicians getting deceived by the presentation of dengue to misdiagnose as an acute abdomen.^17–19,21 Therefore, it is important for clinicians (both physicians and surgeons) to be vigilant, specially in tropics, not only to avoid getting deceived by abdominal symptoms of dengue but also not to miss true acute surgical concerns associated with dengue.

The pathophysiological mechanisms for acute abdomen in dengue are poorly understood.¹⁸ It may be because of direct viral invasion of the abdominal organs such as the appendix, gallbladder wall, pancreas, or spleen leading to inflammation and edema.²¹ A systemic inflammatory response may be another reason. As the vast majority of patients who presented with an acute abdomen had features of DHF or DSS, the systemic inflammatory response and plasma leakage may have led to the edematous and inflammatory changes within organs.^18,21 An edematous appendix with luminal obstruction may precipitate a secondary bacterial infection and cause appendicitis. The pathogenesis of acute acalculous cholecystitis may be multifactorial.¹⁸ The systemic inflammatory response, endotoxemia, cholestasis, secondary bacterial translocation, spasms of the ampulla of Vater, microangiopathic changes, and ischemia reperfusion injury may contribute.¹⁸ Edema of splenic parenchyma due to fluid leakage or bleeding with expansion of a hematoma within a non-yielding splenic capsule may cause spontaneous splenic rupture. The systemic inflammatory response with coagulopathy may cause spontaneous bleeding or bleeding with trivial trauma, particularly when there is an underlying pathology such as mucosal ulceration.

Most cases of acute abdomen in DHF patients may be treated nonsurgically using fluids and symptom/supportive care.^19,21 Fever, body aches and pain, nausea, and vomiting could be treated symptomatically.²¹ Aspirin and other NSAIDs should be strictly avoided. Intravenous fluids should be used and the patient kept nil orally.¹¹⁸ Nasogastric decompression may be needed. Routine prophylactic antibiotics should be avoided but may be needed if the patient requires surgery or an invasive procedure.^17,118,119 Daily monitoring of packed cell volume, platelet counts, and coagulation tests should be carried out in all patients, and liver and renal function tests and blood gases in selected patients.^19,21 Occult or overt bleeding may need transfusion of packed red cells, fresh frozen plasma, and/or platelets.^19,21,119 Appropriate organ support may be needed in critically ill patients (e.g., ventilator support in patients with acute severe pancreatitis and acute respiratory distress syndrome).²¹

Appendectomy and/or intravenous antibiotics is the treatment of choice for uncomplicated acute appendicitis. Surgery is the treatment of choice in the case of complicated appendicitis (due to rupture or peritonitis). In some centers, surgery is performed early for uncomplicated acute appendicitis to minimize local and systemic complications.^120,121 Surgery for acute appendicitis in the context of dengue fever has negative consequences. Khor et al.¹⁹ and Shamim et al.²¹ noted bleeding requiring blood transfusions, and a prolonged hospital stay was observed.²⁰ Furthermore, of the five patients for whom histology was available, two had a normal appendix and three had acute appendicitis with transmural neutrophil infiltration. Therefore, it is clear that the histopathology does not correlate with the clinical suspicion indicating how clinicians have been misled. Thus, with acute appendicitis in a dengue patient, nonsurgical management with intravenous antibiotics should be considered. If needed, a planned interval appendectomy may be considered.

Acute acalculous cholecystitis was more frequently noted than the calculous form. Acute calculous cholecystitis is managed conservatively followed by delayed cholecystectomy or by emergency cholecystectomy depending on the clinical findings and associated complications.^16,17 By contrast, acute acalculous cholecystitis is usually managed conservatively with supportive care and intravenous broad spectrum antibiotics and rarely needs cholecystectomy (in cases of gangrenous perforation). Such complications tend to occur in critically ill, hemodynamically unstable, or immunocompromised patients. They may not be fit for surgery and thus managed with minimally invasive procedures such as percutaneous aspiration and drainage.^16,17 Failing to diagnose and manage DHF in acute cholecystitis may lead to detrimental outcomes. Schmidt-Chanasit et al.⁴⁹ described a German patient who was initially diagnosed with acute acalculous cholecystitis and had a cholecystectomy. The diagnosis of DHF was missed, and the patient died of massive bleeding due to coagulopathy. Thus, DHF needs to be ruled out in such cases with cholecystitis, especially in dengue-endemic regions or in patients with recent travel history to such areas. As plasma leakage with peri-cholecystic edema is a known manifestation in DHF, there may be diagnostic difficulty in identifying acalculous cholecystitis in DHF by ultrasonography. Gallbladder wall thickening and peri-cholecystic edema may be noted in the leaking phase of dengue, raising a diagnostic dilemma among dengue patients. Therefore, clinicians should be cautious in diagnosing acute cholecystitis in dengue patients.

The main stay of management of acute pancreatitis is supportive care. Only very selected patients need surgery within the first few days of symptoms. Similarly, acute pancreatitis in a patient with DHF would only rarely need surgical intervention. Acute pancreatitis in a dengue patient is associated with prolonged hospital stay and complications such as acute lung injury, massive pleural effusion, gastrointestinal bleeding, and acute kidney injury. Because aggressive fluid resuscitation is needed in acute pancreatitis, DHF patients may be at risk of life-threatening fluid overload, especially in the convalescent phase. Intensive monitoring of fluid management may be needed in an intensive care unit setting.

A majority of the splenic ruptures in dengue presented as an emergency. Most needed surgical intervention (laparotomy and splenectomy). Splenic rupture may cause massive hemorrhage, especially in critically ill dengue patients with coagulopathy. In such patients, diagnosing intra-abdominal bleeding may be difficult by ultrasonography, and contrast enhanced computed tomography (CT)computed tomography (CT) scanning may be needed. At present, the exact etiology of splenic rupture in dengue is unclear. Fluid leakage may make lead to a congested/edematous spleen. Bleeding within the spleen (due to coagulopathy) precipitated by minor trauma may lead to rapid expansion of the hematoma. A rigid and non-yielding splenic capsule may trigger rupture of the otherwise normal spleen. Surgery is the mainstay of treatment, but minimally invasive procedures such as angioembolization of the splenic artery may be considered in patients not fit for surgery.

Uncomplicated appendicitis and cholecystitis in dengue usually resolve spontaneously. Wu et al.¹⁸ found the gallbladder wall thickening to return to normal following recovery and cholecystectomy was not necessary. However, any complications such as gangrene or perforation would need surgical intervention. Performing surgery in a critically ill patient is challenging and has more complications. Minimally invasive approaches such as image-guided percutaneous drainage may be considered.^19,21,119 The bleeding tendency due to coagulopathy, both during and after surgery, is challenging to manage. At present, guidance on the perioperative correction of coagulopathy in critically ill dengue patients is limited. Thromboelastography with targeted correction would avoid excessive transfusion of blood products and fluid overload. Studies identifying factors that predict a failure of conservative management in acute abdomen in dengue are lacking. Thus decisions need to be taken on a case-by-case basis by a multidisciplinary team involving a physician, surgeon, critical care specialist, radiologist, and anesthetist. Postoperative complications such as intra-abdominal bleeding, wound hematoma, wound dehiscence, and surgical site infection have been reported in critically ill dengue patients. Thus, correction of coagulopathy should be carried out throughout the perioperative period.

Misinterpretation of acute abdominal signs/symptoms may occur frequently in dengue fever.¹⁷ A prior history of gallstone disease or pancreatitis may confuse clinical decision-making. Furthermore, neutropenia, lymphocytosis, and thrombocytopenia may not be seen in all dengue patients at an early stage of disease. Jayasundara et al.¹⁷ found the hematological changes of dengue fever in only two-thirds of patients at an early stage of the disease (i.e., in the first 24 hours). Misdiagnosing dengue as a surgical acute abdomen may result in significant morbidity and mortality. Surgical intervention during the critical phase of dengue may significantly compromise disease homeostasis. Failure of recognition of the critical phase of dengue may lead to DSS and even death. Also, it is important to note that dengue guidelines may not comply with other surgical disease guidelines. For example, limited fluid management in dengue does not comply with liberal fluid management in pancreatitis, making the management of pancreatitis in a dengue patient challenging. Intramuscular analgesia and NSAIDs which are commonly used analgesics for perceived acute abdomen may worsen coagulopathy and give rise to hematomas and other bleeding manifestations in a dengue patient. Furthermore, thromboembolism prophylaxis in surgical abdomens does not comply with DF management because of the bleeding tendency. A big risk with misdiagnosing dengue fever as an acute abdomen is an invasive surgical procedure, which may lead to severe complications.¹⁷

Recommendations.

Dengue fever should be considered as a possible cause in patients from a dengue-endemic area presenting with acute abdomen or bleeding manifestations or patients with a relevant travel history. Such patients should be evaluated with basic hematological tests, early dengue antigen/serology, and imaging. Aspirin and other NSAIDs should be strictly avoided. Routine prophylactic antibiotics should be avoided, except when surgery is needed or invasive procedures are to be undertaken. Daily monitoring of full blood count, coagulation tests and, liver and renal function tests should be performed. Because surgery is risky and challenging in dengue patients, this should be reserved for highly selected patients with perforation, gangrene, and uncontrollable hemorrhage. Minimally invasive methods such as percutaneous drainage for abscesses and collections and angioembolization for splenic rupture or bleeding should be considered. Uncomplicated cases of acute cholecystitis, appendicitis, and pancreatitis should be managed conservatively. From a surgical point of view, unless there is gangrenous appendicular/gallbladder/viscus perforation, surgery could be avoided in the hyperacute setting. Thromboelastography with targeted correction of coagulopathy would be beneficial to avoid excessive transfusion of blood products and fluid overload. Decisions on care and invasive procedures should be taken on a case-by-case basis by a multidisciplinary team involving a physician, surgeon, critical care specialist, radiologist, and anesthetist.

CONCLUSION

We have outlined the surgical manifestations and complications following dengue infections and described the clinical, pathogenetic, diagnostic, and treatment aspects of dengue and surgical patients. Surgical manifestations are not uncommon, and a majority can be managed nonoperatively or by minimally invasive procedures. Common surgical manifestations include acute acalculous cholecystitis, acute pancreatitis, acute appendicitis, splenic rupture, bowel perforation, gastrointestinal bleeding, and hematomas. A high degree of suspicion of dengue fever is necessary when a patient from a dengue-endemic area presents with acute abdomen or bleeding manifestations. Misdiagnosis and unnecessary surgical procedures lead to poor outcomes. Such misdiagnoses can be prevented by evaluation with basic hematological tests, early dengue antigen tests/serology, and imaging. Multidisciplinary team involvement with case-by-case decision-making is needed for optimal care.

Note: Supplemental figure and tables appear at www.ajtmh.org.