Menorrhagia caused by dengue fever

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Iv% J Ohstet (;Ynaecol2000; 40: 3: 354-355

CASE REPORT

Menorrhagia caused by dengue fever Rose M ~ G r e a d y , ' , ~Eh , ~ . Paw2 ~ and FranCois N o ~ t e n l > ~ > ~ Department of Obstetrics' and Family Planning Clinic? Maela Refugee Camp, Shoklo Malaria Research Unit3,Mae Sot, Thailand, Faculty of Tropical Medicine4, Mahidol University, Bangkok, Thailand

INTRODUCTION On the Thai-Burmese border 100,000 people live in camps for displaced people of the Karen ethnic minority The most serious health problem facing the population is multi-drug resistant Plasmodium falciparum malaria. Medecins sans Frontieres (MSF) and the Shoklo Malaria Research Unit (SMRU) provide health care in the largest of the camps, Maela. The SMRU family planning clinic in Maela camp (population 30,000)attracts an assortment of gynaecological problems apart from the routine provision of contraceptives. There are no operative facilities at the camp and patients require transfer to the Thai town of Mae Sot (one-hour drive). On 6 December 1999, a 14-year-oldgirl was carried to the family planning clinic on a bamboo stretcher, accompanied by her mother. Her presenting complaint was 'too much menstrual blood loss'. This was placed in context (there are no sanitary napkins available in the camp) by her mother who complained she had to wash too many sarongs (traditional dress similar to a straight skirt, which covers the lower half of the body). The patient was a school student and not sexually active. The patient had been menstruating for 8 months, with monthly cycles of 445 days bleeding, and usually used a maximum of 3 sarongs in 24 hours. On presentation she had used 3 sarongs in 6 hours and complained of heavy bleeding with clots for 3 days. The girl had no significant past ill health but reported fever and headache for 3 days for which she had taken acetylsalicylic acid (Aspirin, The British Dispensary Co Ltd) supplied by the local MSF dispensary. At 10.00 am on the day of presentation on routine observation she appeared well, adequately nourished, was afebrile, displayed no signs of hypotension and her blood pressure was recorded at 90/50 mmHg and her pulse rate at 108 beats /minute and temperature 36.7"C.

Address for correspondence Dr Rose McGready Shoklo Malaria Research Unit PO Box 46, Mae Sot, 63110, Thailand Rose McGready Director Obstetric and Family Planning Cinic of SMRU, Eh Paw Manager of Family Planning Clinic, FranCois Nosten Director Shoklo Malaria Research Unit affiliated with the Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand

Her physical examination was unremarkable, and specifically there was no abdominal or pelvic pain, or masses, and examination of the vagina revealed no active blood loss. Speculum examination was not car. ried out a s there was no visible blood loss and the hymen was intact. A finger prick blood sample was taken. Her malaria smear was negative, haematocrit was 34.2%, the white blood cell count was 7.8 x 103/L, with a differential of 74% granulocytes and 26% lym. phocytes/monocytes, and platelet count of 197 x 109/L. A mid-stream urine specimen tested positive for blood and negative for pregnancy Liver function tests (results available from Mae Sot, 2 days later) revealed a slightly elevated aspartate transaminase (131 U/L), while urea, creatinine and thyroid function tests were unremarkable. At 2.00 pm she complained she was bleeding again and on examination she did indeed have a steady flow of fresh blood from the vagina. Her observations were unchanged from admission and she was kept in the inpatient department for observation. In the evening she had a n episode of fever of 38.3"C, treated with paracetamol and at 9.00 am the following morning her observations were significantly worse. The patient looked anxious and her pulse was recorded at 120 beatdminute and blood pressure as 80/60 mmHg, with a temperature of 36.5"C. A full examination was again unremarkable except for a slight generalised red flush of her skin and specifically, no petechiae, or ecchymoses were found. The patient complained of mild pruritis when questioned. There was no jaundice. There was normal bowel activity, with one normal bowel motion at dawn. The vaginal bleeding had continued intermittently overnight but was reported as decreasing. A repeat malaria smear and complete blood count was ordered. She was again smear negative for malaria but her blood picture was significantly different: haematocrit l8.8%, white blood cells 5.3 x 103/L,with a differential of 45% granulocytes and 55% lymphocytes/monocytes, and platelet count of 105 x 109/L. At this stage the girl was cross-matched and transfused 350 cc of fresh whole blood, screened for Hepatitis B, HIV and malaria. The patient's observations remained stable, vaginal bleeding ceased over the next two days and she was discharged, on ferrous sulphate and folic acid supplemention for 2 weeks.

ROSE

MCGREADY, EH PAW A N D FRANCOIS NOSTEN

Table 1 Pathological causes of excessive uterine

bleeding Reproductive tract diseases Complications of pregnancy threatened, incomplete, or missed abortion, ectopic pregnancy, trophoblastic disease, placental polyp, and subinvolution of the placental site. -

Malignant tumours endometrial, cervical, vaginal, vulvar, and oviduct malignancies and granulosa theca cell ovarian tumours. -

Infection - endometriosis, salpingitis. Other benign pelvic disorders (traumatic lesions of the vagina, severe vaginal infections, foreign bodies, cervical polyps, cervical erosion, cervicitis, submucous uterine leiomyoma, adenomyosis, endometriosis, and endometrial polyps. Iatrogenic

Sex steroids, hypothalamic depressants, digitalis, phenytoin, anticoagulants, and intrauterine contraceptive devices Systemic diseases Hypothyroidism, cirrhosis, and coagulation disorders

355

and geographical distributions have increased greatly in recent years with an estimated 50-100 million cases of dengue fever and 250,00~500,000 cases of dengue haemorrhagic fever, worldwide, annuallx2 with associated mortality of 5% in most countries3 Although attempted, the vector Aedes aegypti has never been eradicated from northern Queensland and multiple epidemics have been reported since the late 1800s4 with increasing reports in the 1990s.5,6,7-8 Dengue viruses are maintained in an urban transmission cycle in tropical and subtropical areas. As a result, residents of northern Australia and increasing numbers of Australians who travel to dengue infected areas of the world2are at risk of infection. Rarely reported in the literature, excessive menstrual blood loss is one of the haemorrhagic manifestations of dengue feverg,lO,ll and must be remembered in the differential diagnosis of menorrhagia. According to Brenner's classification of excessive uterine bleeding' this patient with her dengue infection, could be categorized under systemic diseases coagulation disorder.

Differential diagnosis Brenner (1996) comprehensively reviewed the different organic aetiologies of abnormal uterine bleeding and subdivided them into reproductive tract diseases, iatrogenic causes, and systemic disease (Table 1).One further investigation performed on this patient was a Pan Bio (Australia) Rapid Immunochromatographic Test for Dengue Fever IgM and IgG, which indicated a primary infection (IgM positive). Dengue fever with its thrombocytopenic effects, possibly combined with platelet dysfunction from Aspirin use, was the cause of life-threatening vaginal blood loss in this young patient.

Dengue fever Dengue virus infections can be differentiated clinically into dengue fever and dengue haemorrhagic fever. In dengue fever leukopenia and mild thrombocytopenia are frequent with haemorrhagic manifestations such as petechiae, epistaxis, gingival bleeding, gastrointestinal bleeding, microscopic haematuria and hypermenorrhoea being less frequent. Dengue haemorrhagic fever is defined as an acute febrile illness with minor or major bleeding, thrombocytopenia (5 100 x 109/L), and evidence of plasma leakage documented by haemoconcentration, pleural or other effusions, or hypoalbuminaemia or hypoproteinaemia.2 Dengue is the most important human viral disease transmitted by arthropod vectors and the incidence

ACKNOWLEDGEMENT R McGready and F Nosten are supported by the

Wellcome Trust.

REFERENCES 1 Brenner PF. Differential diagnosis of abnormal uterine bleeding. A m J Obstet Gynecoll996; 175: 766-769. 2 Rigau-Prez J, Clark GG, Gubler DJ, Reiter P, Sanders E J ,

Vorndam AV. Dengue and dengue haemorrhagic fever. Lancet 1998; 352: 971-977. 3 Guidelines for treatment of dengue/dengue haemorrhagic fever

in small hospitals. WHO Regional Office for South-East Asia, New Delhi, 1999. 4 Hare FE. The 1987 epidemic of dengue in North Queensland. Aust Med Guz 1898; 17: 98-107. 5 Phillips D, Aaskov J. A recent outbreak of dengue fever in north Queensland. Comm Dis Intell 1990;22: 12-13. 6 Row D, Pearce M, Sheridan J. Dengue and dengue haemorrhagic fever in Charters Towers, Queensland. Comm Dis Intell 1993; 17: 182-183. 7 Streatfield R, Sinclair D, Bielby G, Scheridan J, Pearce M, and Phillips D. Dengue serotype 2 epidemic, Townsville, 1992-93. Comm Dis Intell 1993; 17: 330-332. 8 Hanna JN. Ritchie SA, Merritt AD, et al. Two contiguous outbreaks of Dengue type 2 in north Queensland. Med J Aust 1998; 168: 221-225. 9 Tai DY, Chee YC, Chan KW. The natural history of dengue illness on a study of hospitalised patients in Singapore. Singapore Med J 1999; 40: 238-242. 10 Cobra C, Rigau-Prez JG, Kuno G, Vorndam V. Symptoms of

dengue fever in relation to host immunologic response and virus serotype, Puerto Rico, 1990-1991. A m J Epidemiol 1995; 142: 1204-121 1. 11 Nimmannitya S. Dengue fever / dengue haemorrhagic fever: case management. Trop Med (Nagasaki) 1994; 36: 249-256.

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