title: Dengue fever with diffuse cerebral hemorrhages, subdural hematoma and cranial diabetes insipidus.
abstract: BACKGROUND
  Neurological manifestations in dengue fever occur in <1 % of the patients and known to be due to multisystem dysfunction secondary to vascular leakage. Occurrence of wide spread cerebral haemorrhages with subdural hematoma during the leakage phase without profound thrombocytopenia and occurrence of cranial diabetes insipidus are extremely rare and had not been reported in published literature earlier, thus we report the first case.
  
  
  METHODS
  A 24 year old previously healthy lady was admitted on third day of fever with thrombocytopenia. Critical phase started on fifth day with evidence of pleural effusion and moderate ascites. Thirty one hours into critical phase she developed headache, altered level of consciousness, limb rigidity and respiratory depression without definite seizures. Non-contrast CT brain done at tertiary care level revealed diffuse intracranial haemorrhages and sub arachnoid haemorrhages in right frontal, parietal, occipital lobes and brainstem, cerebral oedema with an acute subdural hematoma in right temporo- parietal region. Her platelet count was 40,000 at this time with signs of vascular leakage. She was intubated and ventilated with supportive care. Later on she developed features of cranial diabetes insipidus and it responded to intranasal desmopressin therapy. In spite of above measures signs of brainstem herniation developed and she succumbed to the illness on day 8. Dengue was confirmed serologically.
  
  
  CONCLUSIONS
  Exact pathophysiological mechanism of diffuse cerebral haemorrhages without profound thrombocytopenia is not well understood. Increased awareness and high degree of clinical suspicion is needed among clinicians for timely diagnosis of this extremely rare complication of dengue fever. We postulate that immunological mechanisms may play a role in pathogenesis. However further comprehensive research and studies are needed to understand the pathophysiological mechanisms leading to this complication.
authors.affiliation: General Medical Unit, National Hospital of Sri Lanka, Colombo, Western Province, Sri Lanka. shermi17@gmail.com.
authors.forename: Nayomi Shermila
authors.initials: NS
authors.lastname: Jayasinghe
authors.affiliation: General Medical Unit, National Hospital of Sri Lanka, Colombo, Western Province, Sri Lanka.
authors.forename: Eranga
authors.initials: E
authors.lastname: Thalagala
authors.affiliation: General Medical Unit, National Hospital of Sri Lanka, Colombo, Western Province, Sri Lanka.
authors.forename: Milanka
authors.initials: M
authors.lastname: Wattegama
authors.affiliation: General Medical Unit, National Hospital of Sri Lanka, Colombo, Western Province, Sri Lanka.
authors.forename: Kanapathipillai
authors.initials: K
authors.lastname: Thirumavalavan
mesh_terms: D000328:Adult; D002543:Cerebral Hemorrhage / Q000150:complications* / Q000000981:diagnostic imaging / Q000628:therapy; D003715:Dengue / Q000150:complications / Q000175:diagnosis* / Q000628:therapy; D003919:Diabetes Insipidus / Q000150:complications* / Q000628:therapy; D017809:Fatal Outcome; D005260:Female; D006408:Hematoma, Subdural / Q000150:complications* / Q000000981:diagnostic imaging / Q000628:therapy; D006801:Humans; D014057:Tomography, X-Ray Computed; D055815:Young Adult
keywords: Case report; Cranial diabetes insipidus; Dengue fever; Intracranial haemorrhage; Subarachnoid haemorrhage; Subdural hematoma