title: Bilateral rectus sheath haematoma complicating dengue virus infection in a patient on warfarin for mechanical aortic valve replacement: a case report.
abstract: BACKGROUND
  The management of Dengue virus infection can be challenging. Varied presentations and numerous complications intrinsic to dengue by itself increase the complexity of treatment and potential mortality. When burdened with the presence of additional comorbidities and the need to continue compulsory medications, clear stepwise definitive guidance is lacking and patients tend to have more complex complications and outcomes calling to question the clinical decisions that may have been taken. The use and continuation of warfarin in dengue virus infection is one such example.
  
  
  METHODS
  We report a 65 year old South Asian female who presented with dengue fever. She had a history bronchial asthma, a prior abdominal surgery, and was on warfarin and maintained a therapeutically appropriate internationalized normalized ratio for a mechanical aortic valve replacement. Though preemptive decision to stop warfarin was taken with decreasing platelet counts, her clinical course was complicated with the development of bilateral rectus sheath haematoma's requiring resuscitation with blood transfusions.
  
  
  CONCLUSIONS
  Though management of dengue viral fever has seen drastic evolution with recent updated guidance, clinical scenarios seen in the course of the illness still pose challenges to the managing physician. The need to continue obligatory anticoagulation which may seem counterintuitive during a complex disease such as dengue virus infection must be considered after understanding the potential risks versus that of its benefits. Though case by case decisions maybe warranted, a clear protocol would be very helpful in making clinical decisions, as the correct preemptive decision may potentially avert catastrophic and unpredictable bleeding events.
authors.affiliation: Internal Medicine, National Hospital of Sri Lanka, Colombo, Sri Lanka. chamithrosa@yahoo.com.
authors.forename: Chamith Thushanga
authors.initials: CT
authors.lastname: Rosa
authors.affiliation: Institute of Cardiology, National Hospital of Sri Lanka, Colombo, Sri Lanka.
authors.forename: Mitrakrishnan Rayno
authors.initials: MR
authors.lastname: Navinan
authors.affiliation: Internal Medicine, National Hospital of Sri Lanka, Colombo, Sri Lanka.
authors.forename: Sincy
authors.initials: S
authors.lastname: Samarawickrama
authors.affiliation: Internal Medicine, National Hospital of Sri Lanka, Colombo, Sri Lanka.
authors.forename: Himam
authors.initials: H
authors.lastname: Hamza
authors.affiliation: Internal Medicine, National Hospital of Sri Lanka, Colombo, Sri Lanka.
authors.forename: Maheshika
authors.initials: M
authors.lastname: Gunarathne
authors.affiliation: Internal Medicine, National Hospital of Sri Lanka, Colombo, Sri Lanka.
authors.forename: Arulprashanth
authors.initials: A
authors.lastname: Arulanantham
authors.affiliation: Internal Medicine, National Hospital of Sri Lanka, Colombo, Sri Lanka.
authors.forename: Neeha
authors.initials: N
authors.lastname: Subba
authors.affiliation: Internal Medicine, National Hospital of Sri Lanka, Colombo, Sri Lanka.
authors.forename: Udari
authors.initials: U
authors.lastname: Samarasiri
authors.affiliation: Internal Medicine, National Hospital of Sri Lanka, Colombo, Sri Lanka.
authors.forename: Thushara
authors.initials: T
authors.lastname: Mathias
authors.affiliation: Internal Medicine, National Hospital of Sri Lanka, Colombo, Sri Lanka.
authors.forename: Aruna
authors.initials: A
authors.lastname: Kulatunga
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use; D001021:Aortic Valve / Q000601:surgery*; D003715:Dengue / Q000150:complications*; D003716:Dengue Virus; D005260:Female; D006349:Heart Valve Diseases / Q000150:complications* / Q000601:surgery*; D006350:Heart Valve Prosthesis / Q000009:adverse effects; D006406:Hematoma / Q000150:complications*; D006470:Hemorrhage; D006801:Humans; D019934:International Normalized Ratio; D018482:Muscle, Skeletal / Q000473:pathology*; D012307:Risk Factors; D014859:Warfarin / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D014859:Warfarin
keywords: Anticoagulation; Bleeding; Case report; Dengue viral fever; Haematoma; Mechanical valves; Rectus sheath; Warfarin