Severe Pancreatic Involvement In Severe Dengue: Simultaneous Presentation Of Acute Pancreatitis And Diabetic Ketoacidosis: A Case Report.

Abstract

Background:
Dengue fever is a major global health problem in tropical and subtropical regions. Moreover, severe dengue is associated with significant morbidity and mortality. Pancreatic involvement is an uncommon but clinically important manifestation which is reported in less than 2% of hospitalized dengue cases. Diabetes mellitus is increasingly recognized as a risk factor for severe dengue and dengue-associated diabetic ketoacidosis (DKA) has been infrequently described. The simultaneous occurrence of severe dengue, acute pancreatitis and DKA is rare and poses significant diagnostic and therapeutic challenges because of overlapping clinical features and competing management priorities.
Case Report:
We report a case of 50-year-old woman with long-standing poorly controlled diabetes mellitus who presented with a 5-day history of febrile illness, severe abdominal pain, vomiting and progressive dyspnea. On admission, she was hypotensive, hypoxemic, hyperglycemic and had Kussmaul breathing. Laboratory evaluation revealed high–anion gap metabolic acidosis with ketonuria
consistent with DKA. Additionally, haemoconcentration, leukopenia, severe thrombocytopenia, acute kidney injury and markedly elevated serum amylase and lipase levels were also present. Dengue NS1 antigen was positive. Contrast-enhanced computed tomography demonstrated acute interstitial edematous pancreatitis (Balthazar grade E) with minimal ascites and bilateral pleural effusions. A diagnosis of severe dengue complicated by acute pancreatitis, DKA and hypovolemic shock was thus made. The patient was managed in the intensive care unit. Carefully titrated intravenous fluids, insulin infusion, vasopressor support was given along with close monitoring of vitals. She showed progressive clinical improvement and was subsequently discharged in stable condition. Follow-up imaging showed asymptomatic pancreatic pseudocyst which was managed conservatively.
Conclusion:
This case of a patient with poorly controlled diabetes mellitus highlights a rare but life-threatening triad of severe dengue, acute pancreatitis and DKA. A high index of suspicion, early diagnostic workup and individualized multidisciplinary management were important determinants for favorable outcomes.