Persistent thrombocytopenia in dengue hemorrhagic fever.

A five-year-old previously healthy, male child from Hubli presented with confirmed dengue hemorrhagic fever on seventh day of illness. At admission, his total leucocyte count was 8500/cmm, hematocrit 40% and platelet count 50,000/cmm. Liver function test was normal. There was no proteinuria or hematuria. On Day 3 of admission, he developed acute respiratory distress syndrome(ARDS) and was ventilated for next fifteen days (he later had ventilator-associated-pneumonia). Meanwhile, platelet count dropped to as low as 7,000/cmm requiring alternate day SDP (single donor platelets) transfusions. For next four weeks, he had persisting intermittent fever spikes without any focus of infection. He received a total of 10 units of SDP to maintain the platelet counts above 20,000/ cmm, without bleeding manifestation. Bone marrow aspirate on fifth week of illness was normal. The patient received intravenous immunoglobulins (IVIg) and later, anti-D immune globulin (250IU/kg) intravenously; platelets transiently went up to 35,000/cmm. On day 44, the child suddenly developed features of raised intracranial tension and had massive pulmonary hemorrhage. He died of intractable hypovolemic shock. Just before death, platelet count was 12,000/cmm, confirmed by peripheral smear examination. DIC profile was normal. Autopsy findings suggested massive cerebral intraparenchymal hemorrhage along with pulmonary and gastric mucosal bleeding.