American Journal of Emergency Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
An unusual cause of acute abdominal pain in dengue fever Abstract Dengue fever is an acute febrile viral disease caused by the bite of Aedes aegypti mosquito. It is a major health problem especially in tropical and subtropical areas including South East Asia and Pakistan. In the past few years, dengue fever has been endemic in Northern Punjab. Physicians managing dengue fever come across varied and uncommon complications of dengue fever. We report a case of dengue fever that developed severe right upper quadrant abdominal pain and induration after extreme retching and vomiting for 2 days. A rectus sheath hematoma was confirmed on noncontrast computed tomography (CT). Rectus sheath hematoma as a complication of dengue fever has rarely been reported before and never from this part of the world. Rectus sheath hematoma is an uncommon and often clinically misdiagnosed cause of abdominal pain. It is the result of bleeding into the rectus sheath from damage to the superior or inferior epigastric artery or their branches or from a direct tear of the rectus muscle. It can mimic almost any abdominal condition (See Fig.) (See Table). A 55-year-old man, known diabetic, and hypertensive taking oral hypoglycemic, angiotensin receptor blockers, and aspirin, presented to emergency department with high-grade continuous fever for last 2 days associated with body aches. He was vitally stable on admission. Diagnosis of dengue fever was confirmed on laboratory investigations (Table). On day 5, patient started having severe vomiting and retching for which oral and intravenous antiemetics were given. He then complained of pain in the right upper quadrant of abdomen. A hard induration without any bruising was noted in right iliac region. Over next 24 hours, induration increased in size, pain worsened, and vomiting persisted. Abdominal ultrasonography showed collection of blood in right rectus sheath. Noncontrast CT abdomen confirmed the diagnosis of right rectus sheath hematoma (RSH) (Fig.). On day 7, his condition deteriorated, blood pressure dropped to 90/60 mm Hg. Patient received multiple fresh frozen plamas and whole blood transfusions and intravenous albumin. Surgical team was consulted and patient was operated on day 7. Surgery revealed inferior epigastric artery leak. After securing homeostasis, 2.5 L of blood was drained from anterior abdominal wall and right RSH. Patient made an uneventful recovery and was discharged on day 10. Dengue fever is an acute viral infection caused by the bite of Aedes aegypti mosquito. It is characterized by high-grade fever, bonebreaking pain, and skin rash. Dengue hemorrhagic fever is manifested by hemorrhagic diathesis, thrombocytopenia, and plasma leakage. Rectus sheath hematoma due to rupture of inferior epigastric artery precipitated by vomiting and retching is a rare presentation of dengue fever. Rectus sheath hematoma [1] is a well-described entity with a reported incidence of misdiagnosis as high as 93%. It is 2 to 3
times more common in females than in males and in elderly [1,2]. Rectus sheath hematoma can occur due to trauma, blood dyscrasia, degenerating muscular disease, anticoagulant therapy, pregnancy or spontaneous rupture of epigastric vessel or the rectus muscle. Acute paroxysmal coughing, asthmatic attacks, bronchitis, or influenza is the precipitating event in 56% of the cases [3]. Three types of RSH can be distinguished by way of the severity of hemorrhage as delineated on CT scan. Type-I RSH are unilateral hematomas contained within the muscle. Type-II RSH is bilateral hematomas or hematomas not contained within the muscle sheath. Type-III RSH enters the prevesicular space or peritoneum. Rectus sheath hematoma has been mistaken for many common acute abdominal diseases such as appendicitis, dissecting abdominal aneurysm, cholecystitis and biliary colic, cholelithasis, diverticular disease, gastritis and peptic ulcer disease, incarcinated intestinal hernias, mesenteric vascular insult, urinary tract obstructions, small and large gut obstruction, pancreatitis, ovarian cysts, and ovarian torsion. A careful history and clinical examination is required to elicit the risk factors and precipitant events. Common presenting signs and symptoms are abdominal pain, abdominal wall mass, and decrease in hemoglobin, abdominal wall ecchymosis, nausea, vomiting, tachycardia, peritoneal irritation, fever, abdominal distention, and abdominal cramping Fothergill sign and Carnett sign [4,5] are positive in RSH and help differentiate this condition from intraabdominal pathologies. Fothergill sign is positive when the hematoma within the rectus sheath produces a mass that does not cross the midline and remains palpable when the patient tenses his rectus muscle by touching his chest using his chin. Carnett sign is exacerbation of the pain and tenderness over the hematoma by contraction of rectus muscle by sitting halfway up in a supine position. Ecchymoses can be noted in the flanks or periumbilical areas, especially late in the course and are referred to as Gray Turner and Cullen sign, respectively. Ultrasonography is a useful initial test due to its wide availability and portability [6,7]. However, noncontrast CT scan is more sensitive and specific and is the diagnostic modality of choice [7]. Management depends on the clinical condition and the CT severity grade [1,4]. For hemodynamically stable patients with nonexpanding hematoma, conservative approach is recommended. Surgery is advised if RSH ruptures into peritoneum, complicating infection is present, or if the patient is hemodynamically unstable. The treatment of RSH comprises rest, analgesia, discontinuation of any anticoagulation therapy, blood and blood products transfusions (if needed), and clinical observation. Surgical procedure may be used for diagnostic purpose as well as in controlling continued hemorrhage or intraperitoneal rupture. Surgical procedures consist of clot evacuation, ligation of all bleeding vessels, and closed suction drainage [8,9]. Coil or gel foam embolization (of the epigastric
0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Waseem T, et al, An unusual cause of acute abdominal pain in dengue fever, Am J Emerg Med (2014), http:// dx.doi.org/10.1016/j.ajem.2014.01.011
2
T. Waseem et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
Fig. Noncontrast CT abdomen.
Table Laboratory investigations
Hemoglobin level g/dL White blood cells (mm3) Platelets (mm3) Hematocrit (%) Prothrombin time (s) NS-1 antigen PCR for dengue RNA Blood glucose (mg/dL) Serum albumin (g/dL).
Day 1
Day 3
Day 5
Day 7
13.2 7500 65,000 39 17 Positive Detected 164 2.8
12 3500 17,000 37 21 – – 178 2.3
8 2100 9000 32 27 – – 210 2.1
7 2200 12,000 35 31 – – 128 3.4
Abbreviations: NS-1, non structural protein 1; PCR, polymerase chain reaction.
arteries) [8] has been successfully used in patients with refractory bleeding despite reversal of coagulopathy. Rectus sheath hematoma is an unusual and rare presentation of dengue fever [10]. Physicians should consider RSH in the initial differential diagnosis of abdominal pain even in the absence of abdominal trauma or strain. Timely diagnosis can prevent unnecessary diagnostic tests and also decreases the morbidity and mortality.
TariqWaseem FCPS Hina Latif MBBS Bilquis Shabbir FCPS
West Medical Ward Mayo Hospital King Edward Medical University Lahore, Pakistan E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.01.011 References [1] Cherry WB, Mueller PS. Rectus sheath hematoma. Review of 126 cases at a single institution. Medicine 2006;85:105–10. [2] Linhares MM, Lopes Filho GJ, Bruna PC, et al. Spontaneous hematoma of the rectus abdominis sheath: a review of 177 cases with report of 7 personal cases. Int Surg 1999;84:251–7. [3] Hershfield NB. The abdominal wall. A frequently overlooked source of abdominal pain. J Clin Gastroenterol 1992;14:199–202. [4] Osinbowale O, Bartholomew JR. Rectus sheath hematoma. Vasc Med 2008;13: 275–9. [5] Thomson H, Francis DM. Abdominal-wall tenderness: a useful sign in the acute abdomen. Lancet 1977;2:1053–4. [6] Klingler PJ, Wetscher G, Glaser K, et al. Use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders. Surg Endosc 1999;13:1129–34. [7] Moreno Gallego A, Aguayo JL, Flores B, et al. Ultrasonography and computed tomography reduce unnecessary surgery in abdominal rectus sheath hematoma. Br J Surg 1997;84:1295–7. [8] Rimola J, Perendreu J, Falcó J, et al. Percutaneous arterial embolization in the management of rectus sheath hematoma. AJR Am J Roentgenol 2007;188(6): W497–502. [9] Berná-Serna JD, Sánchez-Garre J, Madrigal M, et al. Ultrasound therapy in rectus sheath hematoma. Phys Ther 2005;85:352–7. [10] Siu WT, Yau KK, Cheung HY, Law BK, Tang CN, Yang GP, et al. Spontaneous rectus sheath hematoma. Can J Surg 2003;46:390.
Please cite this article as: Waseem T, et al, An unusual cause of acute abdominal pain in dengue fever, Am J Emerg Med (2014), http:// dx.doi.org/10.1016/j.ajem.2014.01.011
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
An unusual cause of acute abdominal pain in dengue fever Abstract Dengue fever is an acute febrile viral disease caused by the bite of Aedes aegypti mosquito. It is a major health problem especially in tropical and subtropical areas including South East Asia and Pakistan. In the past few years, dengue fever has been endemic in Northern Punjab. Physicians managing dengue fever come across varied and uncommon complications of dengue fever. We report a case of dengue fever that developed severe right upper quadrant abdominal pain and induration after extreme retching and vomiting for 2 days. A rectus sheath hematoma was confirmed on noncontrast computed tomography (CT). Rectus sheath hematoma as a complication of dengue fever has rarely been reported before and never from this part of the world. Rectus sheath hematoma is an uncommon and often clinically misdiagnosed cause of abdominal pain. It is the result of bleeding into the rectus sheath from damage to the superior or inferior epigastric artery or their branches or from a direct tear of the rectus muscle. It can mimic almost any abdominal condition (See Fig.) (See Table). A 55-year-old man, known diabetic, and hypertensive taking oral hypoglycemic, angiotensin receptor blockers, and aspirin, presented to emergency department with high-grade continuous fever for last 2 days associated with body aches. He was vitally stable on admission. Diagnosis of dengue fever was confirmed on laboratory investigations (Table). On day 5, patient started having severe vomiting and retching for which oral and intravenous antiemetics were given. He then complained of pain in the right upper quadrant of abdomen. A hard induration without any bruising was noted in right iliac region. Over next 24 hours, induration increased in size, pain worsened, and vomiting persisted. Abdominal ultrasonography showed collection of blood in right rectus sheath. Noncontrast CT abdomen confirmed the diagnosis of right rectus sheath hematoma (RSH) (Fig.). On day 7, his condition deteriorated, blood pressure dropped to 90/60 mm Hg. Patient received multiple fresh frozen plamas and whole blood transfusions and intravenous albumin. Surgical team was consulted and patient was operated on day 7. Surgery revealed inferior epigastric artery leak. After securing homeostasis, 2.5 L of blood was drained from anterior abdominal wall and right RSH. Patient made an uneventful recovery and was discharged on day 10. Dengue fever is an acute viral infection caused by the bite of Aedes aegypti mosquito. It is characterized by high-grade fever, bonebreaking pain, and skin rash. Dengue hemorrhagic fever is manifested by hemorrhagic diathesis, thrombocytopenia, and plasma leakage. Rectus sheath hematoma due to rupture of inferior epigastric artery precipitated by vomiting and retching is a rare presentation of dengue fever. Rectus sheath hematoma [1] is a well-described entity with a reported incidence of misdiagnosis as high as 93%. It is 2 to 3
times more common in females than in males and in elderly [1,2]. Rectus sheath hematoma can occur due to trauma, blood dyscrasia, degenerating muscular disease, anticoagulant therapy, pregnancy or spontaneous rupture of epigastric vessel or the rectus muscle. Acute paroxysmal coughing, asthmatic attacks, bronchitis, or influenza is the precipitating event in 56% of the cases [3]. Three types of RSH can be distinguished by way of the severity of hemorrhage as delineated on CT scan. Type-I RSH are unilateral hematomas contained within the muscle. Type-II RSH is bilateral hematomas or hematomas not contained within the muscle sheath. Type-III RSH enters the prevesicular space or peritoneum. Rectus sheath hematoma has been mistaken for many common acute abdominal diseases such as appendicitis, dissecting abdominal aneurysm, cholecystitis and biliary colic, cholelithasis, diverticular disease, gastritis and peptic ulcer disease, incarcinated intestinal hernias, mesenteric vascular insult, urinary tract obstructions, small and large gut obstruction, pancreatitis, ovarian cysts, and ovarian torsion. A careful history and clinical examination is required to elicit the risk factors and precipitant events. Common presenting signs and symptoms are abdominal pain, abdominal wall mass, and decrease in hemoglobin, abdominal wall ecchymosis, nausea, vomiting, tachycardia, peritoneal irritation, fever, abdominal distention, and abdominal cramping Fothergill sign and Carnett sign [4,5] are positive in RSH and help differentiate this condition from intraabdominal pathologies. Fothergill sign is positive when the hematoma within the rectus sheath produces a mass that does not cross the midline and remains palpable when the patient tenses his rectus muscle by touching his chest using his chin. Carnett sign is exacerbation of the pain and tenderness over the hematoma by contraction of rectus muscle by sitting halfway up in a supine position. Ecchymoses can be noted in the flanks or periumbilical areas, especially late in the course and are referred to as Gray Turner and Cullen sign, respectively. Ultrasonography is a useful initial test due to its wide availability and portability [6,7]. However, noncontrast CT scan is more sensitive and specific and is the diagnostic modality of choice [7]. Management depends on the clinical condition and the CT severity grade [1,4]. For hemodynamically stable patients with nonexpanding hematoma, conservative approach is recommended. Surgery is advised if RSH ruptures into peritoneum, complicating infection is present, or if the patient is hemodynamically unstable. The treatment of RSH comprises rest, analgesia, discontinuation of any anticoagulation therapy, blood and blood products transfusions (if needed), and clinical observation. Surgical procedure may be used for diagnostic purpose as well as in controlling continued hemorrhage or intraperitoneal rupture. Surgical procedures consist of clot evacuation, ligation of all bleeding vessels, and closed suction drainage [8,9]. Coil or gel foam embolization (of the epigastric
0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Waseem T, et al, An unusual cause of acute abdominal pain in dengue fever, Am J Emerg Med (2014), http:// dx.doi.org/10.1016/j.ajem.2014.01.011
2
T. Waseem et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
Fig. Noncontrast CT abdomen.
Table Laboratory investigations
Hemoglobin level g/dL White blood cells (mm3) Platelets (mm3) Hematocrit (%) Prothrombin time (s) NS-1 antigen PCR for dengue RNA Blood glucose (mg/dL) Serum albumin (g/dL).
Day 1
Day 3
Day 5
Day 7
13.2 7500 65,000 39 17 Positive Detected 164 2.8
12 3500 17,000 37 21 – – 178 2.3
8 2100 9000 32 27 – – 210 2.1
7 2200 12,000 35 31 – – 128 3.4
Abbreviations: NS-1, non structural protein 1; PCR, polymerase chain reaction.
arteries) [8] has been successfully used in patients with refractory bleeding despite reversal of coagulopathy. Rectus sheath hematoma is an unusual and rare presentation of dengue fever [10]. Physicians should consider RSH in the initial differential diagnosis of abdominal pain even in the absence of abdominal trauma or strain. Timely diagnosis can prevent unnecessary diagnostic tests and also decreases the morbidity and mortality.
TariqWaseem FCPS Hina Latif MBBS Bilquis Shabbir FCPS
West Medical Ward Mayo Hospital King Edward Medical University Lahore, Pakistan E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.01.011 References [1] Cherry WB, Mueller PS. Rectus sheath hematoma. Review of 126 cases at a single institution. Medicine 2006;85:105–10. [2] Linhares MM, Lopes Filho GJ, Bruna PC, et al. Spontaneous hematoma of the rectus abdominis sheath: a review of 177 cases with report of 7 personal cases. Int Surg 1999;84:251–7. [3] Hershfield NB. The abdominal wall. A frequently overlooked source of abdominal pain. J Clin Gastroenterol 1992;14:199–202. [4] Osinbowale O, Bartholomew JR. Rectus sheath hematoma. Vasc Med 2008;13: 275–9. [5] Thomson H, Francis DM. Abdominal-wall tenderness: a useful sign in the acute abdomen. Lancet 1977;2:1053–4. [6] Klingler PJ, Wetscher G, Glaser K, et al. Use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders. Surg Endosc 1999;13:1129–34. [7] Moreno Gallego A, Aguayo JL, Flores B, et al. Ultrasonography and computed tomography reduce unnecessary surgery in abdominal rectus sheath hematoma. Br J Surg 1997;84:1295–7. [8] Rimola J, Perendreu J, Falcó J, et al. Percutaneous arterial embolization in the management of rectus sheath hematoma. AJR Am J Roentgenol 2007;188(6): W497–502. [9] Berná-Serna JD, Sánchez-Garre J, Madrigal M, et al. Ultrasound therapy in rectus sheath hematoma. Phys Ther 2005;85:352–7. [10] Siu WT, Yau KK, Cheung HY, Law BK, Tang CN, Yang GP, et al. Spontaneous rectus sheath hematoma. Can J Surg 2003;46:390.
Please cite this article as: Waseem T, et al, An unusual cause of acute abdominal pain in dengue fever, Am J Emerg Med (2014), http:// dx.doi.org/10.1016/j.ajem.2014.01.011
