Acute Renal Failure Associated with Dengue Fever in French Guiana

Accessible online at: http://BioMedNet.com/karger Dear Sir, Dengue fever (DF) is a tropical mosquitoborne viral infection caused by any of the four serotypes of dengue viruses, dengue (DEN)-1, DEN-2, DEN-3 and DEN-4. It is a major public health problem in tropical countries: there are millions of cases and thousands of deaths every year [1]. The nations of South America are on the fringe of the current endemic zone. Since 1980, there have been several epidemics in South and Central America, and cases of dengue hemorrhagic fever (DHF) have recently been reported for the first time in this region. DF is also an important public health problem in French Guiana, which is located between Brazil and Surinam on the north-east coast of South America. Indeed an epidemic of DHF caused by DEN-2 was responsible for 40 DHF cases and 6 deaths in 1991 and 1992 [2]. Other epidemics occurred in September 1996 in Kourou and in January 1997 in Cayenne. DF is characterized by an abrupt onset with severe headache, myalgia and fever, usually followed by a rash. There may be renal manifestations, usually associated with multiple organ dysfunction, leading to DHF/dengue shock syndrome (DSS). We report here the first case of isolated acute renal failure (ARF) associated with classical DF. Case report: In January 1996, a 64-yearold man was admitted by the intensive care unit (ICU) of Cayenne Hospital, French Guiana, for an ARF. Previously healthy, he suddenly became ill 1 week before admission. He presented initially with headache, generalized myalgias, arthralgias and fever, and was first admitted by a medical unit of Cayenne Hospital for severe asthenia and a petechial rash. Apart from disorientation, the findings of the clinical examination were normal. The laboratory findings showed a sedimentation rate of 35 mm/h, a platelet count of 6,000/mm3, a hematocrit of 39.7%, a uremia level of 36.5 mmol/l and a creatininemia level of 835 mmol/l. Two days later he developed anuria and was transferred to the ICU. Chest X-ray showed a micronodular infiltration. Hemodialysis and symptomatic renal treatment (furosemide and dopamine) were instituted. Urine flow normalized on the second day after admission and hemodialysis was no longer required. Computed tomography scan showed bleeding from optic radiations. There was gradual clinical improvement toward the end of the first week and the patient was discharged 2 weeks after admission. Kidney biopsy was not performed, but no underlying disease, compatible with the renal deterioration, was found. Dengue serological tests indicated a recent infection with a flavivirus: hemagglutination inhibition titers to dengue viruses were 120,480 and MAC-ELISA showed a high level of dengue IgM. Other viral and bacterial serological tests were negative. The literature contains reports of ARF associated with DSS [3]. The causes or contributing factors are numerous. The most common conditions associated with ARF are prolonged shock with metabolic acidosis, and severe DIC that lead to hypoxia/ischemia and result in multiple organ dysfunction [3]. This was not the case in our patient as he did not suffer from shock and did not fulfill all criteria for DHF. The only hemorrhagic sign was the bleeding from the optic radiations. ARF due to direct invasion of the kidneys is probable as the time between the onset of the disease and the renal symptoms was short. The dengue diagnosis could not be confirmed since only serological tests were positive (the patient was admitted to the ICU only 7 days after the onset of the fever), and cross-reactions are frequent among flaviviruses. However, in a patient vaccinated against yellow fever, and in a country were dengue viruses are almost the only flaviviruses isolated, the diagnosis of DF is highly probable. In conclusion, this case is a new indication that the virulence of dengue viruses may be very diverse and that, in tropical countries, DF must be suspected in every feverish syndrome, even those presenting with unusual clinical manifestations.