The occurrence of bacterial superinfection, or coinfection, in patients with dengue, has been previously reported,but the available information comes from anecdotic reports. We report clinical and pathological data of immunocompetentchildren diagnosed with dengue and had evidence of concurrent bacterial infections

Mittal, Hema

Pandey, Mukul

English

Atharva Scientific Publications (E-Jounals)

Pandey and Mittal Secondary Infection in Dengue
Vol 1 | Issue 2 | Jul - Sep 2014 Indian J Child Health 74
Case Report
Secondary infection in immuno-competent children with dengue: 
Case series
Mukul Pandey, Hema Mittal
From Department of Paediatrics, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi, 
India
Correspondence to: Dr. Mukul Pandey, House no 222B, First floor and K Pocket, Dilshad Garden, New Delhi - 110 095, 
India. Phone: +91-8527275111. E-mail: mukul2k_2000@yahoo.com
Received – 09 June 2014 Initial Review – 12 July 2014 Published Online – 21 September 2014
Abstract
The occurrence of bacterial superinfection, or coinfection, in patients with dengue, has been previously reported, 
but the available information comes from anecdotic reports. We report clinical and pathological data of immuno-
competent children diagnosed with dengue and had evidence of concurrent bacterial infections.
Key words: Children, Dengue, Immuno-competent, Secondary bacterial infection
The clinical spectrum of dengue is highly variable, ranging from a mild flu-like syndrome to severe disease, with shock 
and hemorrhage [1]. Dengue virus infects human 
endothelial cells in vitro and causes cellular 
activation [2]. The enhanced capillary permeability 
appears to be due to endothelial cell dysfunction 
rather than injury as electron microscopy 
demonstrated a widening of the endothelial tight 
junctions [3]. Leukopenia, thrombocytopenia, and 
a hemorrhagic diathesis are the typical hematologic 
findings in dengue virus infections. Leukopenia is 
apparent early in the illness and is of similar degree 
in both severe dengue and dengue fever with warning 
signs [4]. It is thought to represent a direct effect 
of dengue virus on the bone marrow [5]. Known 
leukopenia, lymphocytolysis, and immunological 
alterations may predispose to superadded infections 
in dengue, theoretically. However, bacteremia in the 
course of dengue infection is rarely described in the 
medical literature [6-12]. We report two children 
diagnosed with dengue who developed serious 
bacterial infections and one child with severe 
leucopenia without any bacterial infection.
CASE REPORTS
Case 1
A 4-year-old male child, presented with fever and 
fast breathing for 6 days. There was no history of 
headache, retro-orbital pain, vomiting, bleeding 
manifestation, or altered sensorium. Birth and 
developmental history was normal, and child was 
immunized for his age without any significant family 
history.
On examination, child had a fever (104.6°F) 
and tachypnea (respiratory rate 68/min) with chest 
retractions and nasal flaring. Blood pressure was 
98/60 mmHg (75th centile). Child was underweight 
(11.5 kg, weight/age 72.7%) with no wasting or 
stunting. There were multiple petechiae (abdomen, 
lower limbs). On systemic examination, there was 
decreased movement on the right side of the chest 
in comparison to the left side. On auscultation, 
there was decreased air entry with crepitations on 
right infrascapular area. Within 12 h of admission, 
child developed jaundice and abdominal distension, 
suggesting ascites. Chest X-ray was suggestive of 
Pandey and Mittal Secondary Infection in Dengue
Vol 1 | Issue 2 | Jul - Sep 2014 Indian J Child Health 75
right-sided pleural effusion. Pleural tap revealed 
purulent fluid full of neutrophils, protein as 3.9 g%, 
and sugar as 28mg% suggestive of exudative pleural 
effusion. Intercostal tube was put, and purulent fluid 
was drained out and broad spectrum antibiotics 
(ceftriaxone and vancomycin) were started. Initial 
investigations showed hemoglobin 10.8 g%, 
hematocrit 33.3% with leukopenia (4700/mm³) and 
thrombocytopenia (36,000/mm³). Liver functions 
tests were deranged (Table 1).
Pleural fluid culture and simultaneously drawn 
blood culture revealed pseudomonas species. In 
view of petechiae, thrombocytopenia, and dengue 
epidemic settings dengue serology was sent which 
revealed positive IgM (MAC ELISA) for dengue. 
Child was managed as per standard treatment 
protocols. Child improved; intercostal tube was 
removed after 5 days. Ascites and jaundice slowly 
resolved, and child became afebrile in next 7 days 
and discharged after 18 days of admission with 
14 days of antibiotics.
Case 2
An 11-year-male child, presented with fever, rash 
and congested eyes for 3 days, multiple episodes of 
vomiting, pain abdomen and nasal bleeding for 1 day. 
There was no history of headache, retro-orbital pain, 
altered sensorium, black stool and red urine, abdominal 
distension, swelling over the body or decreased urine 
output. Birth and developmental history was normal, 
and child was immunized up to 5 years of age. 
Family history was not significant. On examination, 
child was febrile (102°F) with erythematous rash all 
over body. Blood pressure was 100/62 (75th centile). 
Child weighed 30 kg (weight/age 83%). On systemic 
examination, cardiorespiratory, abdominal, and 
central nervous system were found within normal 
limits. Investigations revealed hemoglobin 11.7 g% 
and pancytopenia (Table 1). A presumptive diagnosis 
of dengue with warning signs was kept, and child 
was started on standard treatment protocols. Chest 
X-ray was normal, and ultrasound abdomen showed 
gall bladder edema. Dengue serology was positive 
Table 1: Laboratory parameters of three cases
Investigations Case 1 Case 2 Case 3
Admission Discharge Admission Discharge Admission Discharge
Hemoglobin (g%) 10.8 9.4 12.7 10.5 13.7 9.2
Hematocrit (%) 33.3 27.7 35.6 29.2 39.5 26.3
Total leucocyte 
counts (mm3)
4700 7800 600 1600 3900 7100
Absolute neutrophil 
counts
3384 3432 150 400 936 2840
Platelet counts (mm3) 36,000 56,000 20,000 66,000 28,000 64,000
Liver function test Serum bilirubin 
total 5.2 mg% 
direct 3.8 mg%, 
SGPT>500
Normal Normal Normal
Malarial parasite Negative Negative Negative
Widal test Not done Not done <64
Blood culture P. aeroginosa Sterile K. pneumonia
Chest X-ray Right pleural 
effusion
Normal Normal Normal Right pleural 
effusion
Normal
Ultrasound 
abdomen
Ascites Normal Gall bladder 
edema with ascites
Normal Gall bladder 
edema
Normal
Dengue serology (IgM) Positive Positive Positive
SGPT: Serum glutamate-pyruvate transaminase, P. aeroginosa: Pseudomonas aeroginosa, K. pneumonia: Klebsiella 
pneumonia
Pandey and Mittal Secondary Infection in Dengue
Vol 1 | Issue 2 | Jul - Sep 2014 Indian J Child Health 76
for dengue virus IgM by MAC ELISA kit. Patient 
improved clinically (afebrile on day 4), leukocyte and 
platelet counts gradually increased and discharged in 
5 days. There was no feature of secondary bacterial 
infection despite very severe leucopenia (600/mm³) 
and blood culture was sterile after 48 h of incubation 
which was sent on day 2 of admission in view of 
severe leukopenia.
Case 3
A 7-year-old male child presented with fever (8 days), 
pain abdomen, and vomiting (2 days) with black color 
stools since 1 day. There was no history of headache, 
retro-orbital pain, altered sensorium, red urine, nasal 
bleed, or decreased urine output. Next day, patient 
developed abdominal distension and difficulty in 
breathing. On examination, child was febrile (101°F) 
with rash and petechiae (face and limbs), swelling 
over face, and cervical lymphadenopathy. Child 
weighed 18 kg, (weight/age 81.8%). Child had pulse 
rate of 97/min, respiratory rate 68/min, blood pressure 
86/55 mm of Hg (<50th centile). Systemic examination 
revealed right-sided pleural effusion with ascites.
Investigations revealed hemoglobin 13.7g%, 
hematocrit 39.5%, leukopenia, and thrombocytopenia 
(Table 1). A presumptive diagnosis of dengue was 
kept, and child was started on standard treatment 
protocols. Chest X-ray showed right-sided massive 
pleural effusion and ultrasound abdomen showed 
gall bladder edema with moderate ascites. Dengue 
serology was positive done by IgM Antibody (capture 
Elisa by Arbovirus diagnostics, NIV, Pune, India). 
Blood culture sent on the second day of admission 
showed growth of Klebsiella pneumonia species with 
sensitivity to chloramphenicol, ofloxacin, piperacillen-
tazobactum and resistance to cefotaxim. Child was 
treated with intravenous antibiotics. Child improved 
in next 6 days with a gradual increase in leukocyte and 
platelet counts in 6 days.
DISCUSSION
Dengue can be diagnosed by isolation of the virus, 
by serological tests, or by molecular methods. 
MAC-ELISA has become an important tool for 
routine dengue diagnosis, and it has a sensitivity 
and specificity of approximately 90% and 98%, 
respectively [13]. Incidence of bacteremia in 
dengue infections lacks in children. Lee et al. [8] 
observed that 5.5% of the adult patients with dengue 
infection also showed bacteremia (K. pneumonia, 
Enterococcus faecalis). Previous reports of bacterial 
(Escherichia coli, Salmonella sp., Streptococcus 
pneumoniae, Mycobacterium tuberculosis, Mycoplasma 
pneumoniae, Shigella sonnei, K. pneumonia, 
Klebisella ozaenae, E. faecalis, Moraxella lacunata, 
Staphylococcus aureus, Rosemonas sp., Haemophilus 
influenza etc.) and viral (herpes viruses) co-infections 
with dengue virus infection in adults are present in 
literature [6-12,14-17]. Such at Hongsiriwon showed 
occurrence of 21% co-infection in infants with dengue 
(4/19) [12]. However, pseudomonas co-infection has 
not been reported previously in children.
Leukopenia occurs early in the course of illness 
and is probably due to the direct effect of dengue virus 
on the bone marrow [5]. Theoretically immunological 
alterations (leucopenia, proliferation of lymphocytoid 
and plasmacytoid cells, lymphocytolysis, 
lymphophagocytosis, depletion of lymphocyte and 
breakdown of digestive epithelial barrier (endothelial 
damage or intestinal hemorrhage) which help these 
pathogens to enter the circulation, are possible 
explanations for superinfections. There seems to be a 
predominance of intestinal flora micro-organisms in 
such cases [8,17]. The bacterial infection superimposed 
on the dengue virus infection either occurs as a mere 
temporal coincidence or, more likely, occur due to 
immunosuppression caused by the virus [1].
In our first case, child presented with empyema 
and just in setting of outbreak and thrombocytopenia, 
we suspected dengue in which serology came positive. 
On the contrary, our third case presented with severe 
dengue not responding to usual treatment and blood 
culture was positive for Klebsiella. In the second case, 
we simply had severe leukopenia without findings 
of severe dengue or infections. Exact mechanism for 
secondary bacterial infection in dengue fever cannot 
be ascertained as all our three patients had leukopenia 
but with varying degree of clinical manifestation. 
This possibly supports the secondary mechanism of 
gastrointestinal epithelial breakdown.
CONCLUSION
Clinicians should be vigilant to unusual manifestations 
of dengue fever, which points toward a concomitant 
Pandey and Mittal Secondary Infection in Dengue
Vol 1 | Issue 2 | Jul - Sep 2014 Indian J Child Health 77
infection by other microorganisms, mainly bacteria. 
Our case series may contribute to increased awareness 
of these associated life-threatening infections. Here, 
bacterial infection was confirmed by blood culture and 
would never have been disclosed if the procedure had 
not been performed.
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Funding: None; Conflict of Interest: None Stated 
How to cite this article: Pandey M, Mittal H, Secondary 
infection in immuno-competent children with dengue: 
Case series. Indian J Child Health. 2014;1(2):74-7.


Secondary infection in immuno-competent children with dengue: Case series

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Secondary infection in immuno-competent children with dengue: Case series

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