J Vector Borne Dis 52, September 2015, pp.

265–266

Case Reports

Hepatitis A and dengue coinfection

Ira shah & Amit Dey

Pediatric Liver Clinic, BJ Wadia Hospital for Children, Mumbai, India

Key words Dengue; hepatitis A; serositis

Coinfection of both dengue fever and hepatitis A in and bilateral pleural effusion. Blood pressure (BP) and
an individual is rare and can present as a challenging other systems were normal. Investigations at the time of
diagnosis to any medical professional. Dengue, leptospiro- admission are depicted in Table 1. His dengue IgM and
sis, malaria, and viral hepatitis, have many overlapping hepatitis A IgM by Elisa were positive. He was treated
clinical symptoms making it difficult to diagnose them with maintenance intravenous (i.v.) fluids with half-
together. A series of case reports have been published on strength dextrose normal saline and vitamin K for three
various coinfections with dengue in an individual. days. His ascites, pleural effusion and fever responded in
Coinfection of dengue with leptospira, malaria, hepatitis next one week. His liver function test (LFT) normalized
A, hepatitis E and typhoid fever have been reported in in next one month.
literature1-2. We report three cases of children presented Case 2: A 10-month-old boy presented with fever
with dengue and hepatitis A coinfection. and abdominal distension for eight days along with diar-
rhoea. There was no jaundice or vomiting. He was on
Case reports breast feed and weaning diet. On examination, weight
Case 1: A two-yr-old boy presented with fever for was eight kg and height was 72 cm. He had pallor, sple-
eight days along with vomiting and jaundice for one day. nohepatomegaly and ascites. Blood pressure was normal.
There was no abdominal distension or bleeding. On Other systems were normal. Investigations at the time of
examination, weight was 12 kg and height was 86.5 cm. admission are depicted in Table 1. His dengue IgM and
He had pallor, jaundice and hepatomegaly with ascites hepatitis A IgM by Elisa were positive. He was treated
Table 1. Investigation details of reported cases

Parameters/Tests Case 1 Case 2 Case 3

Hemoglobin (g/dl) 9.7 8 6.5

WBC count (cells/mm3) 7500 11,300 16,500
Platelets (cells/mm3) 2,41,000 2,30,000 2,82,000
Bilirubin (mg/dl) 3.1 0.8 4.5
SGOT (IU/L) 1460 83 110
SGPT (IU/L) 1920 56 250
Total proteins (g/dl) 5.4 6.5 7.2
Albumin (g/dl) 3 3 3.2
USG abdomen Ascites and bilateral pleural Hepatosplenomegaly and Hepatosplenomegaly and ascites
effusion ascites with right pleural effusion
Dengue IgM (AI) (> 1.1) 8.2 1.5 (+)
Hepatitis A IgM (+) (+) (+)
Prothrombin time (sec) 16.1 11.3 11.4
Partial thromboplastin time (sec) 35.4 38.6 30.9
Malaria OptiMAL (–) (–) (–)
Widal (–) (–) (–)

IU/L— International units per litre; (+) = Positive; (–) = Negative.

266 J Vector Borne Dis 52, September 2015

with oral fluids and vitamin K for one day. His ascites Other differentiating features of dengue fever include
resolved in three days. hemoconcentration, thrombocytopenia, and third space
Case 3: A two-yr-old boy presented with fever and fluid losses8. In the present cases, though the patients had
abdominal distension for two weeks. There was no vom- third spacing in form of ascites or pleural effusion, they
iting. On examination, his weight was nine kg and height did not have hemoconcentration or thrombocytopenia.
was 84 cm. He had jaundice, pallor, ascites, and However, since all had fever and serositis at the time of
hepatosplenomegaly. BP and other systems were normal. presentation, it was unlikely that hepatitis A alone was
Investigations at the time of admission are depicted in the cause of all abnormalities.
Table 1. His dengue IgM and hepatitis A IgM by An abnormal coagulation profile should alert one to
Elisa were positive. He was treated with i.v. fluids and an underlying infection with a hepatotropic virus as the
vitamin K for two days; jaundice and ascites decreased in coagulation profile is usually not deranged in dengue5.
10 days. Prolonged fever, highly elevated liver enzymes, deranged
prothrombin time along with positive IgM for hepatitis
DISCUSSION and dengue made us suspicious about the possibility of
coexistent viral hepatitis.
Hepatitis A virus (HAV) causes acute hepatitis, as- The endemic areas of both dengue and viral hepatitis
sociated with significant morbidity and occasional mor- throughout the world are most often superimposed on each
tality; and sometimes with rare complications such as other and thus one must rule out both these infections
acalculous cholecystitis, pleural effusion and ascites3. The when someone presents with acute hepatitis. Presence of
pathology of ascites is thought to be venous or lymphatic acute hepatitis with fever and ascites in an endemic area
obstruction due to liver involvement or reduction of for hepatitis A and dengue should make one suspicious
oncotic pressure due to hypoalbuminemia during the of coinfection.
course of infection4. REFERENCES
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Correspondence to: Dr Ira Shah, 1/B Saguna, 271/B St Francis Road, Vile Parle (W), Mumbai–400 056, India.
E-mail: irashah@pediatriconcall.com

Received: 6 January 2015 Accepted in revised form: 15 April 2015