mmHg), had tenderness with guarding and rebound tenderness in the upper abdomen. Ultrasonography showed a thickened gallbladder wall [Figure 1]. He was diagnosed as having DHF with AAC and was treated conservatively with fresh frozen plasma and platelet transfusions. The rebound tenderness persisted for 72 h and he made full recovery. Repeat imaging 2 weeks later was normal.
Th is a PD si F te is ho a st va (w ed ilab w by le w. M f m e or ed d fr kn kno ee ow w do .c Pu wn om b lo ). lica ad tio fr ns om
study of 41 consecutive patients. Eur J Endocrinol 2004;150:681-6. 4. Lucon AM, Pereirra MA, Mendonca BB, Halpern A, Wajchenbeg BL, Arap S. Pheochromocytoma: Study of 50 cases. J Urol 1997;157:1208-12. 5. Piovesan EJ, Moeller L, Piovesan LM, Werneck LC, de Carvalho JL. Headache in patients with pheochromocytoma: Inßuence of arterial hypertension. Arq Neuropsiquiatr 1998;56:2557.
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N. UDAYAKUMAR*, S. SIVAPRAKASH, M. CHANDRASEKARAN
Institute of Internal Medicine, *University of Cincinnati, USA; Madras Medical College, Chennai, India
Correspondence: Dr. N. Udayakumar, Department of Internal Medicine, University of Cincinnati, USA. E-mail:
[email protected]
ACUTE ACALCULOUS CHOLECYSTITIS IN DENGUE HEMORRHAGIC FEVER
Sir, We report on two cases of dengue hemorrhagic fever (DHF) complicated by acute acalculous cholecystitis (AAC) and localized peritonitis that resolved on conservative management. The Þrst patient, a 15-year-old boy, presented with a 3 days’ history of fever, headache, lethargy and a generalized petechial rash. Investigation showed thrombocytopenia (13 × 109/L), hypoalbuminemia (31 g/L) with high transaminases (six times the upper limit of normal). Dengue IgM serology was positive. The next day, he had right hypochondrial and epigastric pain. He was in shock (80/60
The second patient, a 23-year-old woman, presented with a four days’ history of fever and shoulder pain. Examination showed a generalized petechial rash. Investigations revealed thrombocytopenia (13 × 10 9 /L), raised serum transaminases (10 times the upper limit of normal) and low albumin (24 g/L). Dengue IgM serology was positive. ESR and CRP were normal. On the eighth day of illness, she developed shock accompanied by rebound tenderness in the right hypochondrium. Ultrasonography showed thickened gallbladder wall. A final diagnosis of DHF with AAC was made, and she was also managed conservatively. Within 3 days, the platelet count and albumin level improved, with disappearance of rebound tenderness.
Figure 1: Ultrasonogram of the gallbladder showing the thickened wall (7.9 mm) Indian J Med Sci, Vol. 61, No. 11, November 2007
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LETTERS TO EDITOR
Acute acalculous cholecystitis is a rare c o m p l i c a t i o n o f d e n g u e f e v e r . [1-4] T h e pathogenesis is not entirely clear, though a likely mechanism may be the abnormal permeability of serous membranes causing capillary leak, as a result of direct viral invasion and hypoalbuminemia. Both patients had upper abdominal pain, gallbladder wall thickening and transient rebound tenderness, conÞrming the diagnosis of AAC. In a previous report of AAC, the histopathology of two gallbladders removed surgically showed chronic inßammatory cell inÞltrate in the wall with erythrocytes in the lumen.[5] However, a recent contrasting report revealed a normal gallbladder wall in a patient with AAC with DF complicating pyrexia of unknown origin.[6] If a patient with dengue fever develops abdominal pain with localized tenderness in the right upper quadrant, AAC should be suspected and investigated. The course of AAC in DF is usually benign and management is conservative.
mediators in dengue virus infection in children: Interleukin-6 and its relation to C-reactive protein and secretary phospholipase A2. Am J Trop Med Hyg 2001;65:70-5. 6. Surrun SK, Thomas-Golbanov CK. Pyrexia of unknown origin complicated by dengue fever and pseudo-rupture of the gallbladder: A case report. {Abstract presented at the 16th European Congress of Clinical Microbiology and Infectious Diseases, Nice, France, 2006. Available from: http://www.blackwellpublishing.com/eccmid16/ abstract.asp?id=50934)}.
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INDIAN JOURNAL OF MEDICAL SCIENCES
REFERENCES
1. Sharma N, Mahi S, Bhalla A, Singh V, Varma S, Ratho RK. Dengue fever related acalculous cholecystitis in a North Indian tertiary care hospital. J Gastroenterol Hepatol 2006;21:664-7. 2. Sood A, Midha V, Sood N, Kaushal V. Acalculous cholecystitis as an atypical presentation of dengue fever. Am J Gastroenterol 2000;95:3316-7. 3. Wu KL, Changchien CS, Kuo CM, Chuah SK, Lu SN, Eng HL, Kuo CH. Dengue fever with acute acalculous cholecystitis. Am J Trop Med Hyg 2003;68:657-60. 4. Tan YM, Ong CC, Chung AY. Dengue shock syndrome presenting as acute cholecystitis. Dig Dis Sci 2005;50:874-5. 5. Juffrie M, Meer GM, Hack CE, Haasnoot K, Sutaryo, Veerman AJ, Thijs LG. Inß ammatory
FAZLUR REHMAN JAUFEERALLY, SOONDAL KOOMAR SURRUN, PIK EU CHANG*
Department of Internal Medicine, *Gastroenterology, Outram Road, Singapore General Hospital, Singapore Correspondence: Dr. Soondal K. Surrun, Department of Internal Medicine, Outram Road, Singapore General Hospital, 169 608, Singapore. E-mail:
[email protected]
OUTCOME OF CORONARY BYPASS GRAFTING
Sir, We read the article ‘Outcome of coronary artery bypass grafting in patients…….artery disease’ by Nozari et al., which was published in the October 2007 issue of the journal.[1] It is an interesting article; and in the extant literature, one Þnds an endless list of articles focusing on the outcome of coronary artery bypass grafting (CABG) surgery. Under ‘Material and methods,’ the authors describe a stenosis of 50% or more in the left main coronary artery as signiÞcant. We would appreciate an exact anatomical location of the stenosis under such circumstances. As anatomists, we also wonder if 70% or greater than
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