Ref Number = PITIKA-ASPR0131
Kuntum Basitha, Ardhani Indra Puspita, Hario Widhi Nugroho, Elvia Maryani, Isna Nurhayati, Eva Musdalifah
Expanded dengue syndrome (EDS) is an unusual manifestation of dengue infection with severe organ involvement. The manifestations may be associated with coinfection, comorbidities or complication of severe profound shock. This case report describes brain involvement of EDS in an 8-years-old girl.  

An 8-years old girl presented in emergency unit with altered consciousness after 5-minutes generalized tonic-clonic seizure. In recent history, she had high fever since 3 days and abdominal pain. Clinical examinations on admission showed circulation shock, pulse 153/min and weak, temperature 37.9°C, and blood pressure 88/40. The liver was palpable, tourniquet test was positive with no other sign of bleeding. The laboratory examination obtained thrombocytopenia (38x109/L) with hemoconcentration (33.8% rising hematocrit). Elevated serum ALT (141 IU/L), AST (748 IU/L), ureum (96.8 mg/dL) and creatinine (1.34 mg/dL) suggested the signs of acute multi-organ failure. Meanwhile, no electrolyte abnormalities were found. Chest x-ray revealed bilateral bronchopneumonia and non-contrast head CT scan showed cerebral edema. We inserted a nasogastric tube for feeding and drained black-colored byproduct. 
We assessed the patient as expanded dengue syndrome with dengue encephalopathy. The patient was treated with dobutamine as inotropic, mannitol, antibiotics and other supportive drugs. She had gradual improvement in consciousness and after close monitoring in PICU for 3 days, the patient condition’s stable. The patient was discharged after 9 days hospitalization and followed up until recently, there were no sequelae found.
It was quite challenging to assess EDS with dengue encephalopathy in limited resource for serologic confirmation for dengue. The central nervous system involvement is likely associated with direct invasion of the virus, autoimmune reactions or metabolic alterations. The low incidence of dengue encephalopathy reported is because the diagnosis is easily missed. However, EDS should be considered in the differential diagnosis, especially in endemic area.
Keywords: expanded dengue syndrome, dengue hemorrhagic fever, altered consciousness, PICU, shock
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