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|Year : 2014 | Volume
| Issue : 3 | Page : 327-328
Dengue infection presenting as acute hypokalemic quadriparesis
N Gupta1, A Garg1, P Chhabra2
1 Department of Medicine, PG Student University College of Medical Sciences, Dilshad Garden, Delhi University, Delhi, India
2 Department of Internal Medicine, PGIMER, Chandigarh, India
|Date of Submission||09-Feb-2013|
|Date of Decision||27-Mar-2013|
|Date of Acceptance||02-Apr-2013|
|Date of Web Publication||14-Aug-2014|
Dr. N Gupta
Department of Medicine, PG Student University College of Medical Sciences, Dilshad Garden, Delhi University, Delhi
Source of Support: None, Conflict of Interest: None
Dengue infection is one of the most common viral hemorrhagic fevers seen in the tropical countries, including India. Its presentation varies from an acute self-resolving febrile illness to life-threatening hemorrhagic shock and multiorgan dysfunction leading to death. Neurological presentations are uncommon and limited to case reports only. Most common neurological manifestations being encephalitis, acute inflammatory demyelinating polyradiculoneuropathy, transverse myelitis, and acute disseminated encephalomyelitis.Hypokalemic quadriparesis as a presenting feature of dengue is extremely rare. Here, we report this case of a 33-year-old female, who presented with hypokalemic quadriparesis and was subsequently diagnosed as dengue infection.
Keywords: Dengue, hypokalemia, quadriparesis
|How to cite this article:|
Gupta N, Garg A, Chhabra P. Dengue infection presenting as acute hypokalemic quadriparesis. J Postgrad Med 2014;60:327-8
| :: Introduction|| |
Dengue fever remains one of the most common infections in the tropics especially during rainy season. The classic presentation is acute febrile illness with thrombocytopenia and bleeding tendencies. However neurological presentations of dengue fever are increasingly being recognized. When dengue fever presents with quadriparesis, hypokalemia should be suspected to avoid delay in treatment and undue investigations.
| :: Case Report|| |
A 33-year-old lady presented to the emergency room with progressive weakness of all four limbs, spreading proximally, for the past 2 days. This was preceded by high grade fever, associated with chills and rigors for past 7 days, which responded to paracetamol. However, there was no history of bleeding manifestations, cough, burning micturition, dyspnea, altered sensorium or seizures. There were no associated sensory symptoms or features suggestive of bowel and bladder or cranial nerve involvement. There was no preceding history of a high carbohydrate diet intake. Examination revealed no petechiae and tourniquet test was also negative (Hess capillary fragility test). Power in all four limbs was 2/5, at all the joints and the reflexes were 2+ in all four limbs. Complete, blood count revealed a platelet count of 98,000/mm 3 (the lowest count), hemoglobin 14.3 g/dl and a total leucocyte count 3900/mm 3 . Serum electrolytes revealed presence of hypokalemia (potassium 2.0 meq/l) with normal sodium and chloride levels. Arterial blood gas analysis, anion gap, urine pH and electrolytes were within normal limits. Electrocardiogram revealed prominent U waves and ST segment depression. Thyroid function tests were normal ruling out the possibility of thyrotoxic periodic paralysis (tri-iodothyronine - 1.4 ng/ml, tetra-iodothyroxine- 5.8 μg/dl and thyroid stimulating hormone- 3.6 μIU/ml). Nerve conduction study revealed normal F wave responses excluding the possibility of acute inflammatory demyelinating polyradiculoneuropathy (AIDP) where they are lost early [Figure 1]. A rapid card test for malaria was negative and a serology for scrub typhus was also inconclusive, but non structural protein antigen was positive on Day 1 of admission and subsequently the dengue serology also turned out to be positive (anti-IgM). Patient was started on intravenous potassium infusion and next day patient's potassium was 4.2 meq/l. Clinically, there was marked improvement in the power of the limbs (from 2+/5 to 4+/5 in all four limbs) and improvement in the platelet count to 1.86 lacs on Day 3. Patient was managed conservatively and was discharged on Day 4.
|Figure 1: Nerve conduction studies showing normal F responses in the right median and ulnar nerves|
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| :: Discussion|| |
Neurological complications of dengue are very rare. However, recently neuromuscular weakness has been described in association with dengue infection. , Hira et al. have described motor weakness in 12 patients of dengue infection. Out of these 12 patients, 10 had hypokalemia, 1 had Guillain-Barre syndrome, and other one had myositis. Verma et al.  have also described a case of quadriparesis due to cervical compressive myelopathy in a patient with dengue hemorrhagic fever.
Hypokalemia in dengue fever is not very uncommon, but presentation with quadriparesis is very rare. The exact cause is unknown, but it may result from transcellular shift due to release of catecholamines or insulin. It could also be due to loss of potassium in urine as a result of renal tubular damage. A study carried out in children with dengue infection revealed hypokalemia in 14% of patients with dengue fever and 17% of patients with dengue hemorrhagic fever. 
The most common differential diagnosis remains AIDP and the differentiating features being presence of the normal nerve conduction velocity, absent albuminocytological dissociation, and the response to potassium supplementation in dengue infection with hypokalemic quadriparesis. Physicians should be aware that dengue can present with neurological complications.
| :: References|| |
|1.||Gutch M, Agarwal A, Amar A. Hypokalemic quadriparesis: An unusual manifestation of dengue fever. J Nat Sci Biol Med 2012;3:81-3. |
|2.||Gulati S. Dengue infection causing acute hypokalemic quadriparesis. Neurol India 2011;59:143. |
|3.||Hira HS, Kaur A, Shukla A. Acute neuromuscular weakness associated with dengue infection. J Neurosci Rural Pract 2012;3:36-9. |
|4.||Verma SP, Himanshu D, Tripathi AK, Vaish AK, Jain N. An atypical case of dengue haemorrhagic fever presenting as quadriparesis due to compressive myelopathy. BMJ Case Rep 2011;10:3421-23. |
|5.||Lumpaopong A, Kaewplang P, Watanaveeradej V, Thirakhupt P, Chamnanvanakij S, Srisuwan K, et al. Electrolyte disturbances and abnormal urine analysis in children with dengue infection. Southeast Asian J Trop Med Public Health 2010;41:72-6. |
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