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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 12  |  Issue : 2  |  Page : 98-99

Acute quadriparesis in dengue – A rare presentation of a common disease


Department of Medicine, Sukh Sagar Hospital, Amritsar, Punjab, India

Date of Submission27-Dec-2020
Date of Decision27-Dec-2020
Date of Acceptance13-Feb-2021
Date of Web Publication30-Mar-2021

Correspondence Address:
Dr. Swapan Nagpal
Department of Medicine, Sukh Sagar Hospital, 5 Maqbool Road, Amritsar - 143 001, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/injms.injms_174_20

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  Abstract 


Dengue fever commonly presents with electrolyte abnormalities including hypokalemia. Hypokalemic quadriparesis is a very rare manifestation of this common arboviral infection. We report a case of acute reversible quadriparesis caused by hypokalemia in a patient with dengue. Such a presentation has been reported very few times. Various mechanisms have been proposed to explain hypokalemia in dengue, and it is still not completely known why some patients develop motor weakness and others do not. Most such cases have a very good prognosis and the weakness resolves on potassium supplementation.

Keywords: Acute, dengue, hypokalemia, quadriparesis


How to cite this article:
Nagpal S, Nagpal AJ. Acute quadriparesis in dengue – A rare presentation of a common disease. Indian J Med Spec 2021;12:98-9

How to cite this URL:
Nagpal S, Nagpal AJ. Acute quadriparesis in dengue – A rare presentation of a common disease. Indian J Med Spec [serial online] 2021 [cited 2021 Aug 2];12:98-9. Available from: http://www.ijms.in/text.asp?2021/12/2/98/312622




  Introduction Top


Dengue is a common disease in the tropical world. It presents with a myriad of clinical features ranging from mild fever to shock. Electrolyte imbalance is common in dengue but is rarely of any significant consequence. Neurological complications are uncommon in dengue and quadriparesis, among these, the rarest. We present a case of severe hypokalemia in dengue, leading to acute quadriparesis - a very rare presentation.


  Case Report Top


A 28-year-old male presented to the Emergency Department with a complaint of weakness in both upper and lower limbs for the last 3 days. The weakness started in the feet and legs, ascending to involve the thighs, hips, trunk, and progressively the hands, forearms, arms, and shoulders. By the time he presented to us, he was barely able to move all his limbs and was bed-bound. General examination revealed a pulse rate of 82/min, blood pressure of 110/50mmHg. He was dehydrated. Neurological examination revealed grade 2/5 power in both the upper limbs and grade 1/5 power in both the lower limbs. There was truncal weakness and he was not able to lift his neck against gravity. All deep tendon reflexes were absent. Plantar reflexes were bilaterally normal. The examination of mental status, cranial nerves and the sensory system was unremarkable. A quick venous blood gas analysis raised suspicion of severe hypokalemia. An oral load of 10 g of potassium chloride was given over the next 1 hour. By that time, the electrolytes were reported - the serum potassium was 2.6 meq/L, serum creatinine - 1.6 mg/dL, SGOT - 238 IU/L, and SGPT - 168 IU/L. CBC revealed leucocytosis. Serum CPK levels were normal - a diagnosis of myositis was thus, unlikely. He was admitted to the ICU. A strong differential of Guillain-Barré syndrome (GBS) was also considered. On continuing potassium supplementation via IV and oral route, the patient showed some improvement. By the next 12 hours, the power improved to grade 3/5 in the upper limbs and grade 2/5 in the lower limbs. In the evening of the second day of admission, the patient developed fever, with an oral temperature up to 101°F. Blood and urine cultures were sent. Rapid card-based tests for dengue and malaria were reported negative. By the third day of admission, the power in the upper limbs improved to grade 4/5 and in the lower limbs to grade 3/5. He was able to stand on his feet by the fourth day. The patient, however, developed abdominal fullness, breathlessness and an erythematous rash on the back. Chest radiography showed bilateral pleural effusion. Ultrasound abdomen showed mild ascites. The neurological condition improved progressively. However, his pleural effusion, ascites and transaminitis worsened. Antibody tests for rickettsial and leptospiral infections were negative. He developed thrombocytopenia. Strongly suspecting a capillary leak syndrome owing to dengue-like illness, a repeat test for Dengue (IgM ELISA) was sent which was reported to be strongly positive. Conservative management was continued. The patient continued to improve, his breathlessness resolved and he was discharged. He was well on follow-up in OPD; his pleural effusion, ascites and weakness in the limbs having completely resolved.


  Discussion Top


Dengue may present with a myriad of neurological manifestations. These include but are not limited to encephalopathy, myelitis, encephalitis, meningitis, polyneuropathy, GBS, and intracranial hemorrhage and thrombosis.[1] Neuromuscular weakness could be due to GBS, myositis, or hypokalemia, out of which hypokalemia is the most common[2] and responds best to treatment. Hypokalemia is a common electrolyte abnormality in dengue[3] (up to 70%)[4] out of which most cases are mild and a very few - moderate or severe[3]. The mechanism of hypokalemia in dengue is not clear. It may either be due to redistribution of potassium (due to catecholamine release, insulin action or increased consumption during recuperation from cytopenia), [5,6] or increased intestinal or renal losses[7]. Hypokalemia is very common, but hypokalemic quadriparesis very rare in dengue. What makes some individuals more prone to develop neuromuscular weakness in states of hypokalemia is an enigma. Whether a specific channelopathy is responsible for this or not, is still not clear and further genetic studies are required to answer this pertinent question. One must not forget various differential diagnoses while evaluating such a case. GBS, myositis, rhabdomyolysis, and cervical cord compression are important differential diagnoses and must be investigated using CPK levels, CSF studies, nerve conduction studies, and MRI of the cervical spine, especially in a patient who doesn't improve with potassium supplementation. Treatment of hypokalemia in dengue consists of the management of hypokalemia through parenteral and oral routes. Fluid therapy for dengue must be administered according to existing protocols with a preference for potassium-rich fluids. Most such cases have an excellent prognosis and recover within a few days. Persisting weakness must alert the physician to look for an alternate or a co-existing condition.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gulati S, Maheshwari A. Atypical manifestations of dengue. Trop Med Int Health 2007;12:1087-95.  Back to cited text no. 1
    
2.
Li GH, Ning ZJ, Liu YM, Li XH. Neurological manifestations of dengue infection. Front Cell Infect Microbiol 2017;7:449  Back to cited text no. 2
    
3.
Khandelwal VG, Patil VC, Botre A, Patil R. Study of electrolyte disturbances in dengue infected patients. IJCMR 2019 ;6:B5-8.  Back to cited text no. 3
    
4.
Malhotra HS, Garg RK. Dengue-associated hypokalemic paralysis: Causal or incidental? J Neurol Sci 2014;340:19-25.  Back to cited text no. 4
    
5.
Jha S, Ansari MK. Dengue infection causing acute hypokalemic quadriparesis. Neurol India 2010;58:592-4.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Gulati S. Dengue infection causing acute hypokalemic quadriparesis. Neurology India 2011;59:143.  Back to cited text no. 6
    
7.
Binh PT, Matheus S, Huong VT, Deparis X, Marechal V. Early clinical and biological features of severe clinical manifestations of dengue in Vietnamese adults. J Clin Virol 2009;45:276-80..  Back to cited text no. 7
    




 

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