AUTHORS REPLY

June 13, 2014

Sir, the recent report on “thrombocytopenic purpura and dengue” is very interesting¹. AMÂNCIO et al. concluded that “DENV-4 can also result in severe forms of the disease and lead to hemorrhagic complications and death, mainly when dengue infection is associated with coexisting conditions¹”. In fact, dengue is a common arboviral disease that can be seen in several tropical countries. No doubt that this infection can co-occur with other thrombohemostatic disorders. The concomitant disorder between dengue and thrombocytopenic purpura is not common and can be problematic. This problem can induce to severe bleeding as well as atypical manifestations such as angina². To manage those cases, adding to fluid replacement therapy, steroid therapy seems to be useful⁶. Nevertheless, dengue can be the cause of immune thrombocytopenic purpura³,⁴ and it is observed for relationship to severe cardiovascular failure and shock⁵. In the present case, it is needed to clarify whether the observed thrombocytopenic purpura problem is the new superimposed or old problem. Since the clinical management of the dengue case with underlying thrombocytopenic purpura is different from general cases, it is the role of the physician in charge to carefully take the patient past history on personal illness.

REFERENCES

• ¹
  Amâncio FF, Pereira MA, Iani FC, D'anunciação L, Almeida JL, Soares JA, et al. Fatal outcome of infection by dengue 4 in a patient with thrombocytopenic purpura as a comorbid condition in Brazil. Rev Inst Med Trop Sao Paulo. 2014;56:267-70.
• ²
  Campos MA, Junior Prota ML, Gomes CA, Amaral KP, Almeida DC. Ludwig's angina after severe thrombocytopenic purpura associated with dengue fever. Rev Soc Bras Med Trop. 2014;47:116-8.
• ³
  Imbert P, Verrot D, de Pina JJ, Debord T. Purpura thrombopenique aigu post-infectieux: manifestation atypique de la dengue. Med Trop (Mars). 1994;54:191.
• ⁴
  Kumar S, Khadwal A, Verma S, Singhi SC. Immune thrombocytopenic purpura due to mixed viral infections. Indian J Pediatr. 2013;80:421-2.
• ⁵
  Putintseva E. Transient remission of chronic thrombocytopenic purpura induced by dengue virus infection. Acta Haematol. 1985;73:241-3.
• ⁶
  Rodríguez-Angulo EM, Sosa Muñoz J, García-Miss MR, Farfán-Ale JA, Loroño-Pino MA. Caso de púrpura trombocitopénica autoinmune y dengue. Rev Invest Clin. 1997;49:47-9.

AUTHORS REPLY

Authorship SCIMAGO INSTITUTIONS RANKINGS

To the Editor

We would like to thank JOOB & WIWANITKIT for their comments on our article¹. In fact, as a variety of conditions associated with dengue could explain the bleeding and thrombocytopenic picture described, it is difficult to ensure that the patient got worse by an exacerbation of immune thrombocytopenic purpura. That is why it makes difficult the use of steroids in such cases. As reported¹, dengue associated with sepsis or just severe dengue with gastrointestinal bleeding are possible explanations for the described clinical picture. Despite anecdotal reports of favorable outcome in specific dengue cases who used steroids³,⁴, a thorough review showed no benefit from use of corticosteroids in dengue shock². The steroids use during the early acute phase of dengue infection was also not associated with reduction in the development of shock⁷ and there was no benefit of using adjunctive corticosteroid therapy in term of changing the severity of thrombocytopenia⁵,⁶. We completely agree that the treatment of dengue should be personalized considering comorbidities and clinical history of the patients, however, as corticosteroids can potentially do harm, we believe that their use need to be better defined and limited to very specific dengue situations.

We wish to thank JOOB & WIWANITKIT again for their attention and observations. We enjoyed the opportunity to discuss the case reported and we hope that future studies adequately powered, designed and controlled evaluate the possible beneficial effects of steroids on the various manifestations of dengue infection.

REFERENCES

• ¹
  Amâncio FF, Pereira MA, Iani FC, D'anunciação L, Almeida JL, Soares JA, et al. Fatal outcome of infection by dengue 4 in a patient with thrombocytopenic purpura as a comorbid condition in Brazil. Rev Inst Med Trop Sao Paulo. 2014;56:267-70.
• ²
  Panpanich R, Sornchai P, Kanjanaratanakorn K. Corticosteroids for treating dengue shock syndrome. Cochrane Database Syst Rev. 2006;(3):CD003488.
• ³
  Premaratna R, Rodrigo KM, Anuratha A, de Alwis VK, Perera UD, de Silva HJ. Repeated dengue shock syndrome and “dengue myocarditis”’ responding dramatically to a single dose of methyl prednisolone. Int J Infect Dis. 2012;16:e565-9.
• ⁴
  Rodríguez-Angulo EM, Sosa Muñoz J, García-Miss MR, Farfán-Ale JA, Loroño-Pino MA. Caso de púrpura trombocitopénica autoinmune y dengue. Rev Invest Clin. 1997;49:47-9.
• ⁵
  Shashidhara KC, Murthy KA, Gowdappa HB, Bhograj A. Effect of high dose of steroid on plateletcount in acute stage of dengue fever with thrombocytopenia. J Clin Diagn Res. 2013;7:1397-400.
• ⁶
  Srichaikul T, Punyagupta S, Sorakhunpipitkul L, Udomsubpayakul U. Adjunctive corticosteroid therapy in 149 grade II (non-shock) adult DHF patients: an analysis during January 2008-February 2010. J Med Assoc Thai. 2011;94:1419-23.
• ⁷
  Tam DT, Ngoc TV, Tien NT, Kieu NT, Thuy TT, Thanh LT, et al. Effects of short-course oral corticosteroid therapy in early dengue infection in Vietnamese patients: a randomized, placebo-controlled trial. Clin Infect Dis. 2012;55:1216-24.

Publication Dates

• Publication in this collection
  Sep-Oct 2014