Hemolytic Uremic Syndrome Associated with Dengue Fever in an Adolescent Girl

TotheEditor:Dengue virus infection is recognized as oneof tropical acute kidney injury (AKI). Renal involve-ment in dengue is relatively rare and considered as anatypical manifestation [1]. Dengue fever associated AKIsecondary to hemolytic uremic syndrome is very rareand only limited case reports are available [2,3].A 16-y-old girl presented with fever and oliguria for 4 d.There was no diarrhea. Her clinical examination was unre-markable except for pallor.Investigations showed hemoglobin 7.7 g/dL andplatelets 20,000/cmm respectively. Peripheral smear pic-ture revealed micro-angiopathic hemolytic anemia. Renalfunction tests were markedly deranged (Fig. 1) withhyperkalemia. She had class 3 AKI (failure) as permodified pediatric RIFLE (risk, injury, failure, loss,end stage) criteria. Urine analysis revealed microscopichematuria (1+) and proteinuria (2+) with granular casts.Tests for malaria and leptospira were negative. Bloodculture and urine culture were sterile. Serum lactatedehydrogenase (LDH) level was elevated with a valueof 3,046 U/L. Serum C3 level C4 levels were 80 mg/dLand 28 mg/dL respectively. As her antinuclear antibodytitre was negative, anti ds DNA was not performed. IgMantibody and non structural protein antigen 1 (NS1)antigen testing done for dengue virus was positive.She was treated with fluid management as per AKIprotocol and antihyperkalemic measures. She underwentplasmapheresis over next 8 d along with 4 cycles ofhemodialysis. She responded with gradual decrease inrenal parameters (Fig. 1). Child was followed up fornext 6 mo and she remained asymptomatic with normalblood count, renal functions, complement levels andurine analysis.Most cases of hemolytic uremic syndrome (HUS) intropical countries typically occur following diarrhealillness with enteric pathogens (D+) HUS. Howevervarious triggers including non enteric infections havebeen identified in the etiology of atypical (D-) HUS.Proteinuria and abnormal urine sediment are the mostcommon renal manifestations reported in patients withdengue fever [4]. AKI in dengue fever is commonlyattributed to shock induced acute tubular necrosis [5].First ever case of an association of HUS with denguehemorrhagic fever in a child was reported by Mervinet al. [3].