Dengue fever associated cerebral hemorrhages, a rare, poorly understood entity in an era of dengue epidemic A case series and literature review-converted

 Dengue is caused by a flavivirus, which may be a vector borne RNA virus with four anti-genically distinct serotypes (DEN 1, DEN 2, DEN 3 and DEN 4). Neurological manifestations are rare compared to other complications of the disease. Encephalopathy, encephalitis, aseptic meningitis, intracranial hemorrhages, thrombosis, mono-neuropathies / polyneuropathies, Guillain-Barre syndrome and myelitis are reported. Neurological manifestation in dengue haemorrhagic fever usually results from multisystem dysfunction secondary to liver failure, cerebral hypoperfusion, electrolyte imbalance, shock, cerebral edema and hemorrhage associated with vascular leak. The occurrence of brain hemorrhage during a case with dengue shock are often serious and results in death. The occurrence of brainstem hemorrhage are often a really serious fatal situation. We report this case series of dengue haemorrhagic fever with multiple intracranial, sub arachnoid hemorrhages and sub-dural hematoma causing brainstem herniation. Case 1: A 25-year-old previously healthy woman was admitted on third day of fever with thrombocytopenia. Critical phase started on 5th day with evidence of pleural effusion and moderate ascites. 31 hours into critical phase, she developed headache, altered level of consciousness, limb rigidity and respiratory depression without definite seizures. Non-contrast CT brain done at tertiary care level revealed diffuse intra cranial hemorrhages and sub arachnoid hemorrhages in right frontal, parietal, occipital lobes and brainstem, cerebral oedema with an acute subdural hematoma in right temporo-parietal region. Her platelet count was 40,000 at this point with signs of vascular leakage. She was intubated and ventilated with supportive care. Later on, she developed features of cranial diabetes and it skilled intranasal desmopressin therapy. In spite of above measures signs of brainstem herniation developed and she or he succumbed to the illness on day 8. Dengue was confirmed serologically.