Artikel 48 – Multi Organ Complication Due To Dengue Virus Infection (Kidney, Heart and Liver) That as Treated With Heparinization and Hemodialysis

Multi Organ Complication Due To Dengue Virus Infection (Kidney, Heart and Liver) That as Treated With Heparinization and Hemodialysis

Taufiq Muhibbuddin Waly1, Ria Bandiara2, Hardiman Pohan3, Budi Riyanto4

  1. Internist, Department of Internal Medicine, Waled General Hospital, Cirebon, West Java, Indonesia.
  2. Consultant, Division of Kidney and Hypertension, Internal Medicine Department. Hasan Sadikin Central Hospital, Bandung, West Java, Indonesia.
  3. Professor, Division of Tropical Disease and Infection, Internal Medicine Department. Cipto Mangunkusumo Central Hospital, Jakarta, Indonesia.
  4. Consultant, Division of Tropical Disease and Infection, Internal Medicine Department. Kariadi Central Hospital, Semarang, Central Java, Indonesia.


Multiple organ complications because of Dengue infection can be found in hyper endemic Dengue countries such as Indonesia. If it happens, patient’s death on those cases will be hard to avoid. Here we file a report of Dengue infection case with complication of acute renal failure (CCT 7,24), acute lung edema et causa anterior septal STEMI (CKMB 85,9 U/L) and hepatic insufficiency (total bilirubin 3,3 mg/dL). In this patient we performed hemodialysis with heparanization and high doses of corticosteroid injection (methylprednisolone 2 x 250mg/day) for 5 consecutive days. The patient went home in a good condition.

Keywords : Dengue infection, acute renal failure, acute lung edema, STEMI, high dose methylprednisolone injection.


Dengue infection is still often occurs in tropical countries such as Indonesia. Based on the Indonesian health records of 2016, Dengue fever was the third out of ten highest causes of people using public health insurance for hospitalization in Indonesia in 2016. It was placed right behind diarrhea and uterus inertia.[1] WHO itself reported that the death rate caused by Dengue infection can range from under 1% to more than 20% depends on severity of the illness and treatments given to the patient. [2] Spreading of immune complexes and multiple organs impairment, including renal impairments were also reported. [3,4,5] Prathima, et al reported that hemodialysis was given to the patient of acute renal failure who also had liver function impairment caused by Dengue fever. [6] However, there is still no special report about treatment report for more than two organs impairment, including renal failure caused by Dengue infection. Which hemodialysis played parts and reported to be given to treat acute renal failure in those patients. The reality is researches reported were only renal failure observation in DHF patients who underwent DHF treatments but hemodialysis were not reported to take place in those cases. [7]

This article reported there were three different organs affected by Dengue infection, which were STEMI, hepatic insufficiency and acute renal failure.. Whereas, in the treatment for this patient we  gave heparinization to treat cardiac problems and hemodialysis to treat acute renal failure.

Ethical Consideration

Written informed consent was obtained from patient for publication of this case report and any accompanying images. A copy of written consent is available for review by the editor-in-chief of this journal.

 Case Presentation

An Indonesian woman, 59 years old, weight 50 kg, came to emergency room (18-10-16) because of fever that lasts for 3 days before admission. The patient had dyspnea, painful chest pain that was spreading to left arm and back, these symptoms last for one day before she came to the hospital. The patient was also complaining about coughing up white phlegm, nausea, but she didn’t vomiting, body and joint aches had been felt for 3 days before she came to the hospital. History for coughing, diabetes mellitus, hypertension, and other systemic diseases were denied. History of bleeding was also denied.

At the time she came into the emergency room, blood pressure was 90/60, heart rate 133x/minute, respiration rate 26x/minute, temperature 38,8˚C, oxygen saturation 90%. Petechiaes were found in arm and leg. Smooth wet rhonchi in basal (+/+). In abdomen, mild hepatomegaly, epigastric tenderness, urination is smooth, painless, light yellow urine, without leg edema and ascites. Laboratory test showed : Hb 14,7%, leukocytes 6100/mm3, diff count 0/0/1/93/6/0, hematocrit 38%, platelet count 48.000/mm3, SGOT 130,7 U/L, SGPT 39,8 U/L, total bilirubin 3,3 mg/dL, BUN 161,1 mg/dL, creatinine 5,87 mg/dL, urinary erythrocytes 250/ul, leukocytes 550/ul, blood glucose 122 mg/dL, albumin 2,86 mg/dL, CKMB 85,9 U/L, total cholesterol 159,5 mg/dL, HDL 7,2 mg/dL, LDL 87 mg/dL, triglyceride 308,5 g/dL, potassium 6,36 mg/dL, antibody IgG Dengue (+), IgM (-), thorax radiology showed slightly enlarged heart and pulmonary congestion. Infiltrates in the lungs (+). ECG showed ST-segment elevation in lead V1 – V4 with heart rate of 140x/minute. USG showed no enlargement of the hepar, no ascites, no node, fatty liver (+), slightly enlarged sized and appearance of what seems like small stones in renal dextra. In renal sinistra there was also imaging of small stones, but the size was normal. Gall bladder and lien showed in normal range.

Based on the data, the diagnosis were cardiogenic shock, acute pulmonary edema et causa anteroseptal STEMI and acute kidney injury, that were all caused by severe Dengue infection. We also thought of secondary infection (urinary tract infection). Patient was admitted to Intensive Care Unit. On fourth dayh of treatment, BUN and creatinine  were increased to 318 mg/dL and 6,6 mg/dL respectively. Lowest platelet count finding was 13.000/mm3.

The treatment given to the patient were Ringer lactate, hydroxyl ethyl stracth (widahess), dobutamin injection, enoxaparine sodium (lovenox) injection, furosemide injection, fargoxin injection/6 hours, high doses methylprednisolone injection, sliding scale of blood glucose every 6 hours, omeprazole injection, antiemetic injection, electrolyte correction imbalance, antibiotic injection, aspillet, clopidogrel, nitric and O2, and cito hemodialysis on the fourth day of the treatment.

The patient was discharged on the 10th day of treatment in good condition. The patient then never did follow up to internal department and finally she only came for follow up on December 22th 2016 because of gastrointestinal problem. Laboratory results finding: Hb 10,2 gr%, HT 31%, platelet 239.000 /mm3, leukocytes 7800 /mm3, MCV/MCH/MCH 84/28/33 (normal limit), sodium 145 mg/dL, potassium 4.4 mg/dL, chloride 124 mg/dL, BUN 18.3 mg/dL, creatinine 1,32 mg/dL.


The incidence of renal failure (CCT <60) in Dengue infected patient based on creatinine value at the time of admission was 4.04% of all patients infected by Dengue. [7] And from that 4.04%, 28.57% will experience death. If CCT is <15 then the death is about 45%. [7] While deaths from dengue infections in hospitals, in children (<15 years) are in the range of 0.5-3.5% (data on adults not yet agreed). [7] The presence of AKI, in patients infected dengue, based on creatinine when admitted to hospital is 35.7%. [8] And when using creatinine data at the time of entry and return, then the impaired renal function in patients infected by Dengue virus is 27.1%. [7] The details were based on RIFLE value: Risk 21.6% (CCT 60-89), Injury 2.9% (CCT 15-59) and Failure 2,6% (CCT <15).

Based on the data above, it shows that most patients with impaired renal function that occurs due to Dengue viral infection will heal itself. This is consistent with what Lizarraga and Ali Nayer said. [9] While mortality occurs mainly when the kidney function disorder has reached the value of CCT <15. Where its approximate value is 45%.(6) Logically, the death will also increase if in addition to suffering from renal failure (CCT <15), the patient also suffers from acute myocardial infarct. Data in the US in 2008 mentioned 1 of 4 deaths in the US caused by heart disease. [10]

Based on the data above, this case is an interesting case to report. In this case in addition to renal failure with CCT <15 she was also suffering from acute myocardial infarct and hepatic insufficiency.

It was decided to do hemodialysis in this patient after laboratory test found BUN 318 mg/dL and creatinine 6,6 mg/dL (CCT 7,24), potassium 6,04 mg/dL, sodium 138,8 mg/dL, calcium 8,32  mg/dL, and platelet count 19,000 /mm3, CKMB 11,83 U/L, and the patient wasn’t feeling breathless. Blood pressure is 160/90 mmHg.

The HD formula given to this patient is a 400cc pull (UFG) within 3 hours and without heparin. QB 150 and QD 300, and the administration of bicnat was raised by 1 level. Other settings are provided by default. Post HD BUN 138.4 mg/dL, creatinine 2.63 mg/dL, potassium 4.56 mg/dL, sodium 136.4 mg/dL, calcium 8.49 mg/dL. But the platelet count fell to 13,000 /mm3. The patient was discharged on the 10th day of treatment in good condition. Unfortunately the patient just went for follow up to internal department only on December 22th 2016 with laboratory results Hb 10,2 gr%, HT 31%, platelet 239.000/mm3, leukocytes 7800/mm3, MCV/MCH/MCH 28/28/33 (normal limit), Sodium 145 mg/dL, potassium 4.4 mg/dL, chloride 124 mg/dL, BUN 18,3 mg/dL, creatinine 1,32 mg/dL.

Another important point from this patient is the corticosteroid intravenous injection in high doses (500mg/day of methylprednisolone which were divided by twice a day for 250 mg in each administration). Those corticosteroids were given for 5 days consecutively. Meanwhile, to prevent the occurance of tachycardia and hyperglichemic in the patient as a result of high doses of corticosteroids, the patient was given fargoxin 1 cc/ 6 hours and a sliding scale of blood sugar in every 6 hours.

In general the administration of high dose corticosteroid was basically planned to restrict the severity of inflammation reaction due to Dengue viral infection. But, in particular this administration is to show that hypersensitivity as the basic of pathogenesis and pathophysiology of Dengue hemorrhagic fever as what has been stated by Waly is indeed the correct theory. [11]  By which, the effect from hypersensitivity reaction is the possibility of lupus nephritis occurrence in patients with very high sensitivity to Dengue virus or the possibility of lupus nephritis should be calculated even tough ANA or anti-Ds DNA were not evaluated in this patient.

Laboratory value development table :


ECG imaging

EKG saat masuk

Fig 1. ECG of this patient when first admitted to ER (October 18th 2016)

ECG showed ST-segment elevation in lead V1 – V4 with heart rate of 140x/minute. This shows the possibility of anteroseptal myocardial infarction in patient.

EKG Saat Keluar

Fig 2. ECG of the same patient after next follow-up (December 22th 2016).

The ECG shows all leads in normal limit for this patient.


It was hard to avoid that this case should be a lost case. If this case could give a very satisfactory result in the end, then the possible reason can be attributed to the administration of high dose corticosteroid injection besides other therapies that were given to this patient.


  1. H. Soemarmo Sostroatmojo Hospital. 10 Highest Diseases Occurrence Based On National Health Insurance, ( accessed on 30 July 2016)
  2. Dengue guidelines for diagnosis, treartment, prevention and control. A joint publication of the WHO and the special programme for research and training in tropical disease 2009.
  3. Ruangjirachuporn W, et al. Circulating immune complexes in serum from patients with Dengue hemorrhagic fever. Exp. Immunol 1979;36:46-53.
  4. Gulati S, Maheswari A: A typical Manifestation of Dengue. Tropical Medicine and International Health. Vol.12, no 9, 2007:p.1087-1095.
  5. Teoh SCB, (the eye institue Dengue related ophtalmic complications workgroup) et al. Dengue Chorioretinitis and Dengue –Related Ophthalmic Complications. Dengue Bulletin 2006; 30. p.184-190
  6. Prathima P T et al. Hepatic Disfunction and Acute Renal Failure Requiring Heamodialysis in Dengue Hemorrhagic Fever- A Rare Complication. Journal of Evolution of Medical and Dental Sciences 2013; Vol 2, Issue 26, July 1; Page 4725-4728.
  7. Mei Chuan Kuo, Po Liang Lu et al: Impact of Renal Failure on the Outcome of Dengue Viral Infection. Clinical Journal of the American Society of Nephrology 2008 Sep : 3(5): 1350-1356.
  8. Oliveira JFP, Burdmann EA. Dengue-associated acute kidney injury. Clinical kidney journal 2015, vol 8, no.6, 681-685.
  9. Lizarraga KJ, Nayer A. Dengue-associated kidney disease. Journal of Nephropathology 2014; 3(2): 57-62. DOI:10. 12860/jnp.2014.13.
  10. Heart Disease Facts and Statics. U.S. Departement of the Health and Human Service 2015.
  11. Waly TM. Again Let’s Discuss About DHF Pathogenesis and Pathophysiology. ( accessed on August 6th 2017)

Filed under Artikel 48 - Impaired Renal Heart and Liver Functions Due to Complications of Dengue Infection Treated With Heparinization and Hemodialysis : Comments (0) : Jul 22nd, 2018