Bilateral eyelid ecchymosis and subconjunctival haemorrhage manifesting as presenting feature in a case of dengue haemorrhagic fever

Introduction

Periorbital ecchymosis with eyelid haematomas are encountered mostly after trauma. ¹ In both upper and lower eyelids, the orbital septum creates two anatomical layers, the preseptal and postseptal spaces. An acute haemorrhage in the preseptal space, while dramatic in appearance, may not be as threatening to vision as a postseptal haemorrhage. ² Various causes ³ of eyelid haemorrhage include orbit/eyelid surgery, peribulbar injections, orbital varices, lymphangiomas ⁴ and arteriovenous malformations, anticoagulative medication, blood dyscrasias, ⁵ orbital pseudotumors ⁶ and idiopathic factors.

Dengue as a cause for eyelid haemorrhage and ecchymosis is usually not considered. Dengue fever is a mosquito-borne disease caused by a Flaviviridae virus and is transmitted to humans by the bite of an infected female Aedes aegypti mosquito. ⁷ Clinical manifestations of dengue are related to the bleeding diathesis from thrombocytopenia and include skin haemorrhages (petechiae and purpura), gum bleeding, epistaxis, menorrhagia, gastrointestinal (GI) haemorrhage and haematuria. ⁸

We report a case of a rare ocular manifestation of bilateral eyelid ecchymosis and subconjunctival haemorrhage as a presenting feature in a patient with dengue fever.

Case report

A 17-year-old boy presented to the emergency department with complaints of redness in both eyes and vomiting. On ocular examination in the emergency department, the patient had bilateral eyelid ecchymosis (Figure 1) in an arcuate fashion with subconjunctival haemorrhage (Figure 2). Redness in the eyes was not associated with any discharge. There was no history of trauma or foreign body in the eyes. Both ocular globes were normal with no restriction of motility. Visual acuity was 6/6 in both eyes. Pupillary responses and intraocular pressure were normal. A dilated fundus examination revealed no abnormality. The patient was provisionally diagnosed to have idiopathic ocular haemorrhage and was given conservative treatment in the form of cold packs and was asked to come for a review in the eye OPD after 1 week. OPEN IN VIEWER

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Figure 2.

Bilateral subconjunctival haemorrhage.

In the emergency department, on the same day, the patient was given supportive treatment in form of antiemetics. A full blood count was ordered and he was kept under observation. The next morning the patient developed a fever and became drowsy and disoriented. Vital signs showed a pulse rate of 100/min and blood pressure of 90/56 mmHg. He was admitted and transferred to intensive care and given a noradrenaline infusion and other supportive treatment in form of antipyretics and volume replacement. A significantly reduced platelet count of 11000/µL was reported, suggestive in our environment, of dengue haemorrhagic fever (DHF). The patient was transfused 1 unit of platelet concentrate. The following day he developed severe abdominal pain and had blood in his stools. A further unit of platelet concentrate and 1 unit of packed cells were transfused. An ultrasound scan revealed bilateral pleural effusion, gallbladder wall oedema, enlarged hypoechoic liver and free fluid in the abdomen. Dengue serology was positive. The patient’s condition improved but his ocular findings persisted for a while, albeit reduced in extent and severity.

Discussion

Classic dengue fever is characterised by a typical viral fever, frontal headache, retro-orbital pain, nausea, vomiting, joint pains, weakness, associated with the effects of thrombocytopenia. ⁹

The usual sequence of events during dengue viral infection is an acute febrile stage lasting 2–7 days overlapping with classic clinical illness which may or may not be followed by recovery. During defervescence some patients develop DHF which may progress to dengue shock syndrome (DSS). ¹⁰

Dengue has a varying spectrum of ocular manifestations with blurring of vision being the most common ocular complaint, the commonest reason being dengue-related maculopathy. ¹¹ The next common symptom is central scotoma corresponding to the areas of oedema and haemorrhage on the macula. ¹² Uveitis, optic neuropathy and vitreous haemorrhage are some less common ocular manifestations of dengue fever. In this wide spectrum of ocular manifestations, subconjunctival haemorrhage is very common. ¹³

Ophthalmic manifestations, however, are rare as a presenting feature. Review of the literature reveals a single other case of dengue fever causing eyelid ecchymosis being reported. ¹⁴ Bilateral eyelid ecchymosis has not yet been described as a presenting feature of dengue.

The present case is incongruous in the way that the systemic involvement at the time of presentation was not proportionate to the ocular findings. Eyelid and subconjunctival haemorrhages were present without any retinal haemorrhages. Vomiting may have a role in development of haemorrhages but it is unlikely to be the predominant factor unless it is explosive and severe. Vigorous rubbing could, however, explain the lid involvement without retinal affectation.