Abstract
Dengue is endemic in tropical regions and bleeding, ranging from minor to life-threatening, is a dreaded complication. With the increasing incidence of atherosclerotic cardiovascular disease in low- to middle-income countries where Dengue is prevalent, whether to stop or continue antiplatelet agents in patients with thrombocytopenia is a clinical conundrum.
Case presentation
An 88-year old man with a history of non-ST-elevated myocardial infarction (2023), hypertension and dyslipidaemia presented with a four day history of fever with nausea. A NS1 antigen test done on the third day was positive and his platelet count was found to be low (76× 109/L).
On admission, his blood pressure was 110/63 mmHg and pulse rate was 110 bpm. His routine medication included aspirin 75 mg nocte, clopidogrel 75 mg nocte, atorvastatin 40 mg nocte as well as his antihypertensive medication. Aspirin and clopidogrel were withheld forthwith.
Further investigations revealed the following (Table 1):
Summary of investigations.
The platelet counts continued to drop, reaching a nadir of 15× 109/L after two days.
Repeated point of care ultrasound scans to detect early plasma leakage did not show evidence of leaking.
Troponin I levels were elevated but his 2D echocardiogram showed a ejection fraction of 60% without hypokinesia; dengue myocarditis was favoured over an acute coronary syndrome.
As liver function tests were deranged more than three times the upper limit, his atorvastatin was also withheld.
However, during his hospital stay, there was only intermittent gum bleeding, and no other haemorrhage. He remained haemodynamically stable. Two doses of oral tranexamic acid were administered as a precautionary measure.
On review after discharge, atorvastatin was restarted once his liver function had normalized, and aspirin was restarted once the platelet count was >100× 109/L; finally, at two months’ follow up, there were no recurrent cardiovascular events.
Discussion
Preserved haemostatic function persisted in our patient despite severe thrombocytopenia, the severity of which does not alone predict the haemorrhage risk. 1 Bleeding in dengue is multifactorial, and vasculopathy, DIC, and consumptive coagulopathy act synergistically. Therefore, in a patient where these other factors have not set in, significant bleeding may not occur despite thrombocytopenia. However, continuing antiplatelet medication does pose an additional risk of bleeding. Conversely, stopping antiplatelet medication may cause an increase in thrombotic risk and cardiovascular events. Therefore interruption of anti-platelet therapy should be based on the balance between thrombotic and bleeding risks. A pragmatic approach, based on available evidence, is to stop anti-platelet therapy if clinically significant bleeding occurs or if thrombocytopenia reaches <100 × 109/L. Thereafter the patient should be closely monitored for the status of bleeding and haemodynamic stability. Unless the patient develops very severe bleeding or very low platelets (<20 × 109/L) there is no need for platelet transfusions. 2
Footnotes
Acknowledgments
None
Ethical considerations
Ethical approval was not required for this case report in accordance with institutional policy.
Consent for publication
Written informed consent was obtained from the patient for the anonymized information to be published in this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.