Hypopituitarism in a Dengue Shock Syndrome Survivor without known Pituitary Adenoma

Dengue infection is endemic in South East Asia and parts of the Americas. Dengue hemorrhagic fever is characterized by vascular permeability, coagulation-disorders and thrombocytopenia, which can culminate in hypotension i.e. dengue shock syndrome. Hypopituitarism arising as a complication of dengue is extremely rare. Hemorrhagic pituitary apoplexy of pre-existing pituitary adenomas has been rarely reported in dengue. We describe an uncommon case of hypopituitarism in a dengue shock syndrome survivor without known pituitary adenoma. A 49 years old nulliparous lady (from Kuala Lumpur, Malaysia) presented with typical symptoms of hypocortisolism. Postural hypotension was evident with normal secondary sexual characteristics. Further history revealed that she survived an episode of dengue shock syndrome 6 years ago where premature menopause developed immediately after discharge, and subsequently insidious onset of multiple hormonal deficiencies indicative of panhypopituitarism. There were no neuro-ophthalmological symptoms suggestive of pituitary apoplexy during hospitalization for severe dengue. Magnetic resonance imaging of the pituitary 6 years later revealed an empty sella. Autoimmune screen and anti-thyroid peroxidase antibodies were negative. We describe a rare possible causative association of severe dengue with panhypopituitarism without known pituitary adenoma, postulating pituitary infarction secondary to hypotension (mimicking Sheehan’s syndrome), or a direct viral cytopathic effect. Subclinical pituitary apoplexy secondary to asymptomatic pituitary hemorrhage however cannot be excluded. Future research is required to determine the need for and timing of pituitary axis assessment among dengue shock syndrome survivors.

Pattern of Rheumatic Fever in Egyptian Children Younger Than 5 Years.

Aims: Acute rheumatic fever (ARF) is common between 5-15 years, uncommon with different presentation 25 in children below 5 years. The aim of this study is to assess the frequency and characterize the pattern of 26 presentation of rheumatic fever (RF) in Egyptian children younger than 5 years. Study Design: Retrospective study. Place and Duration of the Study: Pediatric department, cardiology division, Cairo University Children’s Hospital, 5 years follow up. Methodology: We retrospectively reviewed the pre-completed data of 766 patients following up in the rheumatic fever clinic. Those with incomplete medical records were excluded. We compared between children younger than 5 years and those who are 5 years or older as regards their demographic data, clinical presentations, laboratory findings and echocardiographic findings. Results: We enrolled 667 patients; 17 of them (2.5%) were younger than 5 years (mean age 3.82± SD 0.393 years). The group of patients younger than 5 years old; included 10 females (58.8%) and 7 males (41.2%). Positive family history was encountered in 6 patients (37.7%). The most common presentations of the younger age group of patients were arthritis in 12 patients (70.5%), followed by carditis in 5 patients (29.4%), chorea in 3 patients (17.6%), and skin manifestations in 2 patients in the form of erythema marginatum (11.7%). Subclinical carditis was more common in younger children than the older group, with more severe valve affection. None of the patients in the younger age group had recurrence of the RF during a period of 5 years follow up while recurrences were encountered in 16 patients (2.5%) of the older age group. Conclusion: ARF can occur in children younger than 5 years. The possibility of rheumatic fever should be adequately investigated in those young children presenting with arthritis, chorea, or skin rash especially in developing countries like Egypt. Echocardiography is an essential tool to diagnose cases with5 subclinical carditis.

MR imaging of cerebral and cerebellar hypervascularity associated with status epilepticus: case report.

A 20 year old male presented to the emergency department with generalized tonic clonic convulsions and up rolling of eye balls. He had history of seizure disorder for three years and on regular medical treatment and is compliant to medication. A non-contrast CT scan of the head was only done on 14th day of admission which showed hypodense areas in the right and left cerebellar hemisphere. MR imaging was performed four days later revealed high signal intensity in the both cerebellar hemispheres, both external capsules, both occipital and right parietal regions on fluid-attenuated inversion recovery (FLAIR). The post contrast MR imaging revealed diffuse cerebral and cerebellar hypervascularity in the similar region. This change of diffuse hypervascularity of both cerebral and cerebellar associated with seizure activity on post-contrast magnetic resonance imaging (MRI) has not been reported in any literature.