Dengue hemorrhagic fever in patients with thalassemia.

Dengue hemorrhagic fever (DHF) causing by dengue viral infection is endemic in Thailand and Southeast Asian countries where thalassemias are prevalent. Thalassemic patients are also at risk to acquire dengue viral infections and to develop DHF. However, they can have different clinical manifestations and complications as well as more severity than general population requiring special awareness for proper diagnosis and management. We reported 20 thalassemic patients (10 boys and 10 girls) with DHF admitted to Department of Pediatrics, Siriraj Hospital during 1977 to 2001. Their ages ranged from 2-16 years (average 9.5 years). These cases included 5 cases of Hb H disease, 5 cases of Hb H with Hb Constant Spring (CS), 9 cases of beta-thalassemia/Hb E disease and 1 case of beta-thalassemia major. Two cases were in Grade I, 10 cases in grade II, 7 cases in Grade III and one case in grade IV severity of DHF. Though there were evidences of plasma leakage, instead of hemoconcentration, eighteen patients (90 percent) had hematocrit dropped at the range of 11-66% of the initial level. Fifteen patients (75 percent) required at least one packed red cell transfusion. Nine patients (45 percent) had mild bleeding symptoms, one of them had upper gastrointestinal hemorrhage requiring platelet concentrate transfusion. Two patients (10 percent) had serious complications including one with infection-associated hemophagocytic syndrome (IAHS) requiring intravenous immunoglobulin (IVIG) and packed red cell transfusion and the other had generalized seizure due to hyponatremia and hypotension. No mortality was observed among this group of patients. Early recognition of the DHF in thalassemic patients and appropriate packed red cell transfusion in patients with anemic symptoms is warranted to reduce morbidity and mortality in these patients.

An infant with minor blunt trauma with shock.

An infant who had a history of minor blunt trauma and later developed shock was reported. He was initially presented at the hospital because his mother noticed an abrasion on his nose that wouldn't stop bleeding for more than ten hours. The day before, his 3-year-old brother, imitating a wrestler, hit him in his abdomen and accidentally scratched his face, which brought him to the trauma emergency department the following and accidentally scratched his face, which brought him to the trauma emergency department the following day. The baby appeared active at first but looked pale; within 2 hours he became hypotensive and drowsy. His blood test had a prolonged bleeding time with very low fibrinogen and his blood concentration dropped 5%. The computed topographic scan located a chronic and subacute subdural hematoma without intraabdominal abnormalities. There had been previous reports of isolated head injuries which caused hypotension but our patient had a coincident coagulopathy also. The management and etiology of the patient were discussed. We concluded that in a traumaized child with shock major systems should be evaluated together because an isolated head injury can cuase hypotension and to emphasize the abdomen as the leading cause would only delay the management.