A 48-year-old Indian woman presented with complaints of fever and body aches for 3 days, and pain in the lower abdomen with inability to move both lower limbs for 1 day. The patient had urinary incontinence and constipation. There was no history of seizures, recent vaccinations, diarrhea, or respiratory infection. The patient had not suffered from any significant illness in the past. There was no relevant family history. At presentation, the patient was febrile (oral temperature 102 °F) and had mild conjunctival suffusion. Higher mental functions, speech, and cranial nerves were normal with grade 0/5 power in both lower limbs. Lower limbs were hypotonic with absent deep tendon jerks and mute plantars on both sides. Sensation to light touch was diminished, while pain, temperature, and posterior column sensations were lost below the umbilicus (T10 level). A provisional diagnosis of acute flaccid paraplegia with bladder and bowel involvement due to acute transverse myelitis was considered.
Laboratory investigations done outside the hospital had shown a rapid fall in platelet count from 130,000/mm3 to 12,000/mm3. Investigations in our hospital showed a normal white blood cell count and low platelet count (9410/mm3 and 40,000/mm3, respectively). Both peripheral blood smear and an immunochromatographic test (OptiMAL-IT, DiaMed AG, Cressier s/Morat, Switzerland) were negative for malaria along with a negative rapid test and IgM serology for scrub typhus. Dengue-specific NS1 antigen and IgG, and IgM antibodies were positive by a commercial micro-well enzyme immunoassay kit. Blood sugar, serum creatinine, serum electrolytes, and serum bilirubin were normal with raised aminotransferases. Bleeding time, clotting time, prothrombin time, international normalized ratio (INR), and activated partial thromboplastin time (aPTT) were normal. Ultrasonographic examination of the abdomen showed fatty liver and mild ascites with bilateral pleural effusion. Fundus examination was normal. Magnetic resonance imaging (MRI) of the dorsolumbar spine was suggestive of intradural, extramedullary hematoma at D7–D8 vertebral level (Fig. 1).
The diagnosis was revised to dengue hemorrhagic fever with thrombocytopenia with acute flaccid paraplegia due to compressive myelopathy caused by spontaneous spinal intradural hematoma at D7–D8 vertebral level. The patient received symptomatic treatment for dengue fever and intravenous methylprednisolone 1000 mg daily. She was given multiple transfusions of platelet concentrates and was taken for emergency surgery on the second day of hospitalization after raising the platelet count above the critical level. Intraoperative findings showed a cord bulge at D7–D8–D9 vertebral level with an intradural hematoma on the posterior and lateral aspects of the cord. Flimsy adhesions were present over nerve roots. D7–D8 laminectomy with excision of the clot and dural repair was performed. Repeat MRI examination of the dorsolumbar spine after 3 days was suggestive of a small hematoma in the anterior epidural space with cord edema with postoperative changes at the D7–D8 vertebral level (Fig. 2). Methylprednisolone was discontinued on the fifth day. The postoperative period was uneventful with good improvement in constitutional symptoms as well as sensory symptoms, but negligible improvement in paraplegia with a change in muscle power from grade 0/5 to grade 1/5. The patient was discharged in stable condition on the 15th day after surgery. At the time of discharge, the patient could accept oral feeds and her bladder and bowel functions had improved. She was advised limb strengthening exercises along with a foot splint. The patient showed marginal improvement in paraplegia during a follow-up period of 1 year.