FATAL CASE OF DENGUE HEMORRHAGIC FEVER DURING AUTOLOGOUS HEMATOPOIETIC STEM CELL TRANSPLANTATION

Abstract

Introduction: Dengue is a viral disease caused by an arbovirus transmitted by mosquitoes,the Aedes aegypti, which proliferates in tropical climates. Factors such as urbanization, population growth, international travel, and climate change contribute to its rapid spread. It can progress with severe complications such as hemorrhage, liver failure, and shock. In the transplant population, fever, headache, muscle, and joint pain are less common, while the chance of developing ascites and pleural effusion is higher. Transplant patients have a higher incidence of severe dengue cases and a higher mortality. Its presentation and evolution in hematologic patients, especially in those undergoing bone marrow transplant, have not been well characterized in the literature, with few reports available to date. Objective: Describe a case of dengue hemorrhagic fever during autologous stem cell transplantation. Method: Review of medical records and literature. Result: A 58-year-old woman from São Paulo, Brazil, with hypertension and diabetes, was diagnosed in January 2023 with Anaplastic Large Cell Lymphoma ALK-negative. Received first-line treatment with 6 cycles of CHOEP and achieved complete response after 4 cycles, being referred for Autologous Hematopoietic Stem Cell Transplantation. Stem cell mobilization was done with GCSF, and hematopoietic progenitor cells were collected at 3.22×10e6/Kg.ECOG:0, was asymptomatic, and started conditioning with BuCyE. On day -5, she had an isolated fever spike without neutropenia or other symptoms.On day -2, she developed headache, abdominal pain, nausea, and diarrhea, with a positive NS1 antigen result, intravenous fluid therapy was initiated, and close monitoring for alarming symptoms of dengue fever commenced. Another fever episode on day -1, with lower back pain, abdominal pain, and elevated transaminases. On day 0, received hematopoietic progenitor cell infusion without complications, but maintained nausea, diarrhea, and abdominal pain. On day +1, she had another fever episode, gastrointestinal symptoms, and complained of arthralgia. Cefepime was started for febrile neutropenia, and cultures were collected. On day +2, due to worsening abdominal pain, an abdominal CT scan was performed, showing diverticulitis. She was transferred to the ICU due to hematuria and hematochezia. On day +4, she developed shock and required vasopressor support. The antimicrobial regimen was escalated to Meropenem and Vancomycin, and she received platelet transfusions (platelets 16,000). On day +5, she had massive hemoptysis, worsened respiratory pattern, and required orotracheal intubation. Laboratory tests showed acute renal failure, thrombocytopenia, and coagulation disorder. Dengue D was considered, and platelet transfusion, prothrombin complex concentrate, and measures for bleeding control were performed. There was suspicion of central nervous system bleeding, but hemodynamic instability prevented a brain CT scan. GCSF was initiated following protocol. The patient developed anisocoria, worsening of renal function, acute hepatitis, high fever, and exams were requested to investigate hemophagocytic lymphohistiocytosis triggered by Dengue. The patient had worsening ventilation, anuria, refractory metabolic acidosis, and died on day +8. Investigations into the source was made. Conclusion: Dengue virus infection can lead to severe complications, especially in patients undergoing Bone Marrow Transplantation, but specialized literature is scarce. A high degree of suspicion for dengue fever is imperative in patients from endemic areas, and pre-screening of both donors and recipients before transplantation should be done.