Autopsy and Case Reports
Autopsy and Case Reports
Article / Clinical Case Report

Dengue fever as a cause of hemophagocytic lymphohistiocytosis

Noely Hein; Gabriel Heiser Bergara; Nathalie Bianchini Vieira Moura; Débora Morais Cardoso; Maki Hirose; Angela Espósito Ferronato; Antônio Carlos Pastorino; Denise Swei Lo; Alfredo Elias Gilio

Downloads: 7
Views: 1342


Dengue is endemic in more than 100 countries in Southeast Asia, the Americas, the western Pacific, Africa and the eastern Mediterranean regions. The virus is transmitted by Aedes mosquitoes. Dengue disease is the most prevalent arthropod-borne viral disease in humans and is a global and national public health concern in several countries. A seasonal pattern of dengue disease is consistently observed. The highest incidences usually correspond to the period of highest rainfall and humidity, providing suitable conditions for Aedes aegypti breeding and survival. In Brazil for instance it is from January to June. Dengue may cause marked changes in bone marrow that result in hypocellularity and, consequently, thrombocytopenia and leucopenia, along with an increase in hematocrit, which is secondary to capillary leakage. However, those abnormalities are usually self-limited, and do not warrant further investigations, such as a marrow biopsy or a myelogram. The occurrence of persistent reactive hemophagocytosis is uncommon and usually leads to serious adverse outcomes. The authors report the case of an 8-year old girl complaining of high-grade fever, malaise, headache, abdominal pain and a cutaneous rash. Laboratory examination revealed atypical lymphocytosis on peripheral blood count, hyperbilirrunemia, abnormal liver enzymes and clotting tests. Serology was positive for dengue. Because of the persistence of fever and laboratory examinations were consistent with hemophagocytic lymphohistiocytosis (HLH) a bone marrow aspiration was performed, which confirmed the presence of hemophagocytosis. Hence we report a rare presentation of dengue accompanied by self-limited HLH that hopefully evolve to favorable outcome.


Dengue, Lymphohistiocytosis, Hemophagocytic, Bone Marrow Examination, Diagnosis


Aricò M, Janka G, Fischer A, et al. Hemophagocytic lymphohistiocytosis. Report of 122 children from the International Registry. FHL study group of the histiocyte society. Leukemia. 1996;10(2):197-203. [PMID:8637226]

World Health Organization (WHO). Dengue: guidelines for diagnosis, treatment, prevention and control – new edition. Geneva: WHO/TDR; 2009.

Lei HY. Transient hemophagocytic activity in dengue immunopathogenesis. J Formos Med Assoc. 2009;108(8):595-8. []. [PMID:19666346]

Lu PL, Hsiao HH, Tsai JJ, et al. Dengue virus-associated hemophagocytic syndrome and dyserythropoiesis: a case report. Kaohsiung J Med Sci. 2005;21(1):34-9. []. [PMID:15754587]

Hadinegoro SRS. The revised WHO dengue case classification: does the system need to be modified? Paediatr Int Child Health. 2012;32(s1):33-8. []. [PMID:22668448]

Rueda E, Méndez A, González G. Síndrome hemofagocítico asociado con dengue hemorrágico. Biomedica. 2002;22(2):160-6. []. [PMID:12152482]

Vijayalakshmi AM, Ganesh VR. Hemophagocytic syndrome associated with dengue hemorrhagic fever. Indian Pediatr. 2009;46(6):545. [PMID:19556676]

Lai M, Stirnemann J, Bibi-Triki T, et al. Dengue associée à un syndrome néphrotique et à un syndrome d’activation macrophagique. Med Mal Infect. 2012;42(1):30-2. []. [PMID:22178240]

Tan LH, Lum LCS, Omar SFS, Kan FK. Hemophagocytosis in dengue: comprehensive report of six cases. J Clin Virol. 2012;55(1):79-82. []. [PMID:22789140]

De Koninck AS, Dierick J, Steyaert S, Taelman P. Hemophagocytic lymphohistiocytosis and dengue infection: rare case report. Acta Clin Belg. 2014;69(3):210-3. []. [PMID:24820925]

Srichaikul T, Punyagupta S, Kanchanapoom T, Chanokovat C, Likittanasombat K, Leelasiri A. Hemophagocytic syndrome in Dengue hemorrhagic fever with severe multiorgan complications. J Med Assoc Thai. 2008;91(1):104-9. [PMID:18386553]

Nakamura I, Nakamura-Uchiyama F, Komiya N, Ohnishi K. [A case of dengue fever with viral-associated hemophagocytic syndrome]. Kansenshogaku Zasshi. 2009;83(1):60-3. [PMID:19227227]

Soler Rosario Y, Garcia R, Fernandez Sein A. Dengue virus associated hemophagocytic syndrome in children: a case report. Bol Asoc Med P R. 2010;102(1):49-54. [PMID:20853575]

Jain D, Singh T. Dengue virus related hemophagocytosis: a rare case report. Hematology. 2008;13(5):286-8. []. [PMID:18854091]

Ribeiro E, Kassab S, Pistone T, Receveur MC, Fialon P, Malvy D. Primary dengue fever associated with hemophagocytic syndrome: a report of three imported cases, Bordeaux, France. Intern Med. 2014;53(8):899-902. []. [PMID:24739615]

Kapdi M, Shah I. Dengue and haemophagocytic lymphohistiocytosis. Scand J Infect Dis. 2012;44(9):708-9. []. [PMID:22264033]

Sharp TM, Gaul L, Muehlenbachs A, et al. Fatal hemophagocytic lymphohistiocytosis associated with locally acquired dengue virus infection - New Mexico and Texas, 2012. MMWR Morb Mortal Wkly Rep. 2014;63(3):49-54. [PMID:24452132]

Rouphael NG, Talati NJ, Vaughan C, Cunningham K, Moreira R, Gould C. Infections associated with haemophagocytic syndrome. Lancet Infect Dis. 2007;7(12):814-22. []. [PMID:18045564]

Wan Jamaludin WF, Periyasamy P, Wan Mat WR, Abdul Wahid SF. Dengue infection associated hemophagocytic syndrome: Therapeutic interventions and outcome. J Clin Virol. 2015;69:91-5. []. [PMID:26209387]

Simmons CP, Farrar JJ, van Vinh Chau N, Wills B. Dengue. N Engl J Med. 2012;366(15):1423-32. []. [PMID:22494122]

Henter JI, Samuelsson-Horne A, Aricò M, et al. Treatment of hemophagocytic lymphohistiocytosis with HLH-94 immunochemotherapy and bone marrow transplantation. Blood. 2002;100(7):2367-73. []. [PMID:12239144]

Nelson ER, Biebman HR, Chulajata R. Hematologic phagocytosis in postmortem bone marrows of dengue hemorrhagic fever: Hematologic phagocytosis in Thai hemorrhagic fever. Am J Med Sci. 1966;252(1):68-74. []. [PMID:4287434]


Publication date:

569635055ce02ae562000000 autopsy Articles

Autops Case Rep

Share this page
Page Sections