Reshma Chillal, Hiremath Sagar, Jasir Usman.
Pediatric intensive care unit, Narayana Hrudalaya Hospital, Bangalore, India.
ADDRESS FOR CORRESPONDENCE
Reshma Chillal, A-008, Ozone Evergreens, Haralur Main Road, Bangalore - 560102, Karnataka.
Email: reshmachll99gmail.com | | Abstract | Background: Dengue is a major cause of paediatric hospitalization in endemic regions, presenting with atypical organ-specific complications that are easily overlooked. This series describes children with dengue and uncommon cardiac, neurological, and hepatobiliary involvement managed in a tertiary paediatric intensive care unit.
Case presentation: 11 children with serologically confirmed dengue infection were admitted to PICU of Narayana Health City, Bengaluru, during August–October 2024. The cohort manifested life-threatening complications, including myocarditis with cardiogenic shock requiring inotropes, levosimendan, and, in one case, VAECMO, ANEC; and hepatobiliary dysfunction with features suggestive of secondary HLH. All patients received protocol-based dengue management, individualized organ support, and, where indicated, immunomodulatory therapy with corticosteroids, ivig, and biologic agents such as anakinra. 3 had single-organ involvement, while others showed multisystem disease with significant plasma leakage. 7 out of 11 children to hospital discharge with some requiring prolonged ICU care.
Conclusions: Atypical manifestations of dengue involving the heart, liver, and central nervous system are not uncommon. Early recognition, appropriate referral to intensive care, meticulous fluid and haemodynamic management, and judicious use of immunomodulation are essential to improving outcomes in such cases. | | | | Keywords | Dengue, Myocarditis, HLH, ANEC, anakinra.
Abbreviations
HLH - Hemophagocytic lymphocytic histiocytosis
IVIG - Intravenous Immunoglobulin
PLEX - Plasma Exchange
CRRT - Continuous Renal Replacement Therapy
ANEC - Acute Necrotising Encephalitis
SGOT - Serum glutamic oxaloacetic transaminase
SGPT - Serum glutamic pyruvic transaminase
IVMPS - Intravenous methylprednisolone
VA ECMO - Venoarterial Extra-Corporeal Membrane Oxygenation
POCUS - Point of Care Ultrasound | | | | Introduction | | Dengue, with a mortality rate of around 2.5%, it continues to be a major public health concern with children particularly at risk.1 The clinical spectrum ranges from mild, self-limiting illness to severe disease characterized by haemorrhagic manifestations, plasma leakage, and organ failure. The exact mechanism of severe manifestations of dengue is unknown but increasing evidence indicating that they are largely immunopathologically mediated affecting multiple organs leading of death.2 No specific therapy for dengue is currently available; therefore, management remains supportive and focuses on meticulous fluid therapy, haemodynamic optimization, and organ support. This case series describes 11 children with serologically confirmed dengue who presented to a single tertiary‑care centre during the same epidemic season with varied cardiac, hepatic, and neurological complications requiring individualized intensive care management. | | | | Case Report | Group A: Myocardial dysfunction
Four children aged 6–12 years with dengue were referred with persistent shock despite guideline‑directed fluid resuscitation. One child was intubated while the others were receiving supplemental oxygen, and inotropic support viz epinephrine
POCUS demonstrated a plethoric inferior vena cava, depressed left ventricular systolic function (ejection fraction ≤25%), and bilateral pulmonary edema with confluent B‑lines. ABG revealing severe metabolic acidosis with hyperlactataemia, hypoxia, and hypercapnia, reflecting impaired peripheral perfusion and cardiogenic pulmonary edema. Inflammatory markers, including C‑reactive protein and ferritin, were modestly elevated.
Challenge was fluid titration to keep macrocirculation intact with support of Inotrope and ventilation. All patients received levosimendan infusion and immunomodulation with IVMPS (10-30 mg/kg) and ivig (2 g/kg). Three children demonstrated progressive improvement in cardiac function and peripheral perfusion, but one went on to VAECMO due to refractory hypotension with persistently poor ventricular function despite maximal medical therapy. All 4 of them survived.
Myocarditis has been reported at approximately 11.3% dengue patients.3 Management is primarily supportive and aims to maintain adequate organ perfusion while the acute inflammatory phase resolves. Although data for corticosteroids versus ivig in dengue myocarditis are lacking, immunomodulation is often considered in fulminant cases given the suspected immune‑mediated pathophysiology.4,5
Table 1. Details of patient admitted with myocardial dysfunction.
| Parameters(at admission) |
Patient 1 |
Patient 2 |
Patient 3 |
Patient 4 |
| Age (in years) |
6 |
9 |
13 |
8 |
| Gender |
Male |
Female |
Female |
Male |
| Day of illness |
4 |
4 |
5 |
5 |
| Hb (at admission)(g/dl) |
14 |
13.1 |
13.6 |
12.1 |
| PCV (%) |
42.7 |
43 |
42.3 |
37 |
| Platelet count (/cumm) |
50000 |
35000 |
150000 |
600000 |
| >CRP(mg/dl) |
8.3 |
1.8 |
0.725 |
1.8 |
| Ferritin (ng/ml) |
211 |
2100 |
554 |
4080 |
| SGOT/SGPT |
129/97 |
86/90 |
107/83 |
301/111 |
| Creatinine(mg/dl) |
0.65 |
0.79 |
0.86 |
0.69 |
| pH |
7.3 |
7 |
7.29 |
7.11 |
| Base excess |
-7 |
-19.7 |
-17.5 |
-14.3 |
| Lactate(mmol/l) |
3.9 |
8.3 |
13.5 |
6.9 |
| Pao2 (mmhg) |
55 |
53 |
53 |
56 |
| Pco2(mmhg) |
35 |
47 |
19 |
48 |
| MPS |
30 mg/kg (3 doses) |
10 mg/kg (3 doses) |
10 mg/kg (3 doses) |
10 mg/kg (1 dose) |
| IVIG |
2 g/kg |
2 g/kg |
1 g/kg |
2 g/kg |
| ECMO |
No |
No |
No |
Yes |
| Levosimendan(0.1 mcg/kg/min) for 48 hrs |
Yes |
Yes |
Yes |
No |
| Invasive mechanical ventilation |
Yes |
Yes |
Yes |
Yes |
| CRRT |
No |
No |
No |
No |
| Outcome |
Discharge |
Discharge |
Discharge |
Discharge |
Group B: HLH
Six children aged 9-14 years presented with fever, myalgia, vomiting, abdominal distension, and varying degrees of encephalopathy having deranged liver function, elevated ferritin, metabolic acidosis, and hyperlactataemia; hyperammonaemia requiring CRRT and PLEX suggestive of secondary HLH.
Immunomodulation included intravenous methylprednisolone (IVMPS), anakinra, and PLEX, with dosing of anakinra and steroids decided in consultation with paediatric rheumatology. CRRT and PLEX were initiated according to severity of organ dysfunction. Despite efforts, this subgroup had highest mortality with 4 of 6 succumbing. This observation is consistent with reports of Bhat et al6 who demonstrated that extreme hyperferritinemia (ferritin >10,000 ng/mL) in children with severe dengue is associated with worse outcomes. Severe dengue is characterized by an inflammatory response with elevated levels of cytokines which contribute to endothelial injury, increased vascular permeability, and MODS. anakinra, IL‑1 receptor antagonist can attenuate the downstream inflammatory cascade, limit hepatocellular necrosis, and help stabilize endothelial function. High mortality associated with hyperferritinemia and HLH‑like presentations indicates early recognition, rapid referral to tertiary care, and timely initiation of advanced organ support and immunomodulation.6
Table 2. Details of patients admitted with hepatobiliary dysfunction/HLH.
| Parameters(at admission) |
Patient 1 |
Patient 2 |
Patient 3 |
Patient 4 |
Patient 5 |
Patient 6 |
| Age (in years) |
14 |
12 |
10 |
9 |
5 |
6 |
| Gender |
Male |
Female |
Female |
Female |
Male |
Male |
| Day of illness |
5 |
4 |
4 |
4 |
3 |
4 |
| Hb (at admission)(g/dl) |
14.9 |
14.8 |
14 |
14.4 |
13 |
13.2 |
| PCV (%) |
45.2 |
46.2 |
42.4 |
44 |
38.6 |
43.1 |
| Platelet count (/cumm) |
25000 |
35000 |
50000 |
10000 |
25000 |
30000 |
| >CRP(mg/dl) |
113 |
3.09 |
2.9 |
9.4 |
3.28 |
50 |
| Ferritin (ng/ml) |
23900 |
94200 |
24100 |
31200 |
18100 |
45500 |
| SGOT/SGPT |
2809/951 |
7295/1925 |
2518/1249 |
4991/2237 |
4536/1280 |
5000/2300 |
| INR |
1.92 |
2.59 |
2.7 |
1.87 |
2.24 |
2.73 |
| Creatinine(mg/dl) |
0.65 |
0.74 |
0.83 |
0.78 |
0.43 |
0.92 |
| pH |
7.06 |
7.14 |
7.28 |
0.31 |
7.25 |
7.1 |
| Base excess |
-25 |
-21 |
-13.1 |
-13 |
-11.4 |
-17.3 |
| Lactate(mmol/l) |
11 |
9.5 |
4.4 |
5 |
6.4 |
7 |
| Pao2 (mmhg) |
55 |
100 |
49 |
332 |
54 |
| Pco2(mmhg) |
18 |
23 |
29 |
26 |
36 |
38 |
| MPS |
Yes |
Yes |
No |
Yes |
Yes |
No |
| IVIG |
No |
No |
No |
1 g/kg |
1 g/kg |
No |
| ECMO |
No |
No |
No |
No |
No |
No |
| Levosimendan(0.1 mcg/kg/min) for 48 hrs |
No |
No |
No |
No |
No |
No |
| Invasive mechanical ventilation |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
| CRRT |
Yes |
Yes |
No |
Yes |
No |
No |
| Outcome |
Survived |
Non Survivor |
Non Survivor |
Non Survivor |
Survivor |
Non Survivor |
| Anakinra |
Yes |
Yes |
No |
Yes |
No |
No |
| Plex |
Yes |
Yes |
No |
Yes |
No |
No |
| Bleeding Tendency |
No |
No |
No |
Yes |
Yes |
Yes |
| Transfusions |
No |
No |
Yes |
Yes |
Yes |
Yes |
Group C: Acute necrotizing encephalopathy of childhood (ANEC)
A 12‑year‑old girl with dengue NS1 antigen positive presented with a 4‑day history of fever, altered sensorium, and seizures was comatose and required immediate intubation. MRI demonstrated bilateral thalamic hyperintensities on T2‑weighted and FLAIR sequences, characteristic of ANEC. She was treated with IVMPS at 30 mg/kg/day for 5 days and ivig at 2 g/kg. The patient was successfully extubated after 3 days of ventilation but was discharged with residual neurological deficits.
Immunomodulatory treatment is central component of management in ANEC, although guidelines are lacking. In the present case, a combination of pulse‑dose corticosteroids and ivig was used, consistent with previous case reports and series like Okumura et al.8
Figure 1. MRI finding of the patient with ANEC showing T2 Flair image with bilateral thalamic hyper intensities.
 | | | | Conclusion | | Atypical manifestations of paediatric dengue, including myocardial dysfunction, HLH‑like hyperinflammatory hepatobiliary disease, and ANEC, were observed in this case series from a single tertiary‑care centre during one epidemic season. These phenotypes are associated with high risk of organ failure and mortality, especially in children with hyperferritinemia and hepatic dysfunction. Early recognition of these complications, prompt referral to centres with paediatric intensive care capability, meticulous hemodynamic and organ support, and judicious use of immunomodulatory therapies—such as corticosteroids, ivig, anakinra and PLEX tailored to the organ system involved and disease severity-are essential to optimizing outcomes. | | | | Compliance with Ethical Standards | | Funding None | | | | Conflict of Interest None | | |
- Shewale NS. Clinical profile and outcome of children admitted for dengue with warning signs and severe dengue. MedPulse Int J Pediatr. 2017; 3(1):23-7.
- Pradesh RU, Pradesh M, Pradesh A, Pradesh A, Nadu T. Indian health: the path from crisis to progress.
- Vuppali NK, Pandey A, Torkadi R, Pallapotu S, Ramadoss N, Dharmapuram AK, Varma S. Fulminant dengue myocarditis requiring VA ECMO support. The Egyptian Journal of Critical Care Medicine. 2018 Dec; 6(3):155-6. [CrossRef]
- Bagde A. Child with fulminant dengue myocarditis survived by ECMO support. Journal of Pediatric Critical Care. 2016 Oct 1;3(4):109-11. [CrossRef]
- Lee CH, Teo C, Low AF. Fulminant dengue myocarditis masquerading as acute myocardial infarction. Int J Cardiol. 2009; 136: e69-e671. DOI: 10.1016/j.ijcard.2008.05.023 [CrossRef] [PubMed]
- Bhat C, Martin F, Chennakeshava D, Ramanan AV, Ramesh D, Viswanathan P, Shetty R. Role of anakinra in the management of children with severe dengue. Archives of Disease in Childhood. 2025 Dec 1;110(12):977-82. [CrossRef] [PubMed]
- Kumar S, Navid A, Sharma R, Suthar R, Vyas S, Angurana SK. Acute necrotizing encephalopathy of childhood: a rare neurological manifestation of dengue. Annals of Indian Academy of Neurology. 2021 Sep 1;24(5):828-31. [CrossRef] [PubMed] [PMC free article]
- Okumura A, Mizuguchi M, Kidokoro H, Tanaka M, Abe S, Hosoya M, et al. Outcome of acute necrotizing en-cephalopathy in relation to treatment with corticosteroids and gammaglobulin. Brain Dev. 2009;31:221-7. doi: 10.1016/j.braindev.2008.03.005. [CrossRef] [PubMed]
DOI: https://doi.org/10.7199/ped.oncall.2027.12
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| Cite this article as: | | Chillal R, Sagar H, Usman J. Atypical Severe Organ Involvement in Paediatric Dengue: A Case Series from a Tertiary Intensive Care Unit in South India. Pediatr Oncall J. 2026 Apr 13. doi: 10.7199/ped.oncall.2027.12 |
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