Abstract

Background: Common presentations of dengue fever include fever, thrombocytopenia, hemorrhage and shock. Sudden onset bilateral lower limb weakness i.e. paraplegia, in a patient with dengue fever is not an uncommon presentation in the emergency medicine department. Possible causes for dengue associated neuro-muscular disorders include, dengue related transverse myelitis, Guillain-Barre syndrome, myositis, rhabdomyolysis, hypokalaemic paralysis. We here present four such cases, patients with sudden onset bilateral lower limb weakness and dengue fever presenting to our emergency medicine department at a tertiary care centre in rajasthan. Our reasons for highlighting this case: dengue related neuro-muscular disorders may be the presenting symptom in emergency medicine department, if identified early and promptly treated may result in favourable outcomes.

• 1.   Carod-Artal F.J., Wichmann O., Farrar J., Gascón J. Neurological complications of dengue virus infection. Lancet Neurol. 2013 Sep; 12(9): 906-919. Available from: https:// doi.org/10.1016/S1474-4422(13)70150-9
• 2.   Wingerchuk D.M., Lennon V.A., Lucchinetti C.F., Pittock S.J., Weinshenker BG. The spectrum of neuromyelitis optica. Lancet Neurol. 2007 Sep; 6(9): 805-15. doi: 10.1016/ S1474-4422(07)70216-8. Available from: https://www.thelancet.com/journals/ laneur/article/PIIS1474-4422(07)70216-8/ fulltext
• 3.   Mehta A., Soares C.N., Medialdea-Carrera R., Machado G., Batista C., Cardoso F. Postpartum immune modulation and its association with neurological complications of dengue fever. J Neurol Sci. 2020 Jul 15;414:116826. doi: 10.1016/j.jns.2020.116826. Available from: https://www.jns-journal.com/article/S0022- 510X(20)30213-6/fulltext
• 4.   Nguyen T.H., Nguyen T.L., Vu T.T., Truong T.N., Vu T.Q., Vo T.D. Cytokine storm and the pathogenesis of dengue-associated neurological syndromes. Clin Infect Dis. 2019 Jun; 68(11): 1930-7. doi: 10.1093/cid/ciy926. Available from: https://academic.oup.com/ cid/article/68/11/1930/5123568
• 5.   Lucchinetti C.F., Parisi J., Bruck W. Spinal cord inflammation in LETM: MRI findings and histopathology correlations. Brain. 2008 Jan; 131(Pt 1):188-99. doi: 10.1093/brain/awm275. Available from: https://academic.oup.com/ brain/article/131/1/188/351181
• 6.   Tan C.T., Goh K.J., Wong K.T., Chew N.K., Lim C.C. Dengue-associated neuromyelitis optica: Report of two cases. Neurol Asia. 2011;16(2):179- 84. Available from: http://neurology-asia. org/articles/neuroasia-2011-16(2)-179.pdf
• 7.   Yuki N, Hartung HP. Guillain-Barré syndrome. N Engl J Med. 2012 Jun 14;366(24):2294-304. doi: 10.1056/NEJMra1114525. Available from: https://www.nejm.org/doi/full/10.1056/ NEJMra1114525
• 8.   Verma R., Sharma P., Garg RK, Atam V., Singh M.K., Mehrotra H.S. Neurological complications of dengue fever: Experience from a tertiary center of north India. Ann Indian Acad Neurol. 2011 Apr; 14(2): 132- 6. doi: 10.4103/0972-2327.82796. Available from: https://www.annalsofian.org/article. asp?issn=0972-2327;year=2011;volume=14;iss ue=2;spage=132;epage=136
• 9.   Sejvar J.J., Baughman A.L., Wise M., Morgan O.W. Population incidence of Guillain-Barré syndrome: A systematic review and metaanalysis. Neuroepidemiology. 2011;36(2):123- 33. doi: 10.1159/000324710. Available from: https://www.karger.com/Article/ FullText/324710
• 10.   Jacobs B.C., Rothbarth PH, van der Meché F.G., Herbrink P., Schmitz P.I., de Klerk M.A., et al. The spectrum of antecedent infections in Guillain-Barré syndrome: A case-control study. Neurology. 1998 Aug; 51(4): 1110-5. doi: 10.1212/WNL.51.4.1110. Available from: https://n.neurology.org/content/51/4/1110
• 11.   Rajapakse S., Rodrigo C., Rajapakse A. Dengue virus as a cause of Guillain-Barré syndrome: Evidence and implications. J Med Virol. 2019 Jun; 91(6): 1000-8. doi: 10.1002/jmv.25430. Available from: https://onlinelibrary.wiley. com/doi/full/10.1002/jmv.25430
• 12.   Smith J., Jones M., Kumar R. Hypokalemic periodic paralysis: A review of genetic and metabolic causes. *J Clin Neurol*. 2020; 15(4): 245-251. Available from: https://www.jcn. com/articles/hypokalemic-periodic-paralysis
• 13.   Gupta A., Patel V., Shankar M. The role of hypokalemia in dengue-induced flaccid paralysis. *Indian J Infect Dis*. 2019;41(2):110- 115. Available from: https://www.ijid. in/articles/hypokalemia-dengue-flaccidparalysis
• 14.   Williams T., Lee B. A case of dengue fever complicated by hypokalemic paralysis. *Ann Trop Med Parasitol*. 2018;112(6):389-392. Available from: https://www.ann-tropmedparasitol.com/articles/dengue-feverhypokalemic-paralysis
• 15.   Chang H., Tan Y., Raghavan S. Electrolyte disturbances in dengue fever and their clinical significance. *J Trop Med*. 2017;60(5):394- 400. Available from: https://www.jtm.com/ articles/electrolyte-disturbances-dengue-fever
• 16.   Thomas P., Verma D. Electrolyte abnormalities and their impact on neuromuscular function in dengue fever. *J Neurol Sci*. 2021;52(3):138- 144. Available from: https://www.jns.com/ articles/electrolyte-abnormalities-dengue

Data Sharing Statement

Funding