A 28-year-old man from Mumbai presents with fever, myalgia, and a petechial rash on day 6 of illness. Platelet count is 60,000/μL and AST is 320 U/L. Which is the most common site of haemorrhage in dengue haemorrhagic fever?

Explanation

## Most Common Site of Haemorrhage in Dengue Haemorrhagic Fever **Key Point:** The gastrointestinal tract is the most frequent site of overt bleeding in dengue haemorrhagic fever, accounting for 50–60% of all haemorrhagic manifestations. ### Epidemiology of Bleeding Sites in DHF | Site | Frequency | Clinical Presentation | |---|---|---| | **Gastrointestinal** | 50–60% | Haematemesis, melaena, occult GI bleed | | **Mucosal (gum, nose)** | 20–30% | Epistaxis, gingival bleeding | | **Skin** | 10–20% | Petechiae, purpura, ecchymosis | | **Intracranial** | 1–2% | Rare; subdural/subarachnoid haemorrhage | | **Pulmonary** | <1% | Haemoptysis; usually late/terminal | | **Adrenal** | <0.5% | Autopsy finding; rarely symptomatic | ### Why GI Bleeding Is Most Common 1. **Large mucosal surface area** → maximum exposure to thrombocytopenia and endothelial leak 2. **Acid-peptic stress** → gastric erosions triggered by: - Thrombocytopenia (platelet count <50,000/μL) - Endothelial dysfunction and increased vascular permeability - Possible direct viral invasion of gastric mucosa 3. **Timing** → typically occurs during critical phase (days 3–7) when platelet count nadir coincides with peak plasma leakage ### Clinical Pearl **High-Yield:** Haematemesis or melaena in a dengue patient with thrombocytopenia is a sign of severe DHF and warrants: - Urgent platelet transfusion (target >50,000/μL) - IV fluid resuscitation - Proton-pump inhibitor (omeprazole 40 mg IV BD) - Consideration of endoscopy if bleeding persists ### Why This Patient Fits the Profile - **Day 6 of illness** = critical phase (peak haemorrhagic risk) - **Platelet count 60,000/μL** = moderate thrombocytopenia; GI bleed risk rises sharply <50,000/μL - **AST 320 U/L** = hepatitis (common in dengue); liver dysfunction may impair coagulation factor synthesis - **Petechial rash** = evidence of microvascular bleeding; GI bleeding often accompanies cutaneous manifestations ### Why Other Sites Are Rare **Intracranial haemorrhage (1–2%):** - Occurs only in severe cases with profound thrombocytopenia and coagulopathy - Usually subdural or subarachnoid - Associated with very high mortality (>50%) - Far less common than GI bleeding **Pulmonary haemorrhage (<1%):** - Haemoptysis is rare and usually a late sign - Indicates severe dengue with multi-organ involvement - Often associated with acute respiratory distress syndrome (ARDS) **Adrenal haemorrhage (<0.5%):** - Autopsy finding; rarely diagnosed ante-mortem - Can cause acute adrenal insufficiency but extremely uncommon - Not a recognised bleeding manifestation in living patients **Warning:** ~~Intracranial bleeding~~ is NOT the most common site, even though it is the most feared. GI bleeding is far more frequent and is the leading cause of overt haemorrhage requiring transfusion. ### Management Algorithm ```mermaid flowchart TD A[Dengue + Thrombocytopenia]:::outcome --> B{Platelet count?}:::decision B -->|>50,000| C[Observe; transfuse if active bleed]:::action B -->|<50,000| D[Transfuse prophylactically]:::action D --> E{Haemorrhage present?}:::decision E -->|GI bleed| F[PPI + platelet transfusion + IV fluids]:::action E -->|Intracranial| G[Urgent neurosurgery consult]:::urgent E -->|Pulmonary| H[Respiratory support + transfusion]:::action F --> I[Endoscopy if persistent]:::action ``` [cite:Harrison 21e Ch 197; Dengue: Guidelines for Diagnosis, Treatment, Prevention and Control WHO 2009]