A 28-year-old man from Bangalore is admitted on day 6 of dengue fever with a platelet count of 50,000/μL and hematocrit of 48%. Which is the most common site of hemorrhage in dengue hemorrhagic fever?

Explanation

## Most Common Hemorrhagic Manifestation in DHF **Key Point:** Gastrointestinal hemorrhage is the most frequent site of bleeding in dengue hemorrhagic fever, occurring in 5–10% of DHF cases. ### Hemorrhagic Manifestations in Dengue **High-Yield:** Bleeding in DHF results from a combination of: - Thrombocytopenia (platelet count typically <100,000/μL) - Coagulopathy (prolonged PT/INR, low fibrinogen) - Endothelial dysfunction and increased vascular permeability - Direct viral invasion of capillary endothelium ### Frequency of Hemorrhagic Sites | Site | Frequency | Clinical Presentation | |---|---|---| | **Gastrointestinal** | 5–10% (most common) | Hematemesis, melena, hematochezia | | Skin/mucous membranes | 80% (petechiae, ecchymosis) | Painless, non-blanching rash | | Intracranial | <1% | Rare; associated with severe DIC | | Pulmonary | <1% | Hemoptysis; usually with DIC | | Retinal | <1% | Cotton-wool spots, retinal hemorrhages | **Clinical Pearl:** GI bleeding in dengue is often occult and detected by rising transfusion requirements or falling hemoglobin despite adequate fluid resuscitation. Melena indicates upper GI bleeding, while hematochezia may suggest lower GI or brisk upper GI source. **Mnemonic: GI BLEEDS MOST** — **G**astrointestinal tract, **I**s the most common hemorrhagic site in dengue. ### Why GI Tract is Most Vulnerable 1. **Large mucosal surface area** — extensive capillary bed exposed to viral antigen 2. **High endothelial permeability** — gastric and intestinal mucosa particularly susceptible 3. **Mechanical trauma** — vomiting and gastric acid erosion in setting of thrombocytopenia 4. **Platelet sequestration** — splenomegaly (present in ~50% of dengue) worsens thrombocytopenia ### Management Approach For GI bleeding in DHF: - Transfuse fresh frozen plasma (FFP) if PT prolonged - Transfuse platelets if count <50,000/μL with active bleeding - Avoid NSAIDs (increase bleeding risk) - Consider proton pump inhibitor for stress prophylaxis - Endoscopy only if bleeding is massive or uncontrolled [cite:Park 26e Ch 5]