Indian Journal of Urology
CASE REPORT
Year
: 2020  |  Volume : 36  |  Issue : 2  |  Page : 136--137

Dengue shock syndrome after percutaneous nephrolithotomy leading to hematuria and renal failure: A rare complication


Manish Kumar, Aswathaman Karthikeyan, Vilvapathy Senguttuvan Karthikeyan 
 Department of Urology, Sri Narayani Hospital and Research Centre, Vellore, Tamil Nadu, India

Correspondence Address:
Aswathaman Karthikeyan
Department of Urology, Sri Narayani Hospital and Research Centre, Vellore, Tamil Nadu
India

Abstract

Hematuria following percutaneous nephrolithotomy (PCNL) is a dreaded complication. It necessitates blood transfusion in up to 10% of patients. It may be severe enough in <1% of patients to require angioembolization. We present a 50-year-old male who underwent PCNL for renal pelvic calculus. Since the day of the surgery, he had low-grade fever (100°F) which worsened (102°F) from the 2nd postoperative day. His preoperative urine culture was sterile. His platelet counts started dropping and NS1 antigen for dengue was positive. He also developed anemia (hemoglobin: 7g%) and platelet counts dropped to 17,000/cmm. He developed anuria on the 7th postoperative day, with serum creatinine rising to 7 mg%. He required two sessions of hemodialysis and urine output improved. There is a need for high index of suspicion for dengue, especially when fever and hematuria coexist in post PCNL patients.



How to cite this article:
Kumar M, Karthikeyan A, Karthikeyan VS. Dengue shock syndrome after percutaneous nephrolithotomy leading to hematuria and renal failure: A rare complication.Indian J Urol 2020;36:136-137


How to cite this URL:
Kumar M, Karthikeyan A, Karthikeyan VS. Dengue shock syndrome after percutaneous nephrolithotomy leading to hematuria and renal failure: A rare complication. Indian J Urol [serial online] 2020 [cited 2022 Jan 22 ];36:136-137
Available from: https://www.indianjurol.com/text.asp?2020/36/2/136/281957


Full Text

 Introduction



Hematuria following percutaneous nephrolithotomy (PCNL) is a worrisome complication. Most of these patients settle with conservative management and serious bleeding necessitates angioembolization.[1],[2] Fever coexisting with hematuria following PCNL is rare. This case highlights the fact that dengue hemorrhagic fever (DHF) can present in a similar fashion and DHF is usually not thought of, in the immediate postoperative patient.

 Case Report



A 50-year-old man underwent right retrograde intrarenal surgery with double J stenting for the right renal calculus (15 mm × 10 mm) and left PCNL for the left renal pelvic calculus (20 mm × 15 mm). He had no comorbidities and his baseline serum creatinine was 0.9 mg/dl. His preoperative urine culture was sterile. Postoperatively, he had a mild fever of 100°F on the first day and started having multiple febrile spikes of 102°F and tachycardia (130 beats/min) from the 3rd day. He was detected to have thrombocytopenia (platelets 46,000/cmm) and dengue NS1-antigen tested positive. Urine culture and other tests for fever workup were negative and antibiotics were stopped. His platelet counts dropped to 17,000/cmm and hemoglobin dropped to 7 g/dl on the 8th postoperative day. He developed hematuria and was transfused four units of platelets. He developed dengue shock syndrome, hematuria with clot retention requiring bladder washes, and diffuse capillary leak syndrome. He went in to anuria and his serum creatinine rose to 7 mg/dl. He underwent two sessions of hemodialysis. He received transfusion with four units of platelet, one unit of packed red blood cells, and two units of fresh frozen plasma. His kidneys recovered with conservative treatment and platelet counts improved. His serum creatinine reached normal levels (1 mg/dl) on the 12th postoperative day.

 Discussion



Post PCNL bleeding is serious in < 1% of patients requiring angiography and embolization.[1] Hemorrhage is the most significant complication following PCNL and transfusion rates reach up to 10%.[2] Causes include arteriovenous malformation or pseudoaneurysm and rarely venous laceration. Medical causes of bleeding are rare following PCNL and rarely thought of.

Infection following PCNL occurs in around 25% of patients and is usually managed with antibiotics.[2] When patient develops fever and hematuria, still infection is the first possibility as considered by most urologists. Only one case has been reported in the English literature to the best of our knowledge, in which fever and gross hematuria started from the 2nd postoperative day. He was diagnosed to have DHF. He settled on the 8th postoperative day.[3]

Our patient had fever from the first postoperative day. However, his platelet counts dropped on the 4th postoperative day and he tested positive for NS1 dengue antigen. Only on the 8th postoperative day, he developed hematuria, clot retention, and diffuse capillary leak syndrome. He developed anuria and required two sessions of hemodialysis. His condition resolved after 3 days and his creatinine reached baseline.

There are similar cases of DHF complicating percutaneous transluminal coronary angioplasty leading to coagulopathy.[4] Dengue virus-induced coagulopathy has also been reported in renal transplant recipients, post hysterectomy, and coronary artery bypass grafting.[3],[5] The management of dengue in the presence of capillary leak syndrome, and renal failure was challenging in our patient. Despite bleeding from the left kidney and presence of stent on the right side, patient developed acute renal shutdown probably secondary to capillary leak. Renal failure improved as he convalesced from dengue.

Dengue is a RNA virus with four serotypes. One serotype confers lifelong immunity against reinfection, but partial and temporary immunity against other serotypes. There are three phases in the infection; febrile phase characterized by fever, retro-orbital pain, flushing and rash. Second is the critical phase constituted by increased vascular permeability and plasma leak and can affect multiple organ systems. This is followed by convalescent phase where lost fluid returns to the circulatory system.[6]

 Conclusion



Hematuria following PCNL is a dreaded complication. Fever complicating hematuria post PCNL is rare. This patient highlights the need for high index of suspicion for dengue in endemic areas and especially when fever and hematuria coexist.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship: Nil.

Conflicts of interest: There are no conflicts of interest.

References

1Keoghane SR, Cetti RJ, Rogers AE, Walmsley BH. Blood transfusion, embolization and nephrectomy after percutaneous nephrolithotomy (PCNL). BJU Int 2013;111:628-32.
2Surgical Management of Upper urinary tract calculi. In: Wein AJ, Kavoussi LR, Partin AW, Peters CA, editor. Campbell-Walsh Urology, 11th ed. Philadelphia: Elsevier 2016. p. 1260-90.
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