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CASE REPORT
Year : 2017  |  Volume : 10  |  Issue : 2  |  Page : 202-204  

Psychosis in dengue fever


1 Department of Psychiatry, Rural Medical College, Pravara Institute of Medical Sciences (DU), Loni, Maharashtra, India
2 Department of Pathology, Rural Medical College, Pravara Institute of Medical Sciences (DU), Loni, Maharashtra, India

Date of Web Publication14-Mar-2017

Correspondence Address:
Suprakash Chaudhury
Department of Psychiatry, Rural Medical College, Pravara Institute of Medical Sciences, Loni - 413736, Ahmednagar, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.202104

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  Abstract 

An 18-year-old male student developed abnormal behavior while undergoing treatment for dengue fever. He was ill-kempt, irritable and had auditory and visual hallucinations and vague persecutory delusions in clear sensorium with impaired insight. The psychotic episode had a temporal correlation with dengue fever. Psychiatric comorbidities of dengue fever including mania, anxiety, depression, and catatonia are mentioned in literature but the literature on the psychosis following dengue is sparse and only two cases have been reported. Patients presenting with acute onset of psychosis along with fever should be screened for dengue fever in areas where dengue is endemic.

Keywords: Auditory hallucinations, dengue fever, persecutory delusions, psychosis, visual hallucinations


How to cite this article:
Chaudhury S, Jagtap B, Ghosh DK. Psychosis in dengue fever. Med J DY Patil Univ 2017;10:202-4

How to cite this URL:
Chaudhury S, Jagtap B, Ghosh DK. Psychosis in dengue fever. Med J DY Patil Univ [serial online] 2017 [cited 2017 Nov 18];10:202-4. Available from: http://www.mjdrdypu.org/text.asp?2017/10/2/202/202104


  Introduction Top


Dengue is the most common human arbovirus infection. It is estimated that dengue infects 390 million persons per year (95% credible interval 284–528 million), out of which 96 million (67–136 million) manifest clinical symptoms of the disease.[1] Infection by arthropod-borne dengue virus may be asymptomatic or may lead to dengue fever or dengue hemorrhagic fever.[2] Mild dengue disease presents with biphasic fever, skin rash, headache, retro-orbital pain, photophobia, cough, vomiting, pain in muscles and joints, leukopenia, thrombocytopenia, and lymphadenopathy.[2] Other common symptoms include sore throat, altered taste, colicky abdominal and inguinal pain, and constipation.[2] Most patients suffering from dengue have symptoms of anxiety and depression.[3] In recent studies, the virus has been demonstrated to be neurotrophic and blamed for neurological sequelae such as Guillain–Barre syndrome, intracranial hemorrhage, ischemic stroke, isolated nerve palsies, and encephalopathy.[2],[4] Encephalopathy is an atypical manifestation of dengue disease and may present with depressed sensitivity, seizures, nuchal rigidity, pyramidal signs, headache, papilledema, myoclonus, and behavioral disorders. Postinfectious sequelae are mainly memory disturbance, dementia, mania, Reye's syndrome, and meningo-encephalitis.[2] A patient with dengue fever who developed psychosis is reported because of its rarity, with the written informed consent of the patient.


  Case Report Top


An 18-year-old male student from an agrarian rural family was hospitalized with a history of fever, headache, backache, and development of generalized weakness of 7 days duration. He was initially treated by a general practitioner for a week with analgesics and antibiotics, but he did not respond adequately to the treatment. His symptoms worsened which led to hospitalization. Physical examination on admission showed no abnormality except fever and tachycardia. Systemic examination including examination of the central nervous system was within normal limits. He became afebrile the day after admission, but in the ward was observed to remain aloof, did not sleep but always lay quietly on the bed. At times, he became agitated and talked to himself. He was then referred for psychiatric evaluation. He was a teetotaler, did not smoke or chew tobacco. There was no past or family history of mental illness. Mental status examination showed an ill-kempt individual who was passively cooperative and not in touch with reality. He answered simple questions in monosyllables and in low tone but otherwise remained mute. He was irritable. He had auditory and visual hallucinations, in that he saw some tantrik-like persons abusing him and threatening to kill him unless he accompanied them which he refused but became very frightened. He believed that some of his neighbors had cast a spell on him and so the “babas” had come to take him away for sacrifice (persecutory delusions). He was conscious, oriented and memory was unimpaired. Insight and judgment were impaired. Routine hemogram, platelet count, blood glucose, serum bilirubin, serum glutamic pyruvic transferase, urea, creatinine, and electrolytes were within normal limits. Serum glutamic oxaloacetic transaminase was 40.6 IU/L, serum lactate dehydrogenase (510 IU/L) was raised indicating hemolysis. Platelet count was 200 × 103. Serum dengue IgG and IgM antibodies tested were negative, but dengue NS1 antigen was positive initially. Subsequently, serum dengue IgG and IgM antibodies also tested were positive. Blood test for malarial parasite, hepatitis B surface antigen, and HIV antibody were negative. Computed tomography (CT) scan with contrast of the brain was within normal limits. He was diagnosed as a case of organic delusional (schizophrenia-like) disorder (F06.2) due to dengue viral fever based on International Classification of Diseases, Tenth Edition Diagnostic Criteria for Research [5] and positive blood test for dengue. He was treated with risperidone 2 mg twice daily. On review after a fortnight, he appeared to be more cooperative and communicative and his self-care had improved. His hallucinations and delusions had disappeared. He was advised to continue antipsychotic drugs for 1 more month. He was lost to further follow-up.





Psychiatric symptoms following dengue fever have been demonstrated to be associated with dengue encephalitis and are rare.[3],[6],[7],[8],[9],[10],[11],[12],[13],[14] Mania is the most common psychiatric disorder reported [10],[11],[12],[13] followed by anxiety and depression [3],[6] and catatonia.[14] In an earlier reported case of psychosis from India following dengue fever, the patient presented after 1 week of onset of fever with only persecutory delusions.[8] Another case reported in Malaysia presented with delusions of persecution along with auditory and visual hallucination 1 day after onset of dengue fever.[9] Thus, psychosis may be the early manifestation or late manifestation in the course of dengue which could possibly reflect the extent of cerebral involvement by the virus. The presentation in this case seems to be similar to that of the Malaysian report with psychosis as the early manifestation of dengue fever. The quick disappearance of psychotic symptoms in this case is in agreement with the earlier reports and is probably due to disappearance of dengue symptoms.

Psychiatric symptoms following dengue fever have been thought to be the result of intracranial hemorrhage, cerebral edema, metabolic disturbances, or encephalopathy.[7],[11] In the present case, there was no neurological deficit and sensorium was clear, CT scan of the brain was normal, and serum bilirubin, serum electrolytes, serum urea, and serum creatinine were all within the normal range; which would tend to rule out encephalitis and metabolic disturbances. This leaves us with the possibility that the psychotic symptoms most likely occurred due to the viral infection of the brain. Dengue virus infection of the nervous system can be partially understood by the three hypotheses of systemic viral infection:

  1. The sequential infection theory of Halsted
  2. The hyperendemicity theory of Rosen
  3. Occurrence of genetic recombination as a result of simultaneous infections by different serotypes.[15]


Pathophysiology of neurological involvement by dengue virus include: Direct tissue lesion caused by the virus, capillary hemorrhage, disseminated intravascular coagulation, and metabolic disorders.[2] Both the earlier patients of dengue fever associated psychosis were treated with atypical antipsychotic drugs along with treatment for dengue fever. The patients responded quickly to psychiatric treatment. In one case, the psychotic symptoms resolved in 3 days while the other patient showed significant improvement in a week.[8],[9]

According to some authors, the explanation for the low reporting of psychiatric consequences of dengue fever is not due to underreporting because of lack of awareness by physicians but due to the lack of clinical association between dengue and psychiatric disorder. These case reports are explained as accidental co-occurrence, quoting that the Thai database from Thailand (where the highest prevalence of dengue in the world is reported) has no report on either psychosis or mania among dengue patients.[16] However, in view of the increasing number of case reports from around the globe, there is a pressing need to systematically study the prevalence, risk factors, and types of psychiatric disorders associated with dengue infection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Bhatt S, Gething PW, Brady OJ, Messina JP, Farlow AW, Moyes CL, et al. The global distribution and burden of dengue. Nature 2013;496:504-7.  Back to cited text no. 1
    
2.
Gulati S, Maheshwari A. Atypical manifestations of dengue. Trop Med Int Health 2007;12:1087-95.  Back to cited text no. 2
    
3.
Hashmi AM, Butt Z, Idrees Z, Niazi M, Yousaf Z, Haider SF, et al. Anxiety and depression symptoms in patients with dengue fever and their correlation with symptom severity. Int J Psychiatry Med 2012;44:199-210.  Back to cited text no. 3
    
4.
Shivanthan MC, Ratnayake EC, Wijesiriwardena BC, Somaratna KC, Gamagedara LK. Paralytic squint due to abducens nerve palsy: A rare consequence of dengue fever. BMC Infect Dis 2012;12:156.  Back to cited text no. 4
    
5.
World Health Organization. The ICD-10 Classification of Mental and Behavioral Disorders (Tenth Revision): Diagnostic Criteria for Research. Geneva: World Health Organization; 1992.  Back to cited text no. 5
    
6.
Rittmannsberger H, Foff C, Doppler S, Pichler R. Psychiatric manifestation of a dengue-encephalopathy. Wien Klin Wochenschr 2010;122 Suppl 3:87-90.  Back to cited text no. 6
    
7.
Blum JA, Pfeifer S, Hatz CF. Psychiatric manifestations as the leading symptom in an expatriate with dengue fever. Infection 2010;38:341-3.  Back to cited text no. 7
    
8.
Kar S. Post dengue psychosis. Indian J Biol Psychiatry 2013;1:58-9.  Back to cited text no. 8
    
9.
Abdullah MF, Bakar MR. A Case of Psychotic Disorder Due to Dengue Fever. Available from: http://www.aseanjournalofpsychiatry.org/files/journals/1/./305-902-1-RV.pdf. [Last accessed on 2016 Apr 02].  Back to cited text no. 9
    
10.
Harder J, Sharma S, Gitlin D. Secondary mania as a possible neuropsychiatric complication of dengue fever. Psychosomatics 2014;55:512-6.  Back to cited text no. 10
    
11.
Tripathi SM, Mishra N. Late onset mania in dengue fever. Immunol Infect Dis 2014;2:1-3.  Back to cited text no. 11
    
12.
Jhanjee A, Bhatia MS, Srivastava S. Mania in dengue fever. Ind Psychiatry J 2011;20:56-7.  Back to cited text no. 12
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13.
Mendhekar DN, Aggarwal P, Aggarwal A. Classical mania associated with dengue infection. Indian J Med Sci 2006;60:115-6.  Back to cited text no. 13
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14.
Aggarwal A, Nimber JS. Dengue fever-associated catatonia. J Neuropsychiatry Clin Neurosci 2015;27:e66-7.  Back to cited text no. 14
    
15.
Baldaçara L, Ferreira JR, Filho LC, Venturini RR, Coutinho OM, Camarço WC, et al. Behavior disorder after encephalitis caused by dengue. J Neuropsychiatry Clin Neurosci 2013;25:E44.  Back to cited text no. 15
    
16.
Wiwanitkit S, Wiwanitkit V. Psychological manifestation in dengue: Did it really exist? Indian J Psychol Med 2013;35:222.  Back to cited text no. 16
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