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COMMENTARY
Year : 2017  |  Volume : 10  |  Issue : 2  |  Page : 204-206  

Neuropsychiatric manifestations in dengue fever


Department of Psychiatry, UCMS and GTB Hospital, New Delhi, India

Date of Web Publication14-Mar-2017

Correspondence Address:
M S Bhatia
Department of Psychiatry, UCMS and GTB Hospital, Dilshad Garden, New Delhi-110 095
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.202111

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How to cite this article:
Bhatia M S, Saha R. Neuropsychiatric manifestations in dengue fever. Med J DY Patil Univ 2017;10:204-6

How to cite this URL:
Bhatia M S, Saha R. Neuropsychiatric manifestations in dengue fever. Med J DY Patil Univ [serial online] 2017 [cited 2017 May 26];10:204-6. Available from: http://www.mjdrdypu.org/text.asp?2017/10/2/204/202111

Dengue fever is a vector-borne disease assuming endemic proportions in the Indian subcontinent and Southeast Asia. It was first reported in 1789 by Benjamin Rush who gave the name “break bone fever” to describe the condition due to its association with joint pain.[1] In the late 1900s, there was a rapid increase in the cases of dengue fever leading to major epidemics in many parts of the world. Currently, as per the WHO, half of the world's population is at risk of dengue fever with nearly 50–100 million people being affected annually in over 100 endemic countries.[2] Because of the rapid increase in incidence and widespread prevalence, dengue has become a major public health concern. The WHO launched “The Global Strategy for Dengue Prevention and Control 2012–2020” to address this threat of an impending pandemic and reduce the burden of dengue.[3]

Dengue fever spreads from the bite of an infected female Aedes mosquito, primarily Aedes aegypti species and Aedes albopictus. It is caused by a positive-stranded encapsulated RNA virus belonging to the family Flaviviridae. Dengue virus has four serotypes, namely, DEN-1, DEN-2, DEN-3, and DEN-4 and infection with all four is responsible for dengue fever. Infection with one serotype does not provide immunity from other serotypes but prevents re-infection from the same serotype. Repeated infections increase the risk of severe dengue.[1],[2]

Dengue fever has a variable clinical picture ranging from subclinical infection to life-threatening outcomes. It can present as dengue fever with high-grade fever, headache, retro-orbital pain, joint pain, nausea, vomiting, and rash. Severe dengue can present as dengue hemorrhagic fever with thrombocytopenia, plasma leakage, and organ impairment or dengue shock syndrome with circulatory failure. Mortality is high in cases of severe dengue, particularly in Asian countries (0.5%–3.5%).[4]

With increase in the number of cases of dengue, there are reports of different neuropsychiatric manifestations associated with this condition from different parts of the world. The exact incidence of neuropsychiatric manifestation is, however, not certain due to lack of adequate studies. The psychiatric symptoms may accompany the acute phase of dengue or can be a late manifestation. There have been numerous case reports of appearance of manic symptoms during febrile phase of dengue fever as well as in convalescence period.[5],[6],[7],[8] Patients generally presented with talkativeness, authoritative and irritable behavior, grandiosity, increased sexual behavior, and reduced need for sleep, and symptoms were controlled rapidly within a week to month in all cases with mood stabilizers and antipsychotics. Only a few cross-sectional hospital-based observational studies have been conducted in acute dengue patients to evaluate for common mental disorders. Anxiety was found to be a prominent finding in all these studies.[9],[10],[11] In the acute phase of the illness, nearly 90% of the patients exhibited thanatophobia (fear of death), 15-23% had panic attacks, and overall 80% had significant anxiety-related symptoms.[9],[11] These symptoms, however, reduced in severity and frequency as the physical condition improved and only a few needed anxiolytics. However, about 50% of these patients developed insect phobia on recovery from dengue fever.[9],[11] Depressive symptoms were observed in 50%–60% patients initially which came down to about 5%–20% once the acute phase was over.[9],[10],[11] All the studies demonstrated a significant female preponderance for depressive and anxiety symptoms.[9],[10],[11] Hashmi et al. 2012 even showed that the depressive and anxiety symptoms were positively correlated to the severity of fever, headache, joint pain, body ache, and retro-orbital pain.[10] Dengue-related psychosis has also been reported in literature. It can present during the acute phase as reported in this case report “Psychosis in Dengue Fever” published in this issue or can be a late manifestation.[12],[13],[14] The symptoms reported are visual/auditory hallucinations, persecutory hallucinations, emotional lability, agitation and disturbed sleep, appetite and self-care. There was rapid resolution of psychosis with low doses of antipsychotics in all these reports. Only two cases of catatonic symptoms in dengue have been reported in published literature so far.[15],[16] Mutism, stupor, posturing, and negativism were the prominent findings in both the cases.

The dengue virus has been known to cause capillary leakage leading to accumulation of fluid in the extravascular space and cerebral edema.[1] This has been hypothesized to be the cause of the neurological manifestations such as encephalopathy, delirium, and paraparesis in severe dengue. Recent evidence of virus isolation from brain tissue, however, indicates dengue neurotropism. Other possible explanations are systemic effect of dengue infection or neuroimmune-mediated response.[17] Increased cytokine levels have also been reported in systemic conditions associated with anxiety and depressive symptoms as well as in dengue fever and can thus be hypothesized to be responsible for psychiatric manifestations in the latter.[18]

Although the exact mechanism of neuropsychiatric manifestations in dengue infection remains unclear, increasing reports of the same makes it imperative to screen patients with dengue fever for psychiatric morbidities.

 
  References Top

1.
Gupta N, Srivastava S, Jain A, Chaturvedi UC. Dengue in India. Indian J Med Res 2012;136:373-90.  Back to cited text no. 1
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2.
World Health Organization. Dengue. WHO. Available from: http://www.who.int/denguecontrol/en/. [Last cited on 2016 Oct 28].  Back to cited text no. 2
    
3.
World Health Organization. Global Strategy for Dengue Prevention and Control, 2012-2020. Geneva, Switzerland: World Health Organization; 2012. Available from: http://www.apps.who.int/iris/bitstream/10665/75303/1/9789241504034_eng.pdf. [Last cited on 2016 Oct 29].  Back to cited text no. 3
    
4.
Halstead SB. Is there an inapparent dengue explosion? Lancet 1999;353:1100-1.  Back to cited text no. 4
    
5.
Jhanjee A, Bhatia MS, Srivastava S. Mania in dengue fever. Ind Psychiatry J 2011;20:56-7.  Back to cited text no. 5
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6.
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. 6
[PUBMED]  [Full text]  
7.
Srivastava S, Bhatia MS, Jhanjee A. Organic mania in dengue. J Clin Diagn Res 2013;7:566-7.  Back to cited text no. 7
    
8.
Tripathi SM, Mishra N. Late onset mania in dengue fever. Immunol Infect Dis 2014;2:1-3.  Back to cited text no. 8
    
9.
Jhanjee A, Bhatia MS, Srivastava S, Rathi A. A study of psychiatric symptomatology in dengue patients. Delhi Psychiatry J 2013;16:21-3.  Back to cited text no. 9
    
10.
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. 10
    
11.
Gill KU, Ahmad W, Irfan M. A clinical study to see the psychological effects of dengue fever. Pak J Med Health Sci 2011;5:101-4.  Back to cited text no. 11
    
12.
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. 12
    
13.
Kar S. Post dengue psychosis. Indian J Biol Psychiatry 2013;1:58-9.  Back to cited text no. 13
    
14.
Rapp C, Debord T, Imbert P, Roué R. A psychiatric form of dengue after a visit to Djibouti. Presse Med 2002;31:1704.  Back to cited text no. 14
    
15.
Bhatia MS, Srivastava S. Catatonia in a patient with dengue fever. JK Pract 2007;14:48.  Back to cited text no. 15
    
16.
Aggarwal A, Nimber JS. Dengue fever-associated catatonia. J Neuropsychiatry Clin Neurosci 2015;27:e66-7.  Back to cited text no. 16
    
17.
Murthy JM. Neurological complication of dengue infection. Neurol India 2010;58:581-4.  Back to cited text no. 17
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18.
Hayley S. Toward an anti-inflammatory strategy for depression. Front Behav Neurosci 2011;5:19.  Back to cited text no. 18
    




 

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