|Year : 2014 | Volume
| Issue : 3 | Page : 121-123
Bleeding from gums: Can it be a dengue
Rajat Bansal1, Purnita Goyel2, Dinesh C Agarwal3
1 Department of Periodontics, Kothiwal Dental College and Research Centre, Moradabad, Uttar Pradesh, India
2 Department of Pedodontics, Kothiwal Dental College and Research Centre, Moradabad, Uttar Pradesh, India
3 General Physician (M.B.B.S), Private Practice, Uttar Pradesh, India
|Date of Web Publication||15-Jul-2014|
Department of Periodontics, Kothiwal Dental College and Research Centre, Moradabad - 244 001, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Bleeding from gums is a common feature in periodontitis patient. But abnormal bleeding from the gingiva or other areas of the oral mucosa that is difficult to control is an important clinical sign suggesting a hematological disorder. Case Report: A-40-year old male patient reported to our clinic with the chief complaint of acute gingival bleeding. There was continuous bleeding, fever since 3-4 days with weakness, retro orbital pain, and severe backache. Patient gave a history of bleeding from gums for last 24 hrs. His blood profile revealed; platelet count of 36,000, total wite blood cell (WBC) count of 6000/cumm, differential leukocyte count (DLC) (P45, L53, E2), and hemoglobin 12 g/dL. Patient sera was positive for dengue non-structural protein-1 antigen, anti-dengue immunoglobulin M (IgM), and anti-dengue immunoglobulin G (IgG) antibodies. Discussion: Here is a case report capable of changing our vision that acute gingival bleeding can also occur in dengue fever. Dengue fever can also be considered as one of the differential diagnosis for the acute gingival bleeding.
Keywords: Acute bleeding, dengue, fever, platelet count
|How to cite this article:|
Bansal R, Goyel P, Agarwal DC. Bleeding from gums: Can it be a dengue. Dent Hypotheses 2014;5:121-3
| Introduction|| |
Disorders of blood or blood forming organs can have a profound effect on periodontium. Ecchymosis and petechiae observed most often in the soft palate area is a sign of an underlying bleeding disorder. Abnormal bleeding from the gingiva or other areas of the oral mucosa that is difficult to control is an important clinical sign suggesting a haematological disorder. 
Other than hematological disorders Dengue fever (DF) is the condition where toxic hemorrhagic state appears during the 3 rd to 5 th day of illness following the onset of fever followed by convalescent stage. DF is a severe, flu-like illness that affects infants, children, adolescents, and adults. The incubation period of DF after the mosquito bite is between 3-8 days. The clinical features vary according to the age of the patient. Infants and young children usually have only a nonspecific febrile illness, with a rash that is hard to distinguish from other viral illnesses. 
The more severe cases usually occur in older children and adults and are characterized by a rapidly rising temperature (> 39°C) that lasts approximately 5-6 days and sometimes may be biphasic. During the febrile period, the patient may experience severe headache, retro-orbital pain, myalgia, arthralgia, nausea, and/or vomiting. More than 50% of infected patients report having a rash during this period that initially is macular or maculopapular and becomes diffusely erythematous. 
Minor hemorrhagic manifestations such as petechiae, epistaxis, and gingival bleeding occur in some patients. The most common hemorrhagic manifestation are epistaxis, skin hemorrhages, and gastrointestinal hemorrhages.  Here, we report a case of patient presenting acute gingival bleeding with DF.
| Case Report|| |
A 40-year-old male patient reported to us with the chief complaint of acute gingival bleeding. There was continuous bleeding. On taking history of patient, we got to know that he is having fever since 3-4 days with weakness, retro orbital pain, and severe backache. Patient gave a history of bleeding from gums for last 24 hrs. On examination, there was continuous bleeding of the molar region [Figure 1] and [Figure 2]. On physical examination, patient appeared emaciated and pale. Informed consent was obtain befor any procedure and ttreatment. We tried to control the bleeding with cotton gauze and pressure packs, but were unable to achieve satisfactory hemostasis.
Since there was outbreak of DF in our city at that time and patient was working in Ramlila committee where most of the time he has to sleep in open, we sent the patient for routine hematological investigations viz.; complete hemogram, general blood picture, platelet count. His report revealed; the platelet count of 36,000, total white blood cell (WBC) count of 6000/cumm, differential leukocyte count (DLC) of (P45, L53, E2), and hemoglobin level of 12 g/dL. Suspecting for dengue, patient was referred to higher centre.
Patient visited the medical college nearby where his sera was tested positive for dengue non-structural protein-1 antigen, anti-dengue immunoglobulin M (IgM), and anti-dengue immunoglobulin G (IgG) antibodies. Patient was immediately admitted and three units of platelets were transfused. After transfusion patient responded favorably. One week later when patient reported to us his condition was improved and stable [Figure 3] and [Figure 4].
| Discussion|| |
DF is an acute mosquito borne transmitted disease caused by the DF virus of family Flaviviridae, the most common cause of arboviral disease in the world.  The dengue virus (DENV) are four genetically related, but distinct serotypes designated DENV-1, DENV-2, DENV-3, and DENV-4 which are circulating world-wide. The main vector for dengue transmission is Aedes aegypti mosquitoes. 
After entering into the blood stream, the virus replicates in sufficient quantity to induce the febrile response. Cytokines that induce fever such as tumor necrosis factor-alpha (TNF-α), interleukin (IL)-1, and IL-6 are released. The period of fever following DF lasts for 2-7 days. 
Infections with the DENV can cause a spectrum of three clinical syndromes with classic DF, dengue hemorrhagic fever (DHF), and dengue shock syndrome (DSS). World Health Organization (WHO) criteria exist for the classification of dengue into these three clinical categories  however, there is a significant overlap between the categories. 
There are two criteria for diagnosis of dengue hemorrhagic fever:
- Clinical criteria: Pyrexia-Sudden onset, high grade lasting 2-7 days. Hemorrhagic manifestations in the form of at least one of the following: Petechiae, purpura, ecchymosis, epistaxis, gingival bleeding, bleeding from mucosa, GIT or injection site, hematemesis and/or malena Positive tourniquet test and hepatomegaly.
- Laboratory criteria: Thrombocytopenia (platelet count < 100,000/cumm),
Mucosal involvement is estimated to occur in 15-30% of patients with DENV infections and more commonly in patients with DHF than with DF.  The mucosal manifestations noted in DENV infections are conjunctival and scleral injection, small vesicles on the soft palate, erythema and crusting of lips and tongue. Chadwick et al.,  reported conjunctival involvement in 14% of patients; however, some reports have shown a higher percentage of mucosal involvement, e.g. scleral injection (90%) and vesicles on the soft palate (> 50%). 
A similar case has been reported by Chen et al. in which 54-year-male patient presented with fever, bone pain, gum bleeding, scrotal, and penile edema with thrombocytopenia (platelet count < 14,000/mm 3 ) and hematocrit elevated to 45.5%. The patients sera showed positive seroconversion of IgG and IgM antibody to DENV. 
Butt et al.,  examined 104 patients with fever less than 2 weeks duration with generalized morbiliform rash and bleeding manifestations, with positive serum for anti-dengue IgM and IgG using polymer chain reaction. Nearly, 81.73% patients presented with fever followed by generalized morbiliform rash, 62.5% backache, and 34.6% with mucosal bleeding manifestations. Laboratory findings in these patients were; thrombocytopenia was seen in all patients (100%), leucopenia in 55 (52.8%), raised hematocrit in 52 (50%) and overall mortality was 2.88%.
| Conclusion|| |
DF can also be considered as one of the differential diagnosis for the acute gingival bleeding cases where there is outbreak of this fever other than hematological disorders like leukemia. This emphasizes the value of taking correct and thorough history along with proper diagnosis as it can save one's life.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]