Anna Shah, Sai Polineni, Mauro Tavares MD, Marcelo Fernandes MD, Stephanie Clauss DO
Dengue fever is a mosquito-borne tropical disease endemic to parts of Asia and South America. We herein present a rare case of dengue fever acquired within the United States.
A 43-year-old male presented to our outpatient clinic with rash, fever, and malaise. Symptoms began one week prior with low grade fevers, myalgias and malaise. On day three, patient had swelling of his feet, followed by swelling of both hands. He developed a concomitant pruritic rash that started on his feet and hands and travelled to his upper arms bilaterally. Other symptoms included intermittent night sweats, retro orbital pain, headaches and nasal congestion. He denied nausea, vomiting, diarrhea, and chest pain. He denied recent travel, exposure to ticks, hiking, unprotected sex or sick contacts. Past medical history was significant for mononucleosis at age 20 and history of dengue fever at age 12 while living in Colombia. Patient's sexual history was pertinent for sexual relations with men. He denied any new sexual partners in the past 6 months and a recent sexually transmitted infection (STI) panel was negative per the patient. His vital signs in clinic were BP 118/66 mmHg, HR 82bpm, RR 15, temperature 98.1F, and saturating 99% on room air. Physical examination revealed plantar and dorsum hand erythema and warmth extending to the wrists bilaterally that was associated with maculopapular lesions. Erythema and warmth, with associated pruritus, was also noted on the dorsal surface of the feet bilaterally. Joints in the hand, including both PIP and DIP showed signs of synovitis with warmth and edema. Constituent values of a complete blood count were all within normal limits and a chest x-ray revealed no acute cardiopulmonary process. Laboratory testing for group A streptococci, influenza, Epstein-Barr, tuberculosis, STIs, ANA, Anti-dsDNA antibody, hepatitis B and C, chikungunya, and zika were negative. Blood and fungal culture and urinalysis were also negative. C-reactive protein (96.0 mg/L) and erythrocyte sedimentation rate (34 mm/h) were elevated. Further testing revealed elevated levels of dengue fever IgM antibody (3.26) and dengue fever virus IgG antibody (1.70).
Incidence of dengue virus in the United States is rare, with only 865 cases reported in the US and 38 in the territories according to the CDC in 2019 (903 total), most of which were attributed to travelers that visited dengue endemic regions. In fact, of these, Florida had the most cases with 286 travel related cases and 12 locally transmitted cases. While the presence of IgG against dengue fever virus may indicate recent or past infection, the presence of IgM antibody is presumptive evidence of infection within the past several months, likely via a different serotype than the one which afflicted the patient in childhood. Although dengue fever acquired in the US is uncommon, clinicians, including outpatient providers, treating patients in subtropical climates as well as areas of high travel from endemic regions should be cognizant of the potential for locally acquired dengue in patients, even among those with no travel history.
Statistics and Maps. (2019, November 7). Retrieved from https://www.cdc.gov/dengue/statistics-maps/index.html.
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