Perinatal transmission of dengue: a case report
© Sinhabahu et al.; licensee BioMed Central Ltd. 2014
Received: 9 July 2014
Accepted: 23 October 2014
Published: 14 November 2014
Dengue in pregnancy is associated with many maternal and foetal outcomes including perinatal transmission of dengue infection.
A baby was born by emergency caesarean section due to foetal distress and meconium stained liquor, to a 27-year old primi-gravidae, Sinhalese female, who was febrile during and 2 days prior to labour. The baby had evidence of respiratory distress due to meconium aspiration and was cared for in the special care baby unit for 3 days. On the 4th day he developed fever and serial blood counts showed a gradual rise in the haematocrit (>20% of baseline value) and lowering of platelet counts. The baby was treated for sepsis and as Sri Lanka was experiencing a massive dengue epidemic was also tested for dengue. His dengue NS1 antigen test was strongly positive and the dengue IgM antibodies weakly positive on day 3 of illness. The mother was positive for both dengue IgM and IgG antibodies.
Although rare, vertical transmission of the dengue virus has been reported and the baby most likely developed dengue due to perinatal transmission of dengue.
Dengue viral infections are estimated to infect 390 million annually resulting in significant morbidity and mortality in resource poor countries . Infection can occur due to any of the four dengue viruses which may manifest as asymptomatic infection, undifferentiated fever, dengue fever or result in severe clinical disease manifestations in the form of dengue haemorrhagic fever (DHF)/ dengue shock syndrome (DSS) or dengue infection complicated with organ failure . Although majority of individuals infected with the dengue virus develop asymptomatic disease, infection during pregnancy has shown to be associated with more severe disease and higher incidence of death . Dengue in pregnancy is associated with preterm delivery, intra-uterine death, miscarriages and acute foetal distress during labour . Apart of foetus adversely been affected by complications due to maternal dengue, the foetus can directly be infected with the virus due to perinatal transmission.
Dengue in the newborn has shown to cause a range of clinical symptoms from asymptomatic infection, mild disease, DHF or DSS . We report a baby who was born by an emergency caesarean section due to foetal distress developing dengue due to perinatal transmission of the virus.
Results of serial haematological parameters and other laboratory investigations of the patient
As the mother was febrile during delivery, possible perinatal dengue was suspected. The baby’s dengue NS1 antigen test was strongly positive on day 3 of fever and the dengue specific IgM antibodies were weakly positive. The PCR was negative. The mother was also tested at the same time and both dengue IgM and IgG were positive. The baby’s blood culture did not yield a bacterial growth and the blood picture showed evidence of viral infection. The liver enzymes were elevated. He was managed as having dengue haemorrhagic fever according to the 2011 WHO guidelines . During the clinical course, he did not develop any evidence of haemorrhage or pleural effusions or ascites. He was discharged on Day 14 of life.
Fever in a newborn especially following intensive care due to meconium aspiration is usually considered to be due to sepsis. However, especially in dengue endemic countries maternal dengue in common  but could be potentially not diagnosed as an acute dengue infection, especially if the clinical symptoms are that of a non specific febrile illness. Sri Lanka has been affected by epidemics of dengue infection for almost three decades and many maternal dengue infections were initially misdiagnosed as complications due to pregnancy and even pulmonary embolism [7, 8]. Apart from miscarriages in 2 women, perinatal dengue was not reported in both of these case series.
Perinatal transmission of dengue although rare, has been reported previously [4, 5, 9, 10]. Perinatal dengue was thought to be transmitted via the placenta as the virus has been isolated in placentas and in cord blood of such infants . However, recently it was also shown that the dengue virus may be transmitted by breast milk, as the virus was detected in breast milk but not in cord blood . Once the dengue virus infects a human, the incubation period is thought to be between 3–10 days . Since this baby developed dengue infections four days following delivery, he is most likely to have been infected perinatally. Although the mother did not have a severe clinical disease, the dengue infection could have resulted in foetal distress leading to meconium aspiration. Virus isolation or dengue antibody detection was not carried out on cord blood or placenta in this instance, as dengue infection was not suspected at the time of delivery.
In conclusion, although perinatal dengue is a rare entity, it should be suspected in neonates whose mothers were suffering from a febrile illness during or just before delivery. Since perinatal dengue has been shown to associate with foetal distress, preterm delivery and intra uterine death, early identification of this condition is crucial to prevent development of complications.
Written informed consent was obtained from the patient’s father for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Funding was provided by the Centre for Dengue Research.
- Bhatt S, Gething PW, Brady OJ, Messina JP, Farlow AW, Moyes CL, Drake JM, Brownstein JS, Hoen AG, Sankoh O, Myers MF, George DB, Jaenisch T, Wint GR, Simmons CP, Scott TW, Farrar JJ, Hay SI: The global distribution and burden of dengue. Nature. 2013, 496 (7446): 504-507. 10.1038/nature12060.PubMedPubMed CentralView ArticleGoogle Scholar
- Malavige GN, Ogg GS: T cell responses in dengue viral infections. J Clin Virol. 2013, 58 (4): 605-611. 10.1016/j.jcv.2013.10.023.PubMedView ArticleGoogle Scholar
- Machado CR, Machado ES, Rohloff RD, Azevedo M, Campos DP, de Oliveira RB, Brasil P: Is pregnancy associated with severe dengue? A review of data from the Rio de Janeiro surveillance information system. PLoS Negl Trop Dis. 2013, 7 (5): e2217-10.1371/journal.pntd.0002217.PubMedPubMed CentralView ArticleGoogle Scholar
- Basurko C, Carles G, Youssef M, Guindi WE: Maternal and fetal consequences of dengue fever during pregnancy. Eur J Obstet Gynecol Reprod Biol. 2009, 147 (1): 29-32. 10.1016/j.ejogrb.2009.06.028.PubMedView ArticleGoogle Scholar
- Ribeiro CF, Lopes VG, Brasil P, Coelho J, Muniz AG, Nogueira RM: Perinatal transmission of dengue: a report of 7 cases. J Pediatr. 2013, 163 (5): 1514-1516. 10.1016/j.jpeds.2013.06.040.PubMedView ArticleGoogle Scholar
- Comprehensive guidelines for prevention and control of dengue fever and dengue haemorrhagic fever. 2011, SEARO, New Delhi, India: World Health OrganizationGoogle Scholar
- Waduge R, Malavige GN, Pradeepan M, Wijeyaratne CN, Fernando S, Seneviratne SL: Dengue infections during pregnancy: a case series from Sri Lanka and review of the literature. J Clin Virol. 2006, 37 (1): 27-33. 10.1016/j.jcv.2006.06.002.PubMedView ArticleGoogle Scholar
- Kariyawasam S, Senanayake H: Dengue infections during pregnancy: case series from a tertiary care hospital in Sri Lanka. J Infect Dev Ctries. 2010, 4 (11): 767-775.PubMedView ArticleGoogle Scholar
- Sirinavin S, Nuntnarumit P, Supapannachart S, Boonkasidecha S, Techasaensiri C, Yoksarn S: Vertical dengue infection: case reports and review. Pediatr Infect Dis J. 2004, 23 (11): 1042-1047. 10.1097/01.inf.0000143644.95692.0e.PubMedView ArticleGoogle Scholar
- Tan PC, Rajasingam G, Devi S, Omar SZ: Dengue infection in pregnancy: prevalence, vertical transmission, and pregnancy outcome. Obstet Gynecol. 2008, 111 (5): 1111-1117. 10.1097/AOG.0b013e31816a49fc.PubMedView ArticleGoogle Scholar
- Barthel A, Gourinat AC, Cazorla C, Joubert C, Dupont-Rouzeyrol M, Descloux E: Breast milk as a possible route of vertical transmission of dengue virus?. Clin Infect Dis. 2013, 57 (3): 415-417. 10.1093/cid/cit227.PubMedView ArticleGoogle Scholar
- Chan M, Johansson MA: The incubation periods of Dengue viruses. PLoS One. 2012, 7 (11): e50972-10.1371/journal.pone.0050972.PubMedPubMed CentralView ArticleGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.