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Psychosis in dengue fever

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DOI: 10.4103/0975-2870.202104

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Case Report
Psychosis in dengue fever
Suprakash Chaudhury, Biswajit Jagtap, Deepak Kumar Ghosh1
Departments of Psychiatry and 1Pathology, Rural Medical College, Pravara Institute of Medical Sciences (DU), Loni, Maharashtra, India
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
Introduction
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
Address for correspondence:
Dr. Suprakash Chaudhury, Department of Psychiatry, Rural Medical College, Pravara Institute of Medical Sciences, Loni ‑ 413 736, Ahmednagar,
Maharashtra, India.
E‑mail: suprakashch@gmail.com
202 © 2017 Medical Journal of Dr. D.Y. Patil University | Published by Wolters Kluwer - Medknow
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DOI:
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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
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
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How to cite this article: Chaudhury S, Jagtap B, Ghosh DK.
Psychosis in dengue fever. Med J DY Patil Univ 2017;10:202-4.
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Chaudhury, et al.: Psychosis in dengue fever
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.
Discussion
Psychiatric symptoms following dengue fever have been
demonstrated to be associated with dengue encephalitis
and are rare.[3,6‑14] Mania is the most common psychiatric
disorder reported[10‑13] 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
Medical Journal of Dr. D.Y. Patil University | Volume 10 | Issue 2 | March-April 2017 203
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.
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Chaudhury, et al.: Psychosis in dengue fever
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Commentary
Neuropsychiatric manifestations in dengue fever
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
204 Medical Journal of Dr. D.Y. Patil University | Volume 10 | Issue 2 | March-April 2017
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8. Kar  S. Post dengue psychosis. Indian J Biol Psychiatry
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mania associated with dengue infection. Indian J Med Sci
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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.