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Diaphragmatic paralysis: a rare consequence of dengue fever
© Ratnayake et al; licensee BioMed Central Ltd. 2012
Received: 30 August 2011
Accepted: 22 February 2012
Published: 22 February 2012
Dengue is considered one of the most common mosquito borne illnesses in the world. Although its clinical course is usually uneventful, complications have rarely been known to arise. These include neurological manifestations such as neuropathies.
We report a middle aged patient from urban Sri Lanka who developed diaphragmatic paralysis secondary to phrenic neuropathy a month after recovering from dengue fever. He was managed conservatively and made a full recovery subsequently.
Isolated phrenic nerve palsy causing diaphragmatic paralysis should be considered a recognized complication of Dengue fever. A patient usually gains full recovery with conservative management.
Dengue virus infections are known to manifest in three main forms: - Dengue with or without warning signs and severe Dengue fever . All three presentations of the disease usually recover uneventfully if accepted protocols are adhered to . Uncommon manifestations of dengue fever, including neurological sequelae such as mononeuropathy, encephalopathy, transverse myelitis, polyradiculopathy and Guillain-Barre syndrome [3–5] have also been recognized in the past.
Dengue fever was confirmed with a positive dengue polymerase chain reaction (PCR) result and positive Dengue IgM antibodies. He was managed with intravenous fluids according to national guidelines  and was discharged from hospital following a 48 h afebrile period, good appetite and adequate platelet rise. Two days prior to discharge he developed a persistent dry cough, without fever. A repeat chest x-ray was performed but did not reveal any abnormalities and he was treated for acute bronchitis with bronchodilators and cough suppressants.
Dengue infection is the most common arboviral disease in the tropics and especially in Sri Lanka, where the season usually peaks in June-July each year. Although the clinical spectrum of the disease is well recognized, rare complications of the infection are encountered. Unusual neurological manifestations of the disease such as Encephalopathy and Guillain-Barre syndrome are reported more commonly than others . Diaphragmatic paralysis due to phrenic nerve involvement has only been reported in two previous instances [6, 7], both from the tropics. Our report introduces the third such patient with this very rare complication.
Our patient had confirmed dengue viral infection which was managed without complications in the ward. He was subsequently found to have a right sided phrenic nerve palsy a month later as confirmed by nerve conduction study and lung function tests. A myopathy or a neuromuscular junction pathology were excluded by normal electromyography. Phrenic nerve compression by mass lesions were excluded by a normal CECT. The presence of f waves on nerve conduction study made Guillain-Barre syndrome an unlikely cause although there was evidence of demyelination.
Post viral phrenic neuropathy has previously been documented following Polio-virus infection (particularly as a post-polio syndrome) , Herpes-Zoster infection  and Human Immunodeficiency virus infection . The pathophysiology behind the manifestation remains obscure due to paucity of literature but an immune mediated mechanism is suggested . Post viral phrenic neuropathy usually runs a self-limiting course, as was seen in our patient but may run a fulminant course with severe respiratory failure requiring mechanical ventilation .
With dengue fever reaching and exceeding epidemic proportions in countries like Sri Lanka, more unusual complications of this very common disease are to be expected. In such light isolated phrenic nerve palsy causing diaphragmatic paralysis should be considered a recognized complication of this usually self limiting disease.
Written informed consent was obtained from the patient for publication of this case report including all images. A copy of the written consent is available for review by the Editor-in-Chief of BMC Infectious Diseases.
The authors thank the departments of radiology and neurophysiology at the National Hospital of Sri Lanka for providing help in diagnosing and managing the patient mentioned in the case report.
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