Lung Disease in Dengue

Viroj Wiwanitkit

Viroj Wiwanitki, Visiting professor, Hainan Medical University, China; visiting professor, Faculty of Medicine, University of Nis, Serbia; adjunct professor, Joseph Ayobabalola University, Nigeria; honorary professor, Dr DY Patil Medical University, India.

Correspondence to: Viroj Wiwanitki, Visiting professor, Hainan Medical University, China; visiting professor, Faculty of Medicine, University of Nis, Serbia; adjunct professor, Joseph Ayobabalola University, Nigeria; honorary professor, Dr DY Patil Medical University, India.
Email: wviroj@yahoo.com
Telephone: +91-6624132436
Received: September 5, 2015
Revised: November 13, 2015
Accepted: November 17, 2015
Published online: December 28, 2015


Dengue is an important tropical arboviral infection. The lung disease in dengue is limited mentioned. In this short, editorial, lung disease in dengue is summarized, detailed and discussed.

© 2015 ACT. All rights reserved.

Key words:Lung; Disease; Dengue

Wiwanitki V. Lung Disease in Dengue. Journal of Respiratory Research 2015; 1(1): 7-9 Available from: URL: http://www.ghrnet.org/index.php/jrr/article/view/1372


Dengue is an important tropical arboviral infection. It is classified as an important mosquito borne disease. Dengue usually presents as an acute febrile illness with thrombocytopenia and hemorrhagic complication. The classical triad, thrombocytopenia, atypical lymphocytosis and hemoconcentration is the laboratory hallmark of dengue infection[1]. This infection is very common in tropical countries especially for Southeast Asian countries. Thousands of patients visit to the hospital and are hospitalized annually.

Not only classical clinical features of dengue but also atypical presentation can be the clinical presentation[2]. It is no doubt that the respiratory presentation of dengue can be seen in clinical practice. Nevertheless, the lung disease in dengue is limited mentioned. In this short, editorial, lung disease in dengue is briefly summarized, detailed and discussed as a source for the readers to further use a short note.

Prevalence of lung disease in dengue

As already noted, lung disease can be seen in dengue but there are only a few reports on it. The interesting question is “what is the prevalence of lung disease in dengue?” As far as known, there is no official report on the lung disease among general patients with dengue. However, there are some reports on the prevalence among dengue death cases or severe dengue cases. Wiwanitkit recently studied magnitude of pulmonary pathology in fatal cases of dengue hemorrhagic fever in Thailand and found that almost all death cases had lung pathology[3]. A similar observation was also reported from Cuba[4]. Guzmán et al. noted that lung pathology could be seen in all fatal dengue cases in their study and the virus could be identified in lung of the death cases[4]. Another report from Venezuela also showed the same finding that all dengue death cases had lung disease[5]. Arismendi-Morillo et al. mentioned that “all these cases showed severe lung disease (diffuse alveolar damage, non cardiogenic pulmonary edema, thromboembolism, bronchopneumonia, pneumonitis, intralveolar hemorrhage[5].” Arismendi-Morillo et al. also reported that respiratory failure was the cause of death in two-thirds of the studied fatal cases[5]. Focusing on non fatal cases, a recent report from Yunnan among severe dengue patients also showed a similar finding[6]. About 38.6 % of severe dengue cases in this report presented pleural effusion due to plasma leakage[6].

Possible pathophysiology of lung disease in dengue

The pathophysiology of lung disease in dengue is still not conclusive. There are many possible causes of lung disorders among dengue patients. First, thrombocytopenia can directly cause spontaneous bleeding in any organs including to lung in dengue patients[1]. Sharma et al. noted that pulmonary haemorrhage among dengue patients was rare and could present with haemoptysis requiring blood transfusion[7]. Second, the plasma leakage during dengue infection can also be the causes of lung problem in dengue[1,6]. This processis approved to be a consequence of dengue immunopathology[8]. Third, the superimposed lung infections in dengue patients are also reported[1]. Those pathophysiological processes can be the causes of lung disease in dengue.

Some important lung diseases in dengue

1. Pulmonary hemorrhage

Pulmonary hemorrhage is a severe lung disease in dengue. It is not common but serious. This can be early detected by lung CT scan[9 – 10]. The pattern is usually diffuse alveolar hemorrhage. In immunocompetent host, dengue must be a differential diagnosis in any cases with problem of diffuse alveolar hemorrhage[11 - 12]. The other differential diagnoses are influenza A (H1N1), leptospirosis, malaria, and Staphylococcus aureus infection[11]. Nevertheless, it should be noted that the combination of dengue and other concurrent tropical infection is also possible to cause pulmonary hemorrhage (such as concurrent dengue and leptospirosis induced pulmonary hemorrhage[13]). The case can be serious and fatal. The management is usually supportive and symptomatic.

2. Pleural effusion

As noted pleural effusion is a sign of severe dengue. Neeraja et al. noted that this problem was accounted for 11 % of severe dengue patients[14]. Namvongsa et al. noted that pleural effusion was the sign of dengue hemorrhagic fever and dengue shock[15]. According to the report by Michels et al[16] and Zaki[17], it was noted that the ultrasonography could help early diagnose effusion and could help the physician in charge to plan for management of pending severe clinical features of dengue. To manage the patients, conservative management can be useful in cases with small effusion. However, in cases with large amount of effusion, the intercostal drainage placement is indicated[18]. In some severe case, a more complex complication, hemothorax can be observed[19] and the use of intercostal drainage placement is useful for management. The fluid replacement therapy and balancing of body fluid is required, which can be based on standard guideline for management of any dengue cases[1].


In general dengue does not cause pneumonia. Finding of pneumonia in dengue case is possible and usually implies superimposed bacterial infection. Staphylococcus aureus[20 – 21] and melioidosis[22] are the two common problematic pneumonias that can superimpose dengue infection. To manage the problem, identification of the pathogen and assignment of proper antibiotic is required.

4.Pulmonary edema

Pulmonary edema can also be the problem in dengue. The pathophysiology is the same as the case of pleural effusion. Disturbance of colloid oncotic pressure is believe to be the main cause of the problem[23]. Sometimes, the problem can also be seen in concordant with other dengue systemic problem such as dengue myocarditits[24]. It should also be noted that pulmonary edema can be sometimes iatrogenic. The case of pulmonary edema after platelet transfusion[25] or excessive fluid therapy[26] in dengue patient is the good example. The acute pulmonary edemas in those cases are usually observed in the convalescence phase[26].

5. Respiratory distress syndrome

Respiratory distress syndrome is the most serious lung disease in dengue and this can result in respiratory failure[27]. Sometimes, the problem can also be seen in concordant with other dengue systemic problem such as acute pancreatitis[28] and myocarditis[29]. Ranjit et al. noted that aggressive management was needed and could be helpful in increasing survival[30]. The fluid replacement therapy, balancing of body fluid as well as ventilation management is required[30].

Concurrent lung problem in patients with dengue.

As already noted, there is a possibility that there might be concurrent infection with dengue. The concurrent lung problem in patients with dengue is possible. The good example is the concurrent tuberculosis and dengue[31]. Indeed, this combination can be easily expected (since both infections are usually endemic in the same tropical areas) but underdiagnosed. Other rarer lung diseases can also be seen. Pulmonary aspergillosis is the good example[32]. This should be carefully thought of by general practitioner.


Lung disease is not common among general dengue patients, however, it is common among severe dengue cases or fatal cases. The problem can be various manifested and can lead to death. The practitioner has to recognize on the lung disease among the patient with dengue and proper manage it.


The authors have no conflicts of interest to declar.


1.Wiwanitkit V. Dengue fever: diagnosis and treatment. Expert Rev Anti Infect Ther 2010; 8(7):841-5

2. Wiwanitkit V. Bleeding and other presentations in Thai patients with dengue infection. Clin Appl Thromb Hemost 2004 Oct;10(4):397-8.

3. Wiwanitkit V. Magnitude and pattern of pulmonary pathology in fatal cases of dengue hemorrhagic fever in Thailand. Int J Tuberc Lung Dis 2005; 9(9):1060.

4. Guzmán MG, Alvarez M, Rodríguez R, Rosario D, Vázquez S, Vald s L, Cabrera MV, Kourí G. Fatal dengue hemorrhagic fever in Cuba, 1997. Int J Infect Dis 1999; 3(3):130-5.

5. Arismendi-Morillo G, Mauriello-Rivas C, Maldonado-Reverol M, Fernández-Abreu M, Larreal M, Torres-Nava VG, Romero-Amaro Z. Clinical and pathological correlation in fatal dengue cases found in Maracaibo, Venezuela. Rev Cubana Med Trop 2011; 63(1):44-51.

6. Zhang FC, Zhao H, Li LH, Jiang T, Hong WX, Wang J, Zhao LZ, Yang HQ, Ma DH, Bai CH, Shan XY, Deng YQ, Qin CF. Severe dengue outbreak in Yunnan, China, 2013. Int J Infect Dis 2014;27:4-6.

7. Sharma SK, Gupta BS, Devpura G, Agarwal A, Anand S. Pulmonary haemorrhage syndrome associated with dengue haemorrhagic fever. J Assoc Physicians India 2007; 55:729-30.

8. Spiropoulou CF, Srikiatkhachorn A. The role of endothelial activation in dengue hemorrhagic fever and hantavirus pulmonarysyndrome. Virulence 2013; 4(6):525-36.

9. Rodrigues RS, Brum AL, Paes MV, Póvoa TF, Basilio-de-Oliveira CA, Marchiori E, Borghi DP, Ramos GV, Bozza FA. Lung in dengue: computed tomography findings. PLoS One 2014; 9(5):e96313.

10. Marchiori E, Ferreira JL, Bittencourt CN, de Araújo Neto CA, Zanetti G, Mano CM, Santos AA, Vianna AD. Pulmonary hemorrhage syndrome associated with dengue fever, high-resolution computed tomography findings: a case report. Orphanet J Rare Dis 2009; 5;4:8.

11. von Ranke FM, Zanetti G, Hochhegger B, Marchiori E. Infectious diseases causing diffuse alveolar hemorrhage in immunocompetent patients: a state-of-the-art review. Lung. 2013; 191(1):9-18.

12. Marchiori E, von Ranke F, Zanetti G, Hochhegger B. Dengue hemorrhagic fever: another cause of diffuse alveolar hemorrhage in immunocompetent patients. Respir Med. 2012; 106(12):1807-8.

13. Cadélis G. Intra-alveolar hemorrhage associated with dengue and leptospirosis. Rev Pneumol Clin 2012; 68(5):323-6.

14. Neeraja M, Iakshmi V, Teja VD, Lavanya V, Priyanka EN, Subhada K, Parida MM, Dash PK, Sharma S, Rao PV, Reddy G. Unusual and rare manifestations of dengue during a dengue outbreak in a tertiary care hospital in South India. Arch Virol 2014; 159(7):1567-73

15. Namvongsa V, Sirivichayakul C, Songsithichok S, Chanthavanich P, Chokejindachai W, Sitcharungsi R. Differences in clinical features between children and adults with dengue hemorrhagic fever/dengueshock syndrome. Southeast Asian J Trop Med Public Health 2013; 44(5):772-9.

16. Michels M, Sumardi U, de Mast Q, Jusuf H, Puspita M, Dewi IM, Sinarta S, Alisjahbana B, van der Ven AJ. The predictive diagnostic value of serial daily bedside ultrasonography for severe dengue in Indonesian adults. PLoS Negl Trop Dis 2013; 7(6):e2277.

17. Zaki SA. Pleural effusion and ultrasonography in dengue Fever. Indian J Community Med 2011; 36(2):163.

18. Azim A, Sahoo JN, Baronia AK, Gurjar M, Singh RK, Poddar B, Ahmed A, Garg P, Saigal S. Severe dengue with massive pleural effusion requiring urgent intercostal chest tube drainage: a case report. Am J Emerg Med 2012; 30(2):389.e1-2

19. Karanth SS, Gupta A, Prabhu M. Unilateral massive hemothorax in Dengue hemorrhagic fever: a unique presentation. Asian Pac J Trop Med 2012;5(9):753-4.

20. Nagassar RP, Bridgelal-Nagassar RJ, McMorris N, Roye-Green KJ. Staphylococcus aureus pneumonia and dengue virus co-infection and review of implications of coinfection. BMJ Case Rep 2012; 2012. pii: bcr0220125804.

21. Miyata N, Yoshimura Y, Tachikawa N, Amano Y, Sakamoto Y, Kosuge Y. Cavity Forming Pneumonia Due to Staphylococcus aureus Following Dengue Fever. Am J Trop Med Hyg 2015; pii: 15-0045.

22. Macedo RN, Rocha FA, Rolim DB, Vilar DC, Araújo FM, Vieira NN, Teixeira JR, Carvalho MC, Oliveira FG, Cavalcanti LP. Severe coinfection of melioidosis and dengue fever in Northeastern Brazil: first case report. Rev Soc Bras Med Trop 2012; 45(1):132-3.

23. Hassan R, Chair I, Darwis D, Latief A. Colloid oncotic pressure in severe dengue shock syndrome. Paediatr Indones 1986; 26(11-12):213-9.

24. Lee IK, Lee WH, Liu JW, Yang KD. Acute myocarditis in dengue hemorrhagic fever: a case report and review of cardiac complications in dengue-affected patients. Int J Infect Dis 2010;14(10):e919-22.

25. Karoli R, Bhat S, Fatima J, Verma P. Acute lung injury after platelet transfusion in a patient with dengue fever. Asian J Transfus Sci 2014; 8(2):131-4.

26. Premaratna R, Liyanaarachchi E, Weerasinghe M, de Silva HJ. Should colloid boluses be prioritized over crystalloid boluses for the management of dengue shock syndrome in the presence of ascites and pleural effusions? BMC Infect Dis 2011; 11:52

27. Kumar N, Gadpayle AK, Trisal D. Atypical respiratory complications of dengue fever. Asian Pac J Trop Med 2013; 6(10):839-40.

28. Agrawal A, Jain N, Gutch M, Shankar A. Acute pancreatitis and acute respiratory distress syndrome complicating dengue haemorrhagic fever. BMJ Case Rep 2011; 2011.

29. Deepak D, Garg R, Pawar M, Banerjee N, Solanki R, Maurya I. Filgrastim as a rescue therapy for persistent neutropenia in a case of dengue hemorrhagic Fever with acute respiratory distress syndrome and myocarditis. Case Rep Anesthesiol 2011; 2011:896783.

30. Ranjit S, Kissoon N, Jayakumar I. Aggressive management of dengue shock syndrome may decrease mortality rate: a suggested protocol. Pediatr Crit Care Med 2005; 6(4):412-9.

31. Joob B, Wiwanitkit V. Concurrent dengue infection in a patient with pulmonary tuberculosis: the first world report. J Thorac Dis 2013; 5(3):E118-9.

32. Wang HC, Chang K, Lu PL, Tsai KB, Chen HC. Fatal invasive aspergillosis: a rare co-infection with an unexpected image presentation in a patient with dengueshock syndrome. Clin Respir J 2015. doi: 10.1111/crj.12323.

Peer reviewer:Sule Comert, MD, Tepecik Training and Research Hospital, Department of Adult Chest Diseases, Division of Allergy and Clinical Immunology, Gaziler Cd., No:468, 35120, Yenisehir, Izmir, Turkey.


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