A recent report describes a case of a 6-year-old Tamil girl who suffered dengue hemorrhagic fever during the previous year and got readmitted with fever, headache, vomiting, and abdominal pain for five days′ duration. It was the heavy rainy season with widespread dengue outbreaks in that region. She tested positive for dengue antigen (NS1) and described a low white blood cell count, low platelet, with hematocrit of 38, serum glutamic-oxaloacetic transaminase (SGOT) of 145 IU/dl, serum glutamic pyruvic transaminase (SGPT) of 98 IU/dl, and normal C-reactive protein. Her sister also suffered dengue hemorrhagic fever (DHF) and received discharged recently. 

Physical examination revealed her to be febrile (39 °C), ill and irritable, with a 22 kg body weight and low-volume peripheral pulses. She showed Blood pressure of 90/70 mmHg, pulse pressure of 20 mmHg, and Capillary refilling time of around 2 s with cold, clammy extremities. 

Inward ultrasound showed fluid in the Morrison pouch and right pleural space, indicating 8 hours of leakage time. 

Her respiratory system was otherwise normal except for reduced air entry in the right lung base. She also described generalized abdominal tenderness with 3-cm hepatomegaly. 

The patient received normal intravenous saline and two boluses, followed by a 5 ml/kg/hour infusion. Her condition improved with meticulous monitoring and fluid management. Her platelet count, which dropped to 30 × 103 /cumm, gradually picked up on the seventh day of illness to 90 × 103 /cumm, with a WBC count of 4.5 × 103 /cumm, indicating the recovery phase. 

She was diagnosed with dengue fever supported by the presence of dengue IgM and IgG antibodies. Her urine and blood cultures were sterile. On the same night, she developed loose stools, which were profuse, watery, and contained mucus. It was accompanied by vomiting and generalized abdominal pain. 

She received initial treatment for infective diarrhea pending stool cultures. However, the stool culture came sterile after 48 hours of incubation. The repeated blood examination showed a WBC count of 11 × 103 /cumm, C-reactive protein of 12 mg/dL, and platelet count of 92 × 103 /cumm. 

She continued to suffer from severe acute abdominal pain with demonstrable guarding and rigidity and thus received repeated ultrasounds late at night, which was compatible with acute appendicitis. She underwent laparoscopic appendectomy and received intravenous ampicillin 50 mg/kg/ dose six hourly and metronidazole 7.5 mg/kg/dose three times a day for seven days.

She received several clinical follow-ups at 1, 2, and 4 weeks after discharge and made a complete recovery. Her histopathological report confirmed the diagnosis of acute appendicitis.

Thadchanamoorthy et al. Journal of Medical Case Reports (2022) 16:219 https://doi.org/10.1186/s13256-022-03443-2