Ocular features of dengue septic shock (DSS).

Dengue fever may occasionally present with high fever, hemorrhagic phenomena and circulatory failure (dengue hemorrhagic fever) or rarely as dengue septic shock.1 A 22 years, non-diabetic and non-hypertensive female patient was evaluated for three-day old high-grade fever. Relevant clinical signs included high fever, multiple skin petechiae and bleeding gums leading to a clinical diagnosis of dengue. Investigations revealed thrombocytopenia (20,000/mm3; normal 150,000 400,000/mm3) with an abnormal coagulation profile [activated prothrombin time of 48.0 seconds (control 30.9 s.)]. Dengue fever serology was confirmative with rising IgM titres (7.99 Novatec units on admission and 12.7 Novatec units on day 10; positive > 11 units) and markedly elevated IgG titres (64.4 Novatec units (positive > 11 units)). She rapidly deteriorated, developed adult respiratory distress syndrome but recovered over the next few days. She was evaluated for a left red eye and bilateral blurred vision. An exposureinduced peripheral hypopyon corneal ulcer was seen in the left eye. Dilated ophthalmoscopy revealed a large premacular hemorrhage in the right eye (Fig. 1) with a mild vitreous haze, multiple large blotchy hemorrhages along the vessels and a few cotton wool spots in the left (Fig. 2). The ulcer was treated with gatifloxacin eye drops. A subsequent examination documented her visual acuity as counting fingers in the right eye and 6/24 in the left with no additional findings on slitlamp examination. Causes of the hemorrhage include: dengue-induced thrombocytopenia, antiplatelet antibodies (IgM type), dengue viral specific antibodies, bone marrow hypocellularity with consequent defective megakaryocytes or destruction of platelets in the liver and spleen.2