At that point I left to review lab tests. Just as expected in a major viral assault, Susie's leukocytes and platelets were low. That meant she was depleted of cells that counter infection and bleeding. At the same time, her liver enzymes were elevated three- to fourfold, corresponding to the swollen, tender edge I felt on exam. Everything fit with dengue, yet nothing was truly diagnostic. Meanwhile, it would take 48 hours before blood cultures were known to be negative for meningococcus.
Sometimes being a purist is a mistake in medicine. Although I was confident that Susie had dengue, a disease for which antibiotics are ineffective, I asked myself: In her shoes, would I want antibiotic treatment until a serious bacterial infection was 100 percent excluded? My answer was yes.
"Let's start ampicillin and ceftriaxone for now," I said to the resident, "but don't forget to order an antibody test for dengue fever. It may take a long time to get the result, but it could be our only proof."
My next stop was the library. All day a vague memory had nagged me. Hadn't I seen a case report describing hemorrhage and shock in first-time dengue? Or was my mind playing tricks on me?
The American Journal of Tropical Medicine and Hygiene came through: "Dengue shock syndrome in an American traveler with primary dengue 3 infection" (March 1987). In the 15 years since that report, with the blossoming of dengue and exotic overseas travel, such cases in tourists are no longer rare. For reasons that are unclear, even these first-time infections can occasionally lead to bleeding and shock.
As for Susie, she spent the next few days in the hospital while her plasma volume restored, her bleeding stopped, her skin hemorrhages cleared, and her lab tests normalized. As expected, her blood cultures remained negative, so we finally shut off her antibiotics 48 hours after admission. Three days later, when she and Jeff were ready to return to the East Coast, the only remnant of her ordeal was depression. Post-dengue blahs, sometimes referred to as neurasthenia, were well known to British colonials. I reassured Susie that her mood was normal and would gradually improve on its own. The following week her dengue antibody sent from the emergency room finally came back positive.
