Therapeutic Plasma Exchange in a Pediatric Patient Infected with Dengue Virus Serotype 3

To the Editor: Recently, an epidemiological alert to provide information about the increase in dengue cases in the Americas was published [1]. Some children may develop rapidly severe dengue due to their susceptibility to vascular permeability [2]; therefore, the patient’s survival may require therapeutic plasma exchange (TPE). This letter reports a case of severe dengue treated with TPE which was associated with a successful outcome. A 9-y-old boy with fever and suspected dengue virus (DENV) infection was admitted to the pediatric intensive care unit (PICU) of a tertiary hospital in Mexico. The child started with a fever of 39 °C, headache, and general malaise, and 48 h later had epistaxis, tachycardia, hypotension, and prolonged capillary refill time. He had a mean oxygen saturation of 84%, intercostal stretch, nasal flaring, and suspected hypoxic-ischemic encephalopathy, ascites and bilateral pleural effusions, and received mechanical ventilation. He was positive for DENV serotype 3 and was diagnosed with severe dengue. He had gastrointestinal bleeding and oronasal bleeding and was managed with TPE using the formula: estimated plasma volume = 80 x weight (kg) x (1-Ht)/100 [3]. Three plasma exchanges (albumin for the first replacement and fresh frozen plasma for the last two replacements) were performed, each with a 24-h interval. The platelet values progressively increased over the next four days after the third plasma exchange (day 4 = 104 × 10³/µL; day 5 = 170 × 10³/µL; day 6 = 222 × 10³/µL; and day 7 = 240 × 10³/µL). The patient had progressive improvement of the pulmonary lesions and was discharged on day 9 after receiving complete TPE. The combined TPE and continuous renal replacement therapy improves survival in critical children with acute liver failure associated with severe dengue [4]. The present report provides additional data on clinical observations in a pediatric patient with coagulopathy associated with severe dengue and improvement after receiving TPE. …