Beta thalassemia major with acute dengue complications and liver failure

Harish Mallapura Maheshwarappa1, T R Hemkumar2, Shilpa Singi3, Ram Mohan Maiya G R4, Chaitra S5, Alankrita Agarwal6, Ashwini N A7, Goura Lokanadha8

Department of Critical Care, Kauvery Hospital, Marathahalli, Bangalore

Case Presentation

A 29-year-old male with a known history of Beta Thalassemia Major on regular blood transfusions, on Iron chelation therapy and post-splenectomy status.

Chief Complaint: Intractable epistaxis. Additional symptoms:  Three episodes of mild melena

Vitals: Hemodynamically stable

Shifted to ICU for observation and monitoring. Started on IV pantoprazole infusion and fluid resuscitation

Initial Investigations

Dengue NS1 Antigen: Positive

CBC

  • Hb: 6.7 g/dL
  • Platelets: 59,000/mm³
  • WBC (TLC): Trending upwards
  • INR: 2.1 → Coagulopathy

ENT consult: Nasal packing done

Melena attributed to swallowed nasal blood.

Clinical Deterioration

Within hours, patient developed:

  • Tachypnea, hypoxia → intubated for airway protection
  • Persistent oral bleeding and massive melena
  • Liver failure and encephalopathy

Acute Liver Failure

  • AST: 6110 IU/L
  • ALT: 3103 IU/L
  • ALP: 160 IU/L
  • Ammonia: 86 µg/dL → later rose to 108 µg/Dl
  • Fibrinogen: 199 mg/dL

Started on IV N-Acetylcysteine (NAC)

Required multiple blood products: PRBCs, Platelets, FFP, Cryoprecipitates

Recurrent fever spikes: > 102°F → cold saline infusion, tepid sponging

Work-up and Imaging

  • UGI Endoscopy: No GI source of bleeding
  • CT Brain: Bilateral petechial hemorrhages (temporo-occipital junction)
  • CT Abdomen: Right basal lung consolidation, no intra-abdominal bleeding

Persistent encephalopathy delayed weaning trial.

Antimicrobial Management

Initial antibiotic: Ceftriaxone

  • Worsening TLC → Escalated to – Based on DTA culture: MDR Klebsiella pneumonia, Ceftazidime-Avibactam + Aztreonam
  • Persistent fever → Anidulafungin added

Weaning and Recovery

Transaminitis resolving by Day 5 of ventilation. Successfully extubated to HFNC on Day 10

Bleeding stopped, platelet and Hb stabilized:

  • Platelets: 70,000 → 278,200/mm³
  • Hb: 6.7 → 8.5 g/dL

Fever spikes, leukocytosis, and ammonia levels down-trending. Shifted to ward, ambulatory, on oral feeds.

Take away Points

  • Complicated dengue with coagulopathy, bleeding, and acute liver failure
  • Pre-existing Beta Thalassemia Major with immunosuppression post-splenectomy
  • Secondary Klebsiella pneumoniae infection and possible fungal sepsis
  • Required multimodal blood product support, mechanical ventilation, and advanced antimicrobials
  • Excellent recovery with improvement in liver function, hematology, and neurological status

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