Wegener’s granulomatosis with dengue fever: an unusual association

Dear Editor, A 14-year-old unmarried girl was admitted to our hospital with a history of high-grade continuous fever for 15 days, along with mild non-productive cough for 7 days and conjunctival congestion for 4 days. On further interrogation, she revealed that she experienced an episode of epistaxis 3 days prior to onset of fever along with a blood-stained purulent discharge from her right ear which persisted for 2 days. She again had an episode of epistaxis on the day following her admission. On examination, she was found to have fever (38.9 C) and tachycardia (110 beats/min). Systemic examination revealed hemorrhagic spots on right nasal mucosa and tenderness over the right tragus. All other examination findings were normal. Possibilities of viral hemorrhagic fever, sepsis, hematological malignancy or aplastic anemia were kept under consideration and investigations followed. A broad-spectrum antibiotic in the form of cefoperazone + sulbactum (1 g + 500 mg) twice daily was also initiated empirically. The complete hemogram revealed Hemoglobin 8.7 g/dL, total leukocyte count 12 100/mm, neutrophil72, lymphocyte22, platelet count 480 000/mm). The erythrocyte sedimentation rate was 62 mm/1st hour. Liver function tests, blood sugar and serum urea and creatinine values were normal. Tests for human immunodeficiency virus antibodies were found to be non-reactive. Blood culture was found to be negative. Enzyme-linked immunosorbent assay done for detection of Dengue antibodies was found to be positive! There was presence of both immunoglobulin (Ig)M and IgG types of Dengue antibodies in the serum of the patient. A raised platelet count in the background of a seropositivity for Dengue infection was considered an unusual finding. So it was followed up with some more investigations. Urine analysis revealed strong presence of occult blood with 60–80 red blood cells per high power field (RBC/hpf). The albumin/creatinine ratio was 10 mcg/ mg. The urine culture was negative. At this juncture, a chest X-ray done incidentally as a part of routine investigation revealed two thick-walled cavity lesions located in both the right and left lung fields. We followed this up with sputum examination for acid fast bacilli and Gram-staining bacteria. Both microscopy and culture were found to be negative. So we decided to undertake a contrast-enhanced computed tomography (CT) scan of the thorax. This revealed multiple thick-walled lesions in both lung fields and few nodular lesions (Fig. 1). As per the radiologist’s opinion, this was suggestive of Wegener’s granulomatosis. CT-guided fine-needle aspiratory cytology from the lesion confirmed the presence of granulomatous inflammation. Test for detection of antineutrophil cytoplasmic antibody was positive with presence of antiproteinase 3 antibody at a level of 70.27 U/mL (normal < 6 U/mL). With these results, a diagnosis of Wegener’s granulomatosis was established for this patient. The patient was hence put on intravenous methylprednisolone