Dual Viral Assault: Unraveling the Complexities of Dengue and Hepatitis E Co-Infection in a Tropical Setting- A CASE REPORT

Dual Viral Assault: Unraveling the Complexities of Dengue and Hepatitis E Co-Infection in a Tropical Setting- A CASE REPORT | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Dual Viral Assault: Unraveling the Complexities of Dengue and Hepatitis E Co-Infection in a Tropical Setting- A CASE REPORT SAHIL, SHIVAM SHARMA, MANJEETA NATH DAS This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6177958/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Dengue fever and Hepatitis E are distinct viral infections endemic to tropical and subtropical regions, both of which can present with overlapping clinical features such as fever, jaundice, and liver dysfunction. While co-infection with these viruses is rare, it complicates the clinical picture and management. This case report discusses the management of a patient with dengue and hepatitis E co-infection, highlighting diagnostic challenges and the importance of supportive care in achieving recovery. Infectious Diseases Dengue Hepatitis A Dual infection Introduction Dengue fever is a vector-borne viral disease caused by four distinct serotypes (DEN-1 to DEN-4), primarily transmitted by Aedes mosquitoes( 1 ). It is the most prevalent arthropod-borne viral illness globally. Liver involvement is a recognized complication of dengue, ranging from mild transaminitis to severe hepatic dysfunction( 2 ). Hepatitis E, caused by the Hepatitis E virus (HEV), is a waterborne infection endemic to South and Central Asia and parts of Africa. Although usually self-limiting, it can lead to acute liver failure, especially in vulnerable populations such as pregnant women( 3 ). Both dengue and hepatitis E are endemic in tropical regions and can share overlapping clinical features, including fever, jaundice, and liver enzyme elevation. Co-infection, though uncommon, poses significant diagnostic and management challenges due to compounded effects on the liver. This report discusses a case of dengue and hepatitis E co-infection, emphasizing the importance of a thorough diagnostic workup and multidisciplinary management in similar cases. Case Report A 35-year-old male presented with a three-day history of fever and extreme weakness. He denied any history of travel or exposure to contaminated water but resided in a dengue-endemic region. On physical examination, he was afebrile, with mild hepatomegaly and icterus. The patient was hemodynamically stable, with no signs of petechiae or bleeding.Complete Blood Count (CBC) was done which showed Haemoglobin 10.7 g/dL, Platelets 60,000/mm³, WBC 7,430/mm³ and Liver Function Tests (LFTs): Total bilirubin 2.04 mg/dL (direct 1.89 mg/dL), ALT 1237 IU/L, AST 2875 IU/L and Coagulation Profile: Prothrombin Time 14.2 seconds, INR 1.30. Dengue NS1 antigen came out to be positive, also, Hepatitis E IgM positive, Hepatitis A, B, and C negative. Ultrasound Abdomen was done which showed Hepatomegaly with grade I fatty infiltration, oedematous gallbladder wall, and splenomegaly. The patient was managed conservatively for dengue with intravenous fluids, antiemetics, and symptomatic care. Despite initial improvement, persistently elevated liver enzymes and the onset of jaundice necessitated further investigation. Hepatitis E was diagnosed through serological testing. Treatment included continued supportive care with hepatoprotective medications. Over the next two days, the patient’s liver enzymes showed a downward trend, and platelet counts improved. He was discharged in stable condition after achieving clinical and biochemical recovery. Discussion Simultaneous co-infection with dengue and hepatitis E is a rare occurrence but may be increasingly recognised in areas endemic to both viruses. Dengue predominantly affects the vascular system, leading to thrombocytopenia and bleeding tendencies, while hepatitis E directly impacts the liver( 4 , 5 ). In this case, overlapping symptoms such as fever, jaundice, and liver enzyme derangements initially obscured the diagnosis. Serological testing confirmed the presence of both dengue and hepatitis E. Dengue-related liver dysfunction is usually mild to moderate but can be severe in certain cases. Similarly, hepatitis E typically resolves spontaneously but can lead to acute liver failure in vulnerable populations. Co-infection exacerbates these effects, emphasising the need for close monitoring and individualised care. Management of co-infection is largely supportive, focusing on maintaining hemodynamic stability, managing complications, and closely monitoring liver function. Our patient responded well to this approach, highlighting the importance of early diagnosis and prompt treatment in similar cases. Conclusion This case of dengue and hepatitis E co-infection underscores the importance of considering multiple infectious etiologies in patients presenting with febrile illness and liver dysfunction, particularly in endemic regions. Early recognition and comprehensive management are essential to preventing severe complications and improving outcomes. Clinicians should maintain a high index of suspicion for co-infections and adopt a multidisciplinary approach to care. Declarations Ethics approval and consent to participate: No ethical approval was required to report this case while consent was taken from the patient before writing the case report. Consent for publication: Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Availability of data and materials: The data is available with the corresponding author which can be provided on request. Competing interests: The authors have no conflict of interest to declare. Funding: Not applicable Authors' contributions: All authors contributed equally. Acknowledgements: None References Roy SK, Bhattacharjee S. Dengue virus: epidemiology, biology, and disease aetiology. Can J Microbiol. 2021 Oct;67(10):687-702. doi: 10.1139/cjm-2020-0572. Epub 2021 Sep 3. PMID: 34171205. Souza LJ, Alves JG, Nogueira RM, Gicovate Neto C, Bastos DA, Siqueira EW, et al. Hepatic involvement in dengue infection in Brazil. J Clin Virol. 2004;30(4):296-301. doi:10.1016/j.jcv.2003.11.007. Teo EC, Tan BH, Purdy MA, Wong PS, Chan YW, Mustafa FB, et al. Hepatitis E in Singapore: A Case-Series and Viral Phylodynamics Study. Am J Trop Med Hyg. 2017;96(4):922-928. doi:10.4269/ajtmh.16-0482. Trung DT, Thao le TT, Hien TT, Hung NT, Vinh NN, Hien PT, et al. Liver involvement associated with dengue infection in adults in Vietnam. Am J Trop Med Hyg. 2010;83(4):774-780. doi:10.4269/ajtmh.2010.10-0090. Purcell RH, Emerson SU. Hepatitis E: an emerging awareness of an old disease. J Hepatol. 2008;48(3):494-503. doi:10.1016/j.jhep.2007.12.008. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6177958","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":425575089,"identity":"7cc68ee9-740b-45f3-8105-72e0baa3d076","order_by":0,"name":"SAHIL","email":"","orcid":"https://orcid.org/0009-0002-4027-3399","institution":"MANIPAL HOSPITALS, DWARKA, NEW DELHI","correspondingAuthor":false,"prefix":"","firstName":"","middleName":"","lastName":"SAHIL","suffix":""},{"id":425575749,"identity":"c9338424-2a3b-449f-ac09-54a45146f816","order_by":1,"name":"SHIVAM SHARMA","email":"","orcid":"","institution":"MANIPAL HOSPITALS, DWARKA, NEW DELHI","correspondingAuthor":false,"prefix":"","firstName":"SHIVAM","middleName":"","lastName":"SHARMA","suffix":""},{"id":425575750,"identity":"b61d239d-a706-479c-a81b-fe02de836a42","order_by":2,"name":"MANJEETA NATH DAS","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABF0lEQVRIiWNgGAWjYDCCAzxAgk2CgQ3ClWBgYGc+AGLIkKCFmS0BxOAhoAVZhJnHAETh1MJ3u/fohg9lFvJ80s1HN/zcYZHH38zz+dWNGgseBvbDRzdg0SJ551zazRnnJAzbZI6l3ew9I1EscZh3m3XOMaDDeNLSbmDRYnAjx+w2b5tEAptEjtkNICOxAajFOIcNqEWCxwynlr9gLfnfbgIZifMP8zwzzvlHQAsjxBY2kHWJGw7zMD/ObcOtRfJGXtrNHpBfJNLMbsu2SRQbHmYzY87tk+Bhw+EXvhu5x278KKuTl5+R/Ozm27a6PLnjzY8/53yrk+NnP3wMmxYMkMAAjlkGtMgipIX5A7GqR8EoGAWjYEQAAE0YZI2gi3vlAAAAAElFTkSuQmCC","orcid":"","institution":"MANIPAL HOSPITALS, DWARKA, NEW DELHI","correspondingAuthor":true,"prefix":"","firstName":"MANJEETA","middleName":"NATH","lastName":"DAS","suffix":""}],"badges":[],"createdAt":"2025-03-07 11:42:27","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6177958/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6177958/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":78109018,"identity":"ecf139fa-72e9-46ab-bffe-3e3fc94a00e3","added_by":"auto","created_at":"2025-03-10 04:35:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":200164,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6177958/v1/501505b5-e4a9-4413-bdc7-6e6b9acea320.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eDual Viral Assault: Unraveling the Complexities of Dengue and Hepatitis E Co-Infection in a Tropical Setting- A CASE REPORT\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDengue fever is a vector-borne viral disease caused by four distinct serotypes (DEN-1 to DEN-4), primarily transmitted by Aedes mosquitoes(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). It is the most prevalent arthropod-borne viral illness globally. Liver involvement is a recognized complication of dengue, ranging from mild transaminitis to severe hepatic dysfunction(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHepatitis E, caused by the Hepatitis E virus (HEV), is a waterborne infection endemic to South and Central Asia and parts of Africa. Although usually self-limiting, it can lead to acute liver failure, especially in vulnerable populations such as pregnant women(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBoth dengue and hepatitis E are endemic in tropical regions and can share overlapping clinical features, including fever, jaundice, and liver enzyme elevation. Co-infection, though uncommon, poses significant diagnostic and management challenges due to compounded effects on the liver.\u003c/p\u003e \u003cp\u003eThis report discusses a case of dengue and hepatitis E co-infection, emphasizing the importance of a thorough diagnostic workup and multidisciplinary management in similar cases.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eA 35-year-old male presented with a three-day history of fever and extreme weakness. He denied any history of travel or exposure to contaminated water but resided in a dengue-endemic region.\u003c/p\u003e \u003cp\u003eOn physical examination, he was afebrile, with mild hepatomegaly and icterus. The patient was hemodynamically stable, with no signs of petechiae or bleeding.Complete Blood Count (CBC) was done which showed Haemoglobin 10.7 g/dL, Platelets 60,000/mm\u0026sup3;, WBC 7,430/mm\u0026sup3; and Liver Function Tests (LFTs): Total bilirubin 2.04 mg/dL (direct 1.89 mg/dL), ALT 1237 IU/L, AST 2875 IU/L and Coagulation Profile: Prothrombin Time 14.2 seconds, INR 1.30. Dengue NS1 antigen came out to be positive, also, Hepatitis E IgM positive, Hepatitis A, B, and C negative.\u003c/p\u003e \u003cp\u003eUltrasound Abdomen was done which showed Hepatomegaly with grade I fatty infiltration, oedematous gallbladder wall, and splenomegaly.\u003c/p\u003e \u003cp\u003eThe patient was managed conservatively for dengue with intravenous fluids, antiemetics, and symptomatic care. Despite initial improvement, persistently elevated liver enzymes and the onset of jaundice necessitated further investigation. Hepatitis E was diagnosed through serological testing.\u003c/p\u003e \u003cp\u003eTreatment included continued supportive care with hepatoprotective medications. Over the next two days, the patient\u0026rsquo;s liver enzymes showed a downward trend, and platelet counts improved. He was discharged in stable condition after achieving clinical and biochemical recovery.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSimultaneous co-infection with dengue and hepatitis E is a rare occurrence but may be increasingly recognised in areas endemic to both viruses. Dengue predominantly affects the vascular system, leading to thrombocytopenia and bleeding tendencies, while hepatitis E directly impacts the liver(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this case, overlapping symptoms such as fever, jaundice, and liver enzyme derangements initially obscured the diagnosis. Serological testing confirmed the presence of both dengue and hepatitis E.\u003c/p\u003e \u003cp\u003eDengue-related liver dysfunction is usually mild to moderate but can be severe in certain cases. Similarly, hepatitis E typically resolves spontaneously but can lead to acute liver failure in vulnerable populations. Co-infection exacerbates these effects, emphasising the need for close monitoring and individualised care.\u003c/p\u003e \u003cp\u003eManagement of co-infection is largely supportive, focusing on maintaining hemodynamic stability, managing complications, and closely monitoring liver function. Our patient responded well to this approach, highlighting the importance of early diagnosis and prompt treatment in similar cases.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case of dengue and hepatitis E co-infection underscores the importance of considering multiple infectious etiologies in patients presenting with febrile illness and liver dysfunction, particularly in endemic regions. Early recognition and comprehensive management are essential to preventing severe complications and improving outcomes. Clinicians should maintain a high index of suspicion for co-infections and adopt a multidisciplinary approach to care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: No ethical approval was required to report this case\u003c/p\u003e\n\u003cp\u003ewhile consent was taken from the patient before writing the case report.\u003c/p\u003e\n\u003cp\u003eConsent for publication: Written informed consent was obtained from the patient for publication\u003c/p\u003e\n\u003cp\u003eof this case report. A copy of the written consent is available for\u003c/p\u003e\n\u003cp\u003ereview by the Editor-in-Chief of this journal.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: The data is available with the corresponding author which can\u003c/p\u003e\n\u003cp\u003ebe provided on request.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors have no conflict of interest to declare.\u003c/p\u003e\n\u003cp\u003eFunding: Not applicable\u003c/p\u003e\n\u003cp\u003eAuthors' contributions: All authors contributed equally.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: None\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRoy SK, Bhattacharjee S. Dengue virus: epidemiology, biology, and disease aetiology. Can J Microbiol. 2021 Oct;67(10):687-702. doi: 10.1139/cjm-2020-0572. Epub 2021 Sep 3. PMID: 34171205.\u003c/li\u003e\n\u003cli\u003eSouza LJ, Alves JG, Nogueira RM, Gicovate Neto C, Bastos DA, Siqueira EW, et al. Hepatic involvement in dengue infection in Brazil. \u003cem\u003eJ Clin Virol.\u003c/em\u003e 2004;30(4):296-301. doi:10.1016/j.jcv.2003.11.007.\u003c/li\u003e\n\u003cli\u003eTeo EC, Tan BH, Purdy MA, Wong PS, Chan YW, Mustafa FB, et al. Hepatitis E in Singapore: A Case-Series and Viral Phylodynamics Study. \u003cem\u003eAm J Trop Med Hyg.\u003c/em\u003e 2017;96(4):922-928. doi:10.4269/ajtmh.16-0482.\u003c/li\u003e\n\u003cli\u003eTrung DT, Thao le TT, Hien TT, Hung NT, Vinh NN, Hien PT, et al. Liver involvement associated with dengue infection in adults in Vietnam. \u003cem\u003eAm J Trop Med Hyg.\u003c/em\u003e 2010;83(4):774-780. doi:10.4269/ajtmh.2010.10-0090.\u003c/li\u003e\n\u003cli\u003ePurcell RH, Emerson SU. Hepatitis E: an emerging awareness of an old disease. \u003cem\u003eJ Hepatol.\u003c/em\u003e 2008;48(3):494-503. doi:10.1016/j.jhep.2007.12.008.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Manipal Hospital","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Dengue, Hepatitis A, Dual infection","lastPublishedDoi":"10.21203/rs.3.rs-6177958/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6177958/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eDengue fever and Hepatitis E are distinct viral infections endemic to tropical and subtropical regions, both of which can present with overlapping clinical features such as fever, jaundice, and liver dysfunction. While co-infection with these viruses is rare, it complicates the clinical picture and management. 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