Online ISSN : 1687-8329

    




Quick Search 
 
Author  
Year    
Title  
Vol:  

 
 
January2008 Vol.45 Issue:      1 Table of Contents
Full Text
PDF


Benign Acute Myositis in Association with Acute Dengue Viruses’ Infections

Sameh M. Said1, Kadry M. Elsaeed2, Zakareya Alyan3
Departments of Neuropsychiatry, Alexandria University1, InternalMedicine, Ain Shams University2;Clinical Pathology, Cairo University3

ABSTRACT

Introduction: Dengue is the most common and widespread arthropod-born arboviral infection in the world today. Early diagnosis and prompt management would help prevent evolution into the more devastating sequelae with hemorrhagic manifestations and dengue shock syndrome. However, the diagnosis of dengue fever in the early febrile phase with undifferentiated symptoms and signs is difficult. The frequent observation of myalgia (sometimes severe) and increased serum CK in patients with dengue fever attending our hospital inspired us the idea of this study. Aim of the work: To study myositis associated with dengue viruses’ infections. Also, to study if the elevated serum CK levels in the early febrile phase among suspect cases with acute dengue viruses’ infections has value in the early diagnosis of dengue fever. Patients and methods: This was a prospective study that was carried out on all cases of dengue fever and dengue hemorrhagic fever presented to Hay Aljamea Hospital, Jeddah, Saudi Arabia from January 2006 till December 2006. All clinics in the hospital were alerted and asked to report suspected cases of dengue viruses’ infections according to the WHO 1997’s case definition. Paired serum samples were collected from 525 patients and  MAC-ELIZA was done on them. Patients with positive serological tests for acute dengue viruses’ infections were re-examined by the investigators and thorough neurological assessment and EMG studies were performed. Results: Serological tests were positive for acute dengue viruses’ infections in 101 patients. One hundred nine patients had elevated serum CK levels in the first serum samples. Among them, 47 patients had acute dengue viruses’ infection by testing the first serum sample. The number increased to 92 patients by testing the second serum sample. This gives the elevated CK levels among febrile patients with suspected criteria of acute dengue viruses’ infection according to the case definition mentioned above, a positive predictive value of 84% and a negative predictive value of 98% in the diagnosis of dengue fever. If the criteria of patients suspected to have dengue fever had been narrowed to only include those who have elevated CK levels, the pre-test probability for the diagnosis of acute dengue viruses’ infection would have been 92.7%. Myalgia was found in 64 patients (63.4%). However, it was severe in 12 patients only. Mild proximal muscle weakness especially in the lower limbs was found in only three patients and they recovered completely before discharge. Nerve conduction studies were normal in all the patients. EMG showed features of muscle hyperirritabilities in 4 patients only; 3 of them had muscle weakness. Conclusions: Benign acute myositis is a very common manifestation in association with dengue viruses’ infection. Serum CK level should be checked in every patient suspected to have dengue fever in the febrile phase and be used as a diagnostic marker till the serology results for dengue viruses are available.

(Egypt J. Neurol. Psychiat. Neurosurg., 2008, 45(1): 193-200)

 




 


INTRODUCTION

 

Dengue is the most common and widespread arthropod-born arboviral infection in the world today. The geographical spread, incidence and severity of dengue fever (DF) and dengue haemorrhagic fever (DHF) are increasing in the Americas, South-East Asia, the Eastern Mediterranean and the Western Pacific. Some 2,500 to 3,000 million people live in areas where dengue viruses can be transmitted. It is estimated that each year 50 million infections occur, with 500,000 cases of DHF and at least 12,000 deaths.1

Epidemics of dengue like disease appeared in the Arabian peninsula in the late 19th century (1870–1873). The disease appeared in Zanzibar, in Dar el Salam, on the East African coast, in Mecca, Madina, and Jeddah, Saudi Arabia. However, this epidemic was preceded by earlier major epidemics affecting the 3 continents of Asia, Africa, and America in 1779 and 1780.1 In 1984, on the basis of serologic results, Jimenez-Lucho et al.2 reported a case of DF with hemorrhagic manifestations in a patient from Yemen. In 1994, dengue virus was isolated in Jeddah, Saudi Arabia, for the first time. Since that time, doctors in Jeddah were alerted to the clinical syndromes associated with dengue infection3.

Dengue fever and DHF are caused by the dengue viruses, which belong to the genus Flavivirus, family Flavivirida. There are 4 antigenically related but distinct dengue virus serotypes, dengue virus types 1–4 (DEN-1, DEN-2, DEN-3, and DEN-4), all of which can cause DF-DHF. The viruses are transmitted to humans by the bite of Aedes aegypti mosquitoes.4

The virus is present in blood in early acute phase only, generally for 1-5 days. The incubation period varies between 3 to 10 days with an average of 4-6 days. There are 2 patterns of host serological responses namely the primary and secondary immune response. The primary response occurs in non immune individuals undergoing their first dengue virus infection, while the secondary (anamnestic) response occurs in individuals having memory cells and repeat dengue infection. During a primary infection, individuals develop IgM antibodies 5-6 days after the onset of illness lasting 30 to 90 days. IgG levels rise after IgM and are detectable for life. During a secondary infection IgM levels are lower. In contrast, IgG levels rise rapidly to higher levels than observed in primary or past dengue infection.5

Early diagnosis and prompt management would help prevent evolution into the more devastating sequelae with hemorrhagic manifestations and dengue shock syndrome (DSS). However, the diagnosis of dengue fever in the early febrile phase with undifferentiated symptoms and signs is difficult. Detection of the virus by culture is of limited clinical value due to many practical considerations. Detection of dengue RNA by the reverse transcription-polymerase chain reaction (PCR)-amplification assay is faster than virus culture but it is no less complex than virus isolation and is highly prone to false-positive results due to contamination. Anti-dengue IgM appears in only half of the patients with a primary infection while they are still febrile. Consequently, serological tests are not quite reliable early in the febrile phase5.

Myalgia is a common manifestation in DF and one of the criteria of a suspect case according to the WHO 1997 criteria5. However, myositis and/or elevated serum CK were only reported infrequently with few cases with muscle paralysis6 or acute rhambdomyolysis7-9. To our knowledge, it is not yet mentioned as a potential complication of dengue fever by major textbooks or review articles7,10,11. The frequent observation of myalgia (sometimes severe) and increased serum CK in patients with dengue fever attending our hospital inspired us the idea of this study

 

Aim of the work:

To study myositis associated with dengue viruses’ infections. Also, to study if the elevated serum CK levels in the early febrile phase among suspect cases with acute dengue viruses’ infections has value in the early diagnosis of dengue fever.

 

PATIENTS AND METHODS

 

This was a prospective study that was carried out on all cases of dengue fever and dengue hemorrhagic fever presented to Hay Aljamea Hospital, Jeddah, Saudi Arabia from January 2006 till December 2006. All clinics in the hospital were alerted and asked to report suspected cases of dengue viruses’ infections according to the WHO 1997’s case definition5:

DF: acute febrile illness of 2-7 days duration associated with 2 or more of the following; headache, retro-orbital pain, myalgias, arthralgia, rash, hemorrhagic manifestations, or leukopenia.

DHF is diagnosed in cases meeting one or more of the following: 1- a positive result from the tourniquet test, 2- petechiae, ecchymoses, or purpura, 3- bleeding from the mucosa, gastrointestinal tract, injection sites, or other sites or 4- hematemesis or melena and thrombocytopenia (<100,000 cells/mm3) and evidence of plasma leakage due to increased vascular permeability manifested by one or more of the following: greater than 20% rise in average hematocrit level for age and sex, greater than 20% drop in hematocrit level following volume replacement compared to baseline, or signs of plasma leakage (eg, pleural effusion, ascites, hypoproteinemia)

DSS is diagnosed in cases meeting all of the above criteria plus evidence of circulatory failure, such as the following: rapid weak pulse, narrow pulse pressure (<20 mm Hg), hypotension, cool, clammy skin, and altered mental status.

Blood samples were collected from 525 patients. They were 268 (51%) males and 257 (49%) females. The age range was from 2 to 71 years, with the mean age 32.8±29.3 years. For all these patients, serological tests for dengue fever were done together with CBC, serum CK, HTC, PT, PTT, ALT, AST, Na, Albumin, blood urea nitrogen, chest X-ray and all other necessary tests to exclude or confirm other potential causes of patients’ condition; e.g. cultures of blood, urine, CSF, and other body fluids.

Patients with positive serological tests for acute dengue viruses’ infections were re-examined by the investigators and thorough neurological assessment and EMG studies were performed.

 

Serological methods:

Serial (paired) serum samples were used to detect anti-dengue IgM antibodies using IgM antibody-capture enzyme-linked immunoabsorbent assay (MAC-ELIZA) method described by Kuno et al.12. The first sample was taken at presentation during the acute febrile phase and a second serum sample was withdrawn from patients 2-14 days later spanning the day of defervescence. Laboratory criteria for diagnosis included demonstration of a 4-fold or greater change in reciprocal immunoglobulin M (IgM) antibody titers to one or more dengue virus antigens in paired serum samples5.

 

Electrophysiological studies:

Nerve conduction velocity (NCV) measurements were made using a standard EMG EP machine (Medtronic systems, USA). NCV recordings were done using standard procedures such as temperature control (32-34 °C), careful distance measurements and recording of well-defined and artifact-free responses. Motor NCV (MCV) of the median and tibial nerves was measured by conventional methods with surface electrodes. Similarly, sensory NCV (SCV) of the median and sural nerves was also measured. A standard electromyogram (EMG) test using a standard 50 mm concentric needle electrode was done for the right quadriceps and deltoid muscles. In patients who showed acute myositic pattern in deltoid and quadriceps examination, the examination was extended to include right biceps, triceps and first dorsal interossiuos muscles in the upper limbs and tibialis anterior, gastrocnemius muscles in the lower limbs13.

 

Statistics

Statistics were done using the SPSS program 12 for windows (USA). Descriptive statistics including mean and standard deviation were computed for continuous variables (e.g., age). Frequency and percentage were computed for numeric variables (e.g., sex). Cross tabulations were used. Results of MAC-ELIZA were used as final diagnostic test (columns) and other variables (e.g., normal or high serum CK levels) were tested against it (raws). Positive predictive values, negative predictive values and pre-test probabilities were calculated.

 

RESULTS

 

Serological tests were positive for acute dengue viruses’ infections in 101 patients. Anti-dengue IgM antibodies were detected in the first serum samples in 63 patients and reached 109 in the second serum samples. In 12 patients whose first serum samples tested positive for anti-dengue IgM antibodies, the titer did not rise in the second sample. This gives the WHO criteria for a suspect dengue fever patient a pre-test probability of 19.2% for the diagnosis of dengue fever. On the other hand, the serological test done on the first serum sample detected 50.1% of those who ultimately proved to have acute dengue viruses’ infections.

One hundred nine patients had elevated serum CK levels in the first serum samples (Table 1). This ranged from 200 to 8000 U/L with a mean of 1000±112 U/L. Among them, 47 patients had acute dengue viruses’ infection by testing the first serum  sample. The number increased to 92 patients by testing the second serum sample. This gives the elevated CK levels among febrile patients with suspected criteria of acute dengue viruses’ infection according to the case definition mentioned above, a positive predictive value in the diagnosis of dengue fever of 84% and a negative predictive value of 98%. If the criteria of patients suspected to have dengue fever had been narrowed to only include those who have elevated CK levels, the pre-test probability for the diagnosis of acute dengue viruses’ infection would have been 92.7% (Table 1).

Patients proved to have acute dengue viruses’ infection (n=101) were 52 (51%) males and 49 (49%) females. The age range was from 2 to 66 years, with the mean age 23+9 years. They were 59 (58%) Saudi patients and 42 (42%) non-Saudi patients. Seventy nine (78%) patients were from Jeddah and 22 (22%) patients were from outside Jeddah. Table (2) shows the symptoms and signs found in these patients. Forty two patients (41.6%) fulfilled the diagnostic criteria of DHF. One patient passed away with DSS. Table 2 shows their laboratory results.

Neurological assessment of the 101 patients with positive serological tests for acute dengue viruses infections showed the following: Consciousness was altered in 3 patients with encephalopathy, 2 of them recovered full conscious and one patient developed deep coma and eventually passed away with DSS. Myalgia was found in 64 of them (63.4%). However, it was severe in 12 patients only. Mild proximal muscle weakness especially in the lower limbs was found in only three patients and they recovered completely before discharge. Nerve conduction studies were normal in all the patients. EMG showed features of muscle hyperirritabilities (increased insertion activities, fibrillation potentials, positive sharp waves, and complex repetitive discharges pattern) in 4 patients only; 3 of them had muscle weakness.


 

 

Table 1. Cross table shows the serology results and the serum CK levels.

 

 

Serological Tests

(MAC-ELIZA)

Total

+ve

-ve

Serum CK

High

92

17

109

Normal

9

407

416

Total

101

424

525

 

 

Table 2. The different symptoms and signs of patients with acute dengue viruses’ infections.

 

Symptom/sign*

n = 101 (%)

Fever

101 (100)

Arthralgia

72 (71.3)

Myalgia

64 (63.4)

Headache

60 (59.4)

Retro-orbital pain

13 (12.8)

Skin rash

23 (22.8)

Petechiae

78 (77.2)

Gum bleeding

34 (33.7)

Gastrointestinal bleeding

19 (18.8)

Hemoptysis

4 (3.9)

Cough

20 (19.8)

Abdominal pain

68 (67.3)

Nausea

27 (26.7)

Diarrhea

3 (2.9)

Altered consciousness

3 (2.9)

Mortality

1 (0.99)

*An individual patient might have more than one symptom and/or sign.

 

 


DISCUSSION

 

Viral myositis and its complications are well described with several acute viral infections, most notably influenza A and B virus, HIV, coxsackieviruses, and cytomegalovirus7. To our knowledge, it is not mentioned as a potential complication of dengue fever by major textbooks or review articles7,10,11. The results of the present study showed that myositis is a very common manifestation in patients with acute dengue viruses’ infections.

Myositis associated with dengue fever is of acute benign nature, short course and requires no specific treatment. In the present study, myositis was subclinical (only elevated serum CK level) in 27.7% of patients, only myalgia without weakness in 63.4% of patients, and mild reversible proximal weakness especially in both lower limbs in 2.9%. Similarly, Malheiros14 reported 15 patients with classic dengue fever, serologically confirmed, during the Brazilian dengue epidemics from September 1986 to March 1987. The 15 patients presented with myalgia but there was no detectable muscle weakness or other neuromuscular involvement. However, muscle biopsy was positive for myositis in 12 patients. Even though, when acute muscle paralysis was recently reported in 6 patients in association with dengue fever6, the patients recovered completely in short time without specific treatment. There are, however, few case reports that described severe muscle complications in association dengue fever. As with benign acute myositis caused by influenza viruses15, there are also few reports describing rhabdomyositis in association with dengue infections. In both viruses, these few case reports, in comparisons with the large series accumulating at many centers over the years, including the results of the current study, are not enough evidence to  change the belief that myositis associated with either influenza or dengue viruses is benign. On the other hand, Finsterer and Kongchan16 reported one case of severe, persistent myalgias following acute dengue infection, responsive only to opiates, and did not resolve before the administration of corticosteroids, 2 months after onset. They concluded that dengue fever may cause persisting, severe, myositis for weeks. None of our patients as well as patients reported by others even those who had muscle paralysis or even rhabdomyositis needed corticosteroids for recovery which casts great doubt on the etiology of myositis in the case reported by Finsterer and Kongchan16.

The EMG findings also support he concept that myositis associated with dengue viruses’ infections is benign. In the present study, EMG showed normal findings in most of the patients of the present study despite the presence of myalgia and elevated CK levels. It showed features of muscle hyperirritabilities in 4 patients only; 3 of them had muscle weakness. Similar findings were reported by other authors. Kalita J et al.6 reported on 7 patients with dengue fever who presented to their department with acute quadriplegia. Serum CK was high in all. However, nerve conduction and EMG studies were normal in all patients except one whose EMG was myopathic.

The results of the present study are believed to be of value as they suggest refinement of the current diagnostic criteria for dengue fever. The WHO 1997 case definition of dengue fever has a high sensitivity, but runs the risk of over-diagnosis17. When these criteria were applied in the present study, 80.8% of patients did not have DF. Elevated serum Ck level in the early undifferentiated febrile phase was found in 109 patients, of whom 92 proved to have dengue fever. This gives the elevated CK levels a positive predictive value of 84% and a negative predictive value of 98% in the diagnosis of dengue fever. If the criteria of patients suspected to have dengue fever had been narrowed to include only those who have elevated CK levels in the febrile phase, the pre-test probability of the proposed criteria for the diagnosis of dengue fever would have been >90%. Further studies are needed to validate the model and test its overall positive and negative predictability for the diagnosis of dengue fever. Till then, we suggest to do serum CK level to every patient whose presentation satisfies the WHO criteria for a dengue fever suspect. If the level is normal, we recommend to investigate immediately for the other causes of fever other than dengue viruses’ infections and not to wait for the results of the dengue viruses’ serology tests. If the serum CK level is elevated, start the management of dengue fever and don’t do other investigations for other etiologies of fever unless otherwise proved later by the serology tests.

In spite of its importance in the diagnosis of myositis, we could not get the approval of the hospital ethics committee to do muscle biopsy due to the invasive nature of the procedure and the lack of enough support in the literature to justify it. In the old study reported by Malheiros14 muscle biopsy was done in the 15 patients with dengue fever and myalgia without any weakness. They reported the presence of a light to moderate perivascular mononuclear infiltrate in 12 patients and lipid accumulation in 11. On the other hand, more recently, myositic findings on histopathology was found in 1 patient only (14.3%) out of the 7 patients with dengue fever and acute muscle paralysis reported by Kalita J et al.6. This means that the likelihood to find positive findings on muscle biopsy would be much less if they had included asymptomatic patients or patients with myalgia without muscle weakness. This low expectation for positive findings on muscle biopsy is also supported by normal findings on EMG on their series (6) and in the present study.

 

Conclusions:

Benign acute myositis is a very common manifestation in association with dengue viruses’ infection. Serum CK level should be checked in every patient suspected to have dengue fever in the febrile phase and be used as a diagnostic marker till the serology results for dengue viruses are available.

 

Recommendations:

We recommend carrying out a multi-center study in endemic areas of dengue fever; e.g. Jeddah, Saudia Arabia, to test the positive and negative predictability and the overall pre-test probability for the diagnosis of a dengue fever according to the following modified case definition: acute febrile illness of 2-7 days duration associated with elevated serum CK level and 2 or more of the following; headache, retro-orbital pain, myalgias, arthralgia, rash, hemorrhagic manifestations, or leukopenia.

 

REFERENCES

 

1.      World Health Organization. Report on dengue prevention and control: WHO, 55th World Health Assembly, 4 March 2002, document A55/19.

2.      Jimenez-Lucho VE, Fisher EJ, Saravolatz LD, 1984. Dengue with hemorrhagic manifestations: an imported case from the Middle East. Am J Trop Med Hyg 33: 650-653.

3.      World Health Organization, 1995. Dengue and dengue hemorrhagic fever, Saudi Arabia. Wkly Epidemiol Rec 70: 237–238.

4.      Calisher CH, Karasbarsos N, Dalrymple JD, et al. Antigenic relationships between flaviviruses as determined by cross-neutralization tests with polyclonal antisera. J Gen Virol 1989;(70): 37–43.

5.      World Health Organization. Dengue haemorrhagic fever: diagnosis, treatment and control. WHO, Geneva, 1997.

6.      Kalita J, Misra UK, Mahadevan A, Shankar SK. Acute pure motor quadriplegia: is it dengue myositis? Electromyogr Clin Neurophysiol. 2005;45(6):357-61.

7.      Joshua S. Davis and Peter Bourke. Rhabdomyolysis Associated with Dengue Virus Infection. Clinical Infectious Diseases 2004;38:e109-e111

8.      M Lim, H K Goh.  Rhabdomyolysis following dengue virus infection. Case Report. Singapore Med J 2005; 46(11) : 645

9.      Gomes M, Müller K, Busch H, et al. An unusual cause of acute rhabdomyolysis. Rheumatology 2006 45(5):643-644.

10.    Halstead SB. Dengue. Curr Opin Infect Dis 2002; 15(5):471–6.

11.    DeBiasi RL, Solbrig MV, and Tyler KL. Infections of the nervous system; B. Viral infections. In: Bradley WG, Daroff RB, Fenichel GM, and Jankovic. Neurology in Clinical Practice. 2004, 4th ed.  Elsevier Inc. Philadelphia, USA. Vol II; 1515-1554.

12.    Kuno G, Gomez I, Gubler DJ. An ELISA procedure for the diagnosis of dengue infection. J Virol Methods 1991;33: 101–113.

13.    Kimura J. Electrodiagnosis in diseases of nerve and muscle, principles and practice. 3rd eds. Oxford University Press, Inc. New York. 2001.

14.    Malheiros SM, Oliveira AS, Schmidt B, Lima JG, Gabbai AA. Dengue. Muscle biopsy findings in 15 patients. Arq Neuropsiquiatr. 1993 Jun;51(2):159-64.

15.    Barasz M. Benign acute myositis. Am J Emerg Med 2000;18 : 35-37.

16.    Finsterer J, Kongchan K. Severe, persisting, steroid-responsive Dengue myositis. J Clin Virol. 2006 Apr;35(4):426-8. Epub 2006 Jan 18.

17.    Sawasdivorn S, Vibulvattanakit S, Sasavatpakdee M and Iamsirithavorn S. Efficacy of clinical diagnosis of dengue fever in paediatric age groups as determined by WHO case definition 1997 in Thailand. Dengue Bulletin 2001(25):56-64.

 

 

الملخص العربى

 

التهاب العضلات الحميد والحاد المصاحب للعدوى الحادة بحُمَّى الدَّنْك

 

المقدمة: ان حمى الدنك  هى الأكثر شيوعا وانتشارا بين العدوى المتعلقة  بالفيروسات المَنْقولَةِ بِالمَفْصِلِيَّات فى العالم اليوم. التشخيص المبكر و العلاج السليم يساعد على الوقاية من تطور المرض الى العواقب الخطيرة مثل الأعراض النزيفية  ومتلازمة صدمة الدنك. الا انه من الصعب  تشخيص حمى الدنك فى المراحل الأولى من ارتفاع الحرارة والمصحوبة بأعراض ودلالات عامة. وقد ألهمتنا ملاحظة كثرة حدوث آلام العضلات وارتفاع إنزيم كيناز الكِرْياتين بالمصل الى أجراء هذه الدراسة.

هدف البحث: دراسة التهاب العضلات المصاحب للعدوى الحادة بحُمَّى الدَّنْك. وايضا دراسة قيمة استخدام ارتفاع إنزيم كيناز الكِرْياتين  بالمصل فى المراحل الاولى من ارتفاع الحرارة فى التشخيص المبكر لحمى الدنك.

          المرضى وطرق البحث: هذه كانت دراسة استباقية تم إجراءها بمستشفى حى الجامعة بجدة بالمملكة العربية السعودية من بداية يناير 2006 الى ديسمبر 2006. و قد طلب من كل العيادات بالمستشفى ان تبلغ عن كل حالات اشتباه حمى الدنك المتفقة مع تعريف الحالة لمنظمة الصحة العالمية لسنة 1997. و قد تم جمع عينات مصل مزدوجة من 525 مريض وتم عمل اختبار اليزا عليهم. المرضى ذوى النتائج الايجابية لعدوى حمى الدنك اعيد الكشف عليهم إكلينيكيا بالباحثين بالإضافة الى تقييم الأعصاب وعمل دراسات تخطيط عضلات لهم.

النتائج: كانت نتائج الاختبارات السيرولوجية لعدوى حمى الدنك ايجابية فى 101 مريض.  لقد كانت مستويات إنزيم كيناز الكِرْياتين مرتفعة فى  عينة الأمصال الأولى فى 109 مريض.  اثبتت نتائج السيرولوجى اصابة  47  مريض من هؤلاء بحمى الضنك فى عينات المصل الأولى، ثم ازداد العدد الى 92 مريض بعد اختبار العينة الثانية للأمصال. وقد اعطت هذه النتائج لارتفاع إنزيم كيناز الكِرْياتين بالمصل فى المرضى المشتبه اصابتهم بحمى الدنك حسب تعريف الحالة السابق ذكره قيمة توقع ايجابية بلغت 84% و قيمة توقع سلبية بلغت 98%  فى تشخيص حمى الدنك. اما أذا انحصرت معايير الاشتباه فى حمى الدنك لتشمل فقط المرضى الذى ارتفعت فيهم مستويات إنزيم كيناز الكِرْياتين بالمصل، لكان احتمال ما قبل-الاختبار فى تشخيص عدوى حمى الدنك الحادة هو  92.7%. كانت آلام العضلات موجودة فى 64 مريض (63.4%)، الا انها كانت شديدة فى 12 مريض فقط.  تم تشخيص ضعف بسيط بالعضلات الدانية خاصة بالطرفين السفليين فى ثلاثة مرضى و قد شفوا تماما قبل خروجهم من المستشفى. دراسات توصيل الأعصاب كانت طبيعية فى كل المرضى. أما مخطط كهربية العضلات فقد اظهر فَرْطُ هَيُوجِيَّة العضلات فى 4 مرضى فقط ، ثلاثة منهم كانوا يعانوا من ضعف فى العضلات.

الموجز: التهاب العضلات الحميد الحاد عرض شائع مصاحب لعدوى حمى الدنك.  يجب قياس مستوي إنزيم كيناز الكِرْياتين بالمصل فى كل المرضى المشتبه انهم يعانوا من حمى الدنك فى مرحلة ارتفاع الحرارة و يستخدم كعلامة تشخيصية الا ان تظهر النتائج السيرولوجية.

 

 



2008 � Copyright The Egyptian Journal of Neurology,
Psychiatry and Neurosurgery. All rights reserved.

Powered By DOT IT