Fissure sign in dengue

How to cite this article:
Agarwal MP, Giri S, Sahu SK, Sharma V. Fissure sign in dengue. Ann Trop Med Public Health 2011;4:149-50


How to cite this URL:
Agarwal MP, Giri S, Sahu SK, Sharma V. Fissure sign in dengue. Ann Trop Med Public Health [serial online] 2011 [cited 2020 Aug 13];4:149-50. Available from:


A 23-year-old male presented with history of breathlessness for 3 days. The breathlessness had progressed over the past 3 days. The patient had been having high grade fever associated with chills and rigors. The fever had started 5 days before onset of dyspnoea but the patient had been afebrile for past 2 days. On the day of presentation, the patient had noted mild gum bleed. At presentation, the patient was tachypneic (RR-22/min) and his blood pressure was 96/60 with a pulse rate of 118/min. He had a palpable liver and the breath sounds were diminished on the right side. Investigations revealed a hematocrit of 58, a total leukocyte count of 3200/mm 3 and a platelet of 12,000/μL. The ultrasonogram of abdomen confirmed the presence of hepatomegaly and cholecystoedema and ascites. Chest roentgenogram revealed presence of bilateral pleural effusions more on the right side [Figure 1]. The IgM serology for dengue, negative at presentation, was positive at one week. Interestingly the x ray also revealed fluid in fissure, which is not commonly seen in dengue fever. The patient was transfused platelets, given intravenous fluids and improved. The chest roentgenogram at one week was normal [Figure 2].

Figure 1: Chest Roentgenogram showing fi ssure sign

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Figure 2: Chest Roentgenogram showing resolution

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Dengue is an arboviral disease, which represents a major challenge to health care systems in many tropical countries including India. It is characterized by an acute febrile illness accompanied by leukopenia and bleeding manifestations secondary to thrombocytopenia. [1] Dengue haemorrhagic fever (DHF) is the more severe form of disease developing in a minority of affected individuals and is characterised by plasma leakage syndrome. Severe plasma leakage may result in hypovolemia and may manifest as circulatory shock. Dengue shock syndrome refers to that subgroup of DHF with reduced pulse pressure and/or hypotension. Other manifestations of plasma leakage include development of hemoconcentration, pleural effusions, and ascites. The present case is presented for the interesting phenomenon of fissure sign, which accompanied dengue due to plasma leakage. The phenomenon of plasma leakage, interestingly, develops around the time of improvement of pyrexia. Increased risk of DHF is noted in secondary infection, certain genetic polymorphisms, etc. [1],[2] Mechanism of plasma leakage includes excessive activation of dengue specific T cells, and viral infection of endothelial cells modulating cytokine action. [2] Researchers have labelled this abnormal activation of various cytokines as a cytokine tsunami resulting in dengue hemorrhagic fever. The cytokines elevated in IL-2, IL-4, IL-6, IL-8, IL-10, IL-13, IL-18, TNF-α, TGF-β; a profile markedly different from dengue fever. Apart from these other mediators like NO, endothelin, cytotoxic factor, anti-NS1 antibody, and matrix metallopeptidases. [3] Management of severe cases primarily is supportive and includes fluid therapy with intravenous crystalloids and needs continuous monitoring of vital signs. [1]



1. Teixeira MG, Barreto ML. Diagnosis and management of dengue. BMJ 2009;339:b4338.
2. Srikiatkhachorn A. Plasma leakage in dengue haemorrhagic fever. Thromb Haemost 2009;102:1042-9.
3. Basu A, Chaturvedi UC. Vascular endothelium: The battlefield of dengue viruses. FEMS Immunol Med Microbiol 2008;53:287-99.

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.85779


[Figure 1], [Figure 2]

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