An Unusual Presentation of Dense Deposit Disease Triggered by Dengue Infection: Severe Acute Kidney Injury with Nephritic-Nephrotic Syndrome — A Case Report
Saraswathi Yashaswini *
Department of Nephrology, Gandhi Medical College and Hospital, Hyderabad–500003, Telangana, India.
Manjusha Yadla
Department of Nephrology, Gandhi Medical College and Hospital, Hyderabad–500003, Telangana, India.
P. Srinivas
Department of Nephrology, Gandhi Medical College and Hospital, Hyderabad–500003, Telangana, India.
*Author to whom correspondence should be addressed.
Abstract
Background: Dense deposit disease (DDD), a rare subtype of C3 glomerulopathy, arises from dysregulation of the alternative complement pathway and is characterised by distinctive intramembranous, ribbon-like electron-dense deposits on electron microscopy. Its clinical presentation is heterogeneous, ranging from isolated haematuria to fulminant nephritic-nephrotic syndrome and acute kidney injury, and it is frequently precipitated by infectious or immune triggers. Dengue infection has rarely been described as a trigger for DDD.
Case Presentation: We report a 9-year-old boy who presented with a three-month history of intermittent fever and pedal oedema, followed by facial puffiness and gross haematuria. He was initially managed conservatively but was subsequently admitted with anasarca, a hypertensive emergency, altered sensorium, and hypoxia requiring mechanical ventilation. Investigations revealed severe anaemia, thrombocytopenia, acute kidney injury, liver dysfunction with coagulopathy, low serum C3 with normal C4, and positive dengue IgM; other infectious and autoimmune investigations were negative. He required peritoneal dialysis, blood product transfusions, and multidrug antihypertensive therapy, with resolution of acute kidney injury after five days of dialysis. A renal biopsy performed after blood pressure stabilisation showed diffuse mesangial and endocapillary hypercellularity with thickened, focally duplicated basement membranes on light microscopy, minimal immune deposits on immunofluorescence, and extensive ribbon-like intramembranous electron-dense deposits with focal confluent "sausage-shaped" deposits on electron microscopy, confirming dense deposit disease. He was started on steroids, with continuation of antihypertensive therapy, and showed significant clinical and renal recovery.
Conclusion: This case illustrates a severe, acute presentation of dense deposit disease apparently triggered by dengue infection, with multiorgan involvement requiring critical care and renal replacement therapy, followed by substantial recovery with timely supportive management and immunosuppression. Dengue infection should be considered among the infectious triggers that may unmask or precipitate complement-mediated glomerulopathies, and a high index of suspicion, together with renal biopsy, is warranted in children presenting with atypical or severe nephritic-nephrotic syndrome in this setting.
Keywords: Dense deposit disease, C3 glomerulopathy, dengue infection, acute kidney injury, nephrotic-nephritic syndrome, pediatric nephrology