Transient polycythemia during diabetic ketoacidosis triggered by dengue fever in a middle-aged woman

Either dengue fever or diabetic ketoacidosis can cause the high hemoglobin concentration due to intravascular volume loss. When both entities were found together as in our case, the hemoglobin concentration could access the strikingly high level until either of them could not contribute it. She was a Thai woman with 46 years of age presenting with fever, fatigue and severe sore throat for a few days. The physical examination showed she had mild dyspnea and oral thrush, the temperature was 36.4 degree Celsius, and her pulse rate was 102/min. Her blood tests showed: Hb 18.3 g%, WBC 9,850/mm3, atypical lymphocyte 10%, platelet 16,000/mm3, MCV 89.2 fl, Dengue NS1 antigen-positive, dengue IgG-positive, IgM-weakly positive, KOH preparation of curd from buccal mucosa-positive for budding yeasts and pseudo-hyphae, blood sugar 442 mg%, triglyceride 578 mg%, Na 122.8 mEq/L, K 6.28 mEq/L, Cl 90.6 mEq/L, CO2 9.2 mEq/L, blood ketone 53.6 mmol/L, lactate 4.5 mmol/L, pH 7.257, pCO2 27.4 mmHg, HCO3 11.9 mmo/L, BUN 22.9 mg%, creatinine 0.64 mg%, AST 375 U/L, ALT 224 U/L, alkaline phosphatase 151 U/L. She was diagnosed as having diabetes with diabetic ketoacidosis, dengue fever and polycythemia. She was immediately treated with intravenous fluid therapy to correct the metabolic acidosis, electrolyte imbalance and dehydration, insulin for hyperglycemia, clotrimazole for oral thrush and platelet transfusion. Her high hemoglobin level was dramatically lowered until became normal within one day of therapy whereas she also recovered from DKA although the platelet was progressively lowered every day. It suggested that transient polycythemia was solely contributed by DKA that was triggered by dengue fever hence DKA from dengue fever should be added in the list of unusual causes of transient polycythemia.