A challenge to clinical management: A case of expanded dengue syndrome co-infection with dengue 1 and dengue 3 serotypes in Nepal

Rapid progression to fatal expanded dengue syndrome is unusual, presenting a challenge for clinical management. We present a case of a 32-year-old female with atypical dengue manifestations who underwent extensive evaluation at a Kathmandu infectious disease hospital, including vital signs assessment, clinical scoring, and routine and advanced laboratory analyses. Severe abdominal pain, disorientation, and abnormal hemodynamics with multi-organ involvement were noted with a secondary dengue virus (DENV) infection. Co-infection of DENV-1 and DENV-3, exhibiting high viral loads, was observed, marking the first fatal case of its kind in Nepal. Despite intensive care management, the patient’s condition rapidly deteriorated, leading to fatal expanded dengue syndrome within four days of a hospital visit. This poses a serious challenge to clinicians. Heightened vigilance from the onset of DENV infection is imperative, regardless of serotypes or viral load levels. Predictive markers for early detection and management strategies are urgently needed to achieve the WHO's goal of zero dengue-related deaths by 2030.