Discussion
COVID-19 and dengue have a spectrum of disease with overlap in clinical
manifestations. Here, we reported a confirmed case of COVID-19 along
with coinfection by dengue. Hemoptysis was the initial and only
indication of COVID-19 infection in this patient with dengue fever,
which was atypical. Hemoptysis can range from mild to severe from a
smear of blood in the sputum to a life-threatening hemorrhage (6). The
majority of dengue infection patients have bleeding, shock, organ
failure, and metabolic acidosis as a result of their illness. It is
unusual for lower respiratory tract to be involved. Dengue fever is a
potentially fatal disease characterized by pulmonary capillaritis, which
causes diffuse alveolar hemorrhage (DAH) which can lead to hemoptysis
(7). It may be the symptom of a number of diseases such as tuberculosis,
malignancy, bronchiectasis, and pneumonia or other conditions (8). This
patient had no anticoagulated or antiplatelet drugs history previously.
As she had no long-term history of low-grade fever, weight loss or
cough, tuberculosis test for hemoptysis was not performed. However
unusual symptoms, such as hemoptysis or atypical CT findings, may emerge
in certain individuals, posing a significant challenge to the epidemic’s
management (9). In our case the patients had hemoptysis with other
accompanying symptoms. In a recent study, hemoptysis was found to be
1.45-2.7 percent in the case of dengue fever, whereas in COVID-19 it was
about 13 percent (10, 11). COVID-19 characteristics such as spike and
nucleocapsid proteins activate the host’s immune system, causing the
virus to be eliminated. In the acute stage, these viral antigens can be
identified by B cells or conveyed to T cells via MHC complexes, leading
in antibody formation, enhanced cytokine secretion, and cytolytic
activity (12). Increased blood levels of IL-2, IL-6, IL-10, and IFN- are
signs of excessive cytokine production in severe instances of COVID-19
(13). High cytokine release and possible ACE2 expression downregulation
in severe COVID-19 can not only promote a hypercoagulable condition
separately, but also bilaterally boost each other’s pro-thrombotic
activities (13). Coagulation system activation is common in critically
ill COVID-19 patients (14). Hemoptysis may be an initial symptom of
venous thromboembolism (VTE), and there is a case presenting with
hemoptysis owing to pulmonary emboli associated with COVID-19 (3). In
our patients, hypercoagulability values such as D-dimer and ferritin
were within normal limits, and no VTE was observed in the radiological
examination. Alveolar hemorrhage is a potential COVID-19 consequence in
this case. Dengue is not known to cause lung alterations, and imaging
results are likely due to increased vascular permeability. Dengue fever,
hemoptysis, especially diffuse pulmonary infiltration needs to be
evaluated in the differential diagnosis. Bilateral regions of
ground-glass opacity or consolidation, as well as bilateral pleural
effusions, are the most prevalent radiographic findings in dengue that
also seen COVID-19 pneumonia (10). The key take away message from this
case is that a lack of knowledge of hemoptysis as a potential COVID-19
clinical manifestation has resulted in initial misdiagnosis and delayed
diagnosis. When dealing with any patient arriving to the hospital in
this pandemic situation with a history of hemoptysis, COVID-19 should be
evaluated in the differential diagnosis list, even if the other
characteristic clinical symptoms of COVID-19, such as fever, dry cough,
myalgia, and shortness of breath are missing. COVID-19 is a novel
illness with many unknown features, unusual presentations such as severe
hemoptysis should also arouse concern regarding the diagnosis of
COVID-19, particularly in pandemic situations in dengue endemic
settings.