Severe dengue fever with life-threatening gastrointestinal hemorrhage in a liver transplant recipient undergoing adjuvant chemotherapy for hepatocellular carcinoma

Dengue fever poses a significant diagnostic and therapeutic challenge in immunocompromised hosts, particularly in solid organ transplant recipients. We report a severe case in a patient during the early post-operative period following liver transplantation for hepatocellular carcinoma, who was concurrently receiving adjuvant chemotherapy with oxaliplatin and fluorouracil. This unique confluence of iatrogenic immunosuppression and chemotherapy-induced myelosuppression resulted in a life-threatening presentation characterized by grade 3 bone marrow suppression, severe anemia, overt gastrointestinal hemorrhage from gastric ulcers and colonic erosions, and acute kidney injury, necessitating intensive care management. Diagnosis was confirmed via dengue virus RNA testing, which was critical in differentiating the etiology from other potential causes of fever and pancytopenia in this complex setting. Management required a delicate balance of aggressive multidisciplinary supportive care, including endoscopic hemostasis and judicious blood product support, alongside cautious adjustment of immunosuppressive therapy to control the viral infection without precipitating graft rejection. This case underscores the severe, multifaceted complications dengue can precipitate in patients with dual vulnerabilities from transplantation and oncological therapy, highlighting the imperative for high clinical suspicion, rapid molecular diagnostics, and a coordinated, multidisciplinary approach to navigate competing clinical priorities and achieve a successful outcome.