Sir,

We read with interest the report by Nainiwal et al1 of a 14-year-old girl with bilateral vitreous haemorrhage associated with dengue haemorrhagic fever (DHF). The authors suggested that if a patient with DHF was to present with bilateral vitreous haemorrhage, severe headache and myalgias after the initial fever and rashes have subsided, a misdiagnosis of Terson's syndrome could be made. Terson's syndrome is vitreous haemorrhage occurring in association with subarachnoid haemorrhage. From the report, it is unclear if the authors have satisfactorily excluded subarachnoid haemorrhage in their patient. There was no mention of any detailed neurological examination or imaging of the brain performed on the patient to suggest that intracranial pathology has been excluded.

Although rare, DHF has been associated with subarachnoid haemorrhage.2 A sudden increase in intracranial pressure from subarachnoid haemorrhage can rupture the epipapillary and peripapillary capillaries, resulting in Terson's syndrome. In a systematic review by McCarron et al,3 24 out of 181 (13%) patients with subarachnoid haemorrhage assessed prospectively had vitreous haemorrhage. Rarely, there may be no neurological symptoms or signs in Terson's syndrome at the initial presentation.4 Computed tomography has a high sensitivity (91–98%) for the detection of subarachnoid haemorrhage, although it cannot unequivocally exclude subarachnoid haemorrhage.5

In summary, while we agree that it is possible for vitreous haemorrhage to occur in DHF, we wish to highlight that Terson's syndrome could be a plausible explanation for the occurrence of vitreous haemorrhage in DHF and this life-threatening condition should not be overlooked.