Evaluation of a commercial dengue NS1 antigen-capture ELISA for laboratory diagnosis of acute dengue virus infection

Emergence of infectious diseases and role of advanced nanomaterials in point-of-care diagnostics: a review

Infectious outbreaks are the foremost global public health concern, challenging the current healthcare system, which claims millions of lives annually. The most crucial way to control an infectious outbreak is by early detection through point-of-care (POC) diagnostics. POC diagnostics are highly advantageous owing to the prompt diagnosis, which is economical, simple and highly efficient with remote access capabilities. In particular, utilization of nanomaterials to architect POC devices has enabled highly integrated and portable (compact) devices with enhanced efficiency. As such, this review will detail the factors influencing the emergence of infectious diseases and methods for fast and accurate detection, thus elucidating the underlying factors of these infections. Furthermore, it comprehensively highlights the importance of different nanomaterials in POCs to detect nucleic acid, whole pathogens, proteins and antibody detection systems. Finally, we summarize findings reported on nanomaterials based on advanced POCs such as lab-on-chip, lab-on-disc-devices, point-of-action and hospital-on-chip. To this end, we discuss the challenges, potential solutions, prospects of integrating internet-of-things, artificial intelligence, 5G communications and data clouding to achieve intelligent POCs.

ISCCM Position Statement: Management of Severe Dengue in Intensive Care Unit

Dengue is one of the commonest causes of undifferentiated acute febrile illness in India as well as South East Asia. Nearly two-fifths of the world population is at risk of infection, and nearly 96 million infections reported worldwide, it is a major cause of concern across the globe. The ISCCM leadership felt that there have been no new directives/guidelines except the MOH guidelines for the management of dengue fever since 2014. Under the auspices of the Indian Society of Critical Care Medicine (ISCCM), an expert group of 14 intensivists from across the country, was formed. The task force members formulated questions that needed to be answered. These questions were validated by the members of ISCCM attending research conclave 2023. All the members systematically searched PubMed, MEDLINE, and Science Direct for original articles on different aspects of dengue management between January 1, 2000, and July 1, 2023. From the collected articles, duplicates were removed. Based on the evidence collected, the expert group members prepared statements/answers to the questions. Since most of the evidence is of moderate to low quality, a consensus was generated amongst the members of the task force. Each statement was agreed upon by 70% of the task force. The statements presented in the article are consensus statements as answers to queries raised.

How to cite this article

Bhalla A, Singh H, Suri V, Yaddanapudi L, Poddar B, Ghawat R, et al. ISCCM Position Statement: Management of Severe Dengue in Intensive Care Unit. Indian J Crit Care Med 2024;28(S2):S42-S58.

Age, gender, and infectious status-wise assessments of hematological parameters among patients with dengue infection

Background

The aim of this study was to examine the impact of different stages of dengue infection on immune cell counts among dengue patients and to compare them with cases of non-dengue febrile illness.

Methods

The recruited patients were divided into two groups: the first group served as a control (n = 55), representing non-dengue febrile illness, and the second group was identified as dengue febrile illness (n = 149), which was further divided into three groups based on infection stage. Blood samples were collected from the selected patients and subjected to blood cell component analysis. To find IgG and IgM as well as the dengue virus non-structural antigen-1 (NS1), an immunochromatographic test (ICT) kit was utilized. Additionally, a hematological analyzer was used to determine complete blood cell counts (CBC). Data was thoroughly analyzed using Graph Pad Prism 6 software. The differences in means of different groups were calculated by applying the student's t-test.

Results

The findings revealed the presence of severe leucopenia and thrombocytopenia at stages 1 and 2, accompanied by lymphopenia at stage 1. Group comparisons indicated that only teenagers exhibited a significantly lower white blood cell count compared to older individuals, while no significant differences were observed in lymphocytes, platelets, and monocytes across all age groups. Comparing different age groups of normal individuals to dengue-infected patients, the results unveiled that leucopenia was most severe in adults, followed by teenagers and children, with no significant difference in the elderly. Furthermore, adults showed the greatest degree of thrombocytopenia, followed by teens and kids, with the elderly showing the greatest degree of thrombocytopenia. Adults and teens showed extreme neutrophilia, whereas young children and the elderly showed no discernible abnormalities. Elderly patients experienced a marked decrease in monocyte count, a phenomenon not observed in other age groups.

Conclusion

In conclusion both, leucopenia & thrombocytopenia, are most severe in stages 1 and 2, whereas neutrophilia & lymphopenia are predominantly severe in stage 1. These results imply that the consequences associated with dengue infection are more severe in the early stages and tend to ameliorate as the patient progresses toward recovery.

Distinct inflammatory markers in primary and secondary dengue infection: can cytokines CXCL5, CXCL9, and CCL17 act as surrogate markers?

Dengue fever poses a significant global health threat, with symptoms including dengue hemorrhagic fever and dengue shock syndrome. Each year, India experiences fatal dengue outbreaks with severe manifestations. The primary cause of severe inflammatory responses in dengue is a cytokine storm. Individuals with a secondary dengue infection of a different serotype face an increased risk of complications due to antibody-dependent enhancement. Therefore, it is crucial to identify potential risk factors and biomarkers for effective disease management. In the current study, we assessed the prevalence of dengue infection in and around Aligarh, India, and explored the role of cytokines, including CXCL5, CXCL9, and CCL17, in primary and secondary dengue infections, correlating them with various clinical indices. Among 1,500 suspected cases, 367 tested positive for dengue using Real-Time PCR and ELISA. In secondary dengue infections, the serum levels of CXCL5, CXCL9, and CCL17 were significantly higher than in primary infections (P < 0.05). Dengue virus (DENV)-2 showed the highest concentrations of CXCL5 and CCL17, whereas DENV-1 showed the highest concentrations of CXCL9. Early detection of these cytokines could serve as potential biomarkers for diagnosing severe dengue, and downregulation of these cytokines may prove beneficial for the treatment of severe dengue infections.

Comprehensive evaluation on progressive development strategies in DENV surveillance and monitoring infection rate among vector population

The elevated rise in dengue infection rate has been a health burden worldwide and it will continue to impact global health for years to come. Accumulated literature holds accountable the geographical expansion of the mosquito species transmitting the dengue virus DENV. The frequency of this viral disease outbreaks has increased rapidly in the recent years, owing to various geo-climatic and anthropological activities. Due to scarcity of any effective control measures, there has been a continuous traceable rise in mortality and morbidity rates. However, it has been reported that the spate of incidences is directly related to density of the virus infected vector (mosquito) population in a given region. In such a scenario, systems capable of detecting virus infected vector population would aid in estimating prediction of outbreak, as well as provide time to deploy suitable management strategies for vector control, and to break the vector-human transmission chain. This would also help in identifying areas, where much improvement is needed for vector management. To this context, we illustrate an exhaustive overview of both gold standards and as well as emerging advents for sensitive and specific mosquito population strategized viral detection technologies. We summarize the cutting-edge technologies and the challenges faced in pioneering to field application. Regardless the proven popularity of the gold standards for detection purpose, they offer certain limitations. Thus with the surge in the infection rate globally, approaches for development of newer advancements and technique upgradation to arrest the infection escalation and for early detection as a part of vector management should be prioritized.

Roles of NS1 Protein in Flavivirus Pathogenesis

Flaviviruses such as dengue, Zika, and West Nile viruses are highly concerning pathogens that pose significant risks to public health. The NS1 protein is conserved among flaviviruses and is synthesized as a part of the flavivirus polyprotein. It plays a critical role in viral replication, disease progression, and immune evasion. Post-translational modifications influence NS1's stability, secretion, antigenicity, and interactions with host factors. NS1 protein forms extensive interactions with host cellular proteins allowing it to affect vital processes such as RNA processing, gene expression regulation, and cellular homeostasis, which in turn influence viral replication, disease pathogenesis, and immune responses. NS1 acts as an immune evasion factor by delaying complement-dependent lysis of infected cells and contributes to disease pathogenesis by inducing endothelial cell damage and vascular leakage and triggering autoimmune responses. Anti-NS1 antibodies have been shown to cross-react with host endothelial cells and platelets, causing autoimmune destruction that is hypothesized to contribute to disease pathogenesis. However, in contrast, immunization of animal models with the NS1 protein confers protection against lethal challenges from flaviviruses such as dengue and Zika viruses. Understanding the multifaceted roles of NS1 in flavivirus pathogenesis is crucial for effective disease management and control. Therefore, further research into NS1 biology, including its host protein interactions and additional roles in disease pathology, is imperative for the development of strategies and therapeutics to combat flavivirus infections successfully. This Review provides an in-depth exploration of the current available knowledge on the multifaceted roles of the NS1 protein in the pathogenesis of flaviviruses.

Diagnostic approaches for dengue infection

INTRODUCTION

Every year, a significant rise in dengue incidence observed is responsible for 10% of fever episodes in children and adolescents in endemic countries. Considering that the symptoms of dengue are similar to those of many other viruses, early diagnosis of the disease has long been difficult, and lack of sensitive diagnostic tools may be another factor contributing to a rise in dengue incidence.

AREAS COVERED

This review will highlight dengue diagnostics strategies and discuss other possible targets for dengue diagnosis. Understanding the dynamics of the immune response and how it affects viral infection has enabled informed diagnosis. As more technologies emerge, precise assays that include some clinical markers need to be included.

EXPERT OPINION

Future diagnostic strategies will require the use both viral and clinical markers in a serial manner with the use of artificial intelligence technology to determine from the first point of illness to better determine severity status and management. A definitive endpoint is not in the horizon as the disease as well as the virus is constantly evolving and hence many developed assays need to be constantly changing some of their reagents periodically as newer genotypes and probably too serotypes emerge.

Laboratory Evaluation and Field Testing of Dengue NS1 and IgM/IgG Rapid Diagnostic Tests in an Epidemic Context in Senegal

In Senegal, the burden of dengue is increasing and expanding. As case management and traditional diagnostic techniques can be difficult to implement, rapid diagnostic tests (RDTs) deployed at point of care are ideal for investigating active outbreaks. The aim of this study was to evaluate the diagnostic performance of the Dengue NS1 and Dengue IgM/IgG RDTs on the serum/plasma samples in a laboratory setting and in the field. During laboratory evaluation, performance of the NS1 RDT was assessed using NS1 ELISA as the gold standard. Sensitivity and specificity were 88% [75–95%] and 100% [97–100%], respectively. Performance of the IgM/IG RDT was assessed using the IgM Antibody Capture (MAC) ELISA, indirect IgG, and PRNT as gold standards. The IgM and IgG test lines respectively displayed sensitivities of 94% [83–99%] and 70% [59–79%] and specificities of 91% [84–95%] and 91% [79–98%]. In the field, the Dengue NS1 RDT sensitivity and specificity was 82% [60–95%] and 75% [53–90%], respectively. The IgM and IgG test lines displayed sensitivities of 86% [42–100%] and 78% [64–88%], specificities of 85% [76–92%] and 55% [36–73%], respectively. These results demonstrate that RDTs are ideal for use in a context of high prevalence or outbreak setting and can be implemented in the absence of a confirmatory test for acute and convalescent patients.

Evaluation of an Immunoglobulin E Capture Enzyme-Linked Immunosorbent Assay for the Early Diagnosis of Dengue

Dengue virus (DENV) is the etiological agent of dengue, the most important mosquito-transmitted viral disease of humans worldwide. Enzyme-linked immunosorbent assays (ELISAs) designed to detect DENV IgM are commonly used for dengue diagnosis. However, DENV IgM is not reliably detected until ≥4 days after illness onset. Reverse transcription-polymerase chain reaction (RT-PCR) can diagnose early dengue but requires specialized equipment, reagents, and trained personnel. Additional diagnostic tools are needed. Limited work has been performed to determine whether IgE-based assays can be used for the early detection of vector-borne viral diseases, including dengue. In this study, we determined the efficacy of a DENV IgE capture ELISA for the detection of early dengue. Sera were collected within the first 4 days of illness onset from 117 patients with laboratory-confirmed dengue, as determined by DENV-specific RT-PCR. The serotypes responsible for the infections were DENV-1 and DENV-2 (57 and 60 patients, respectively). Sera were also collected from 113 dengue-negative individuals with febrile illness of undetermined etiology and 30 healthy controls. The capture ELISA detected DENV IgE in 97 (82.9%) confirmed dengue patients and none of the healthy controls. There was a high false positivity rate (22.1%) among the febrile non-dengue patients. In conclusion, we provide evidence that IgE capture assays have the potential to be explored for early diagnosis of dengue, but further research is necessary to address the possible false positivity rate among patients with other febrile illnesses.

Predicting Antigenic Peptides from Rocio Virus NS1 Protein for Immunodiagnostic Testing Using Immunoinformatics and Molecular Dynamics Simulation

The mosquito-borne disease caused by the Rocio virus is a neglected threat, and new immune inputs for serological testing are urgently required for diagnosis in low-resource settings and epidemiological surveillance. We used in silico approaches to identify a specific antigenic peptide (p_ROCV2) in the NS1 protein of the Rocio virus that was theoretically predicted to be stable and exposed on its surface, where it demonstrated key properties allowing it to interact with antibodies. These findings related to the molecular dynamics of this peptide provide important insights for advancing diagnostic platforms and investigating therapeutic alternatives.

Diagnostic Efficacy of Rapid Immunochromatographic Test in Diagnosis of Dengue Infection

Dengue is a mosquito-borne arboviral disease of grave public health concern worldwide. Early diagnosis and treatment is required to reduce morbidity & mortality from complications caused by secondary dengue infection. According to WHO, the three main diagnostic modalities for the diagnosis of dengue infection are cultivation and identification of viruses, molecular methods, and serology. Whereas virus cultivation is labour intensive and available only in reference laboratories, molecular methods require expensive infrastructure & expertise. Serology on the other hand not only less tedious but is also able to differentiate between primary and secondary dengue. This study was undertaken to evaluate the diagnostic efficacy of rapid immunochromatographic assay in the diagnosis of dengue infection as compared to ELISA. The study was conducted in the serology section of the Microbiology laboratory, Sri Guru Ram Das Institute of Medical Sciences, Amritsar. Blood samples from 429 patients with clinical suspicion of dengue virus infection were received in the lab from August 2020 to December 2020. All samples were subjected to rapid ICT and ELISA to detect NS1 Ag and IgM antibodies. The majority number of cases were observed in the age group of 31 to 40 years while the gender-wise ratio was 1.43:1 showing male preponderance. Out of 429 samples tested, 156 were reactive for either NS1 antigen or IgM antibodies by the ELISA method. Results of rapid ICT for NS1Ag and results of NS1Ag by ELISA were analyzed and compared. A sensitivity of 81.25% was noted and specificity of 100%. IgM detection by rapid ICT in comparison to IgM ELISA shows a sensitivity of 82.14% and specificity of 100%. Rapid ICT kits performed at par with the ELISA. Rapid immunochromatographic assays are important diagnostic tools in the identification of dengue and early treatment of dengue patients is possible, reducing mortality significantly.

Generation of Nanoyeast Single-Chain Variable Fragments as High-Avidity Biomaterials for Dengue Virus Detection

Bioengineered yeast bio-nanomaterials termed nanoyeasts displaying antibody single-chain variable fragments (scFvs) against diagnostic targets are a promising alternative to monoclonal antibodies (mAbs). A potential limitation for translating nanoyeasts into diagnostic tools is batch-to-batch variability. Herein, we demonstrate a systematic approach for cost-efficient production of highly specific nanoyeasts that enabled accurate dengue virus (DENV) detection by immunoassay (2.5% CV). Yeasts bioengineered to surface express DENV-specific scFvs (up to 66% of the total cell population) were fragmented into nanoyeast fractions trialing sonication, bead beating, and high-pressure disruption methods. Nanoyeast fractions from sonication had optimal target binding, uniform particle size (±89 nm), were stable, and retained diagnostic activity for 7 days at 37 °C compared to traditional mAbs that lost activity after 1 day at 37 °C. We engineered a panel of nanoyeast scFvs targeting DENV nonstructural protein 1 (NS1): (i) specific for serotyping DENV 1-4 and (ii) cross-reactive anti-DENV scFvs that are suitable for "yes/no" diagnostic applications. We demonstrate highly specific nanoyeast scFvs for serotyping DENV. We show that nanoyeast scFvs specifically detect NS1 in simulated patient plasma with a limit of detection of 250 ng/mL, the concentration found in infected patients.

Dengue Detection: Advances in Diagnostic Tools from Conventional Technology to Point of Care

The dengue virus (DENV) is a vector-borne flavivirus that infects around 390 million individuals each year with 2.5 billion being in danger. Having access to testing is paramount in preventing future infections and receiving adequate treatment. Currently, there are numerous conventional methods for DENV testing, such as NS1 based antigen testing, IgM/IgG antibody testing, and Polymerase Chain Reaction (PCR). In addition, novel methods are emerging that can cut both cost and time. Such methods can be effective in rural and low-income areas throughout the world. In this paper, we discuss the structural evolution of the virus followed by a comprehensive review of current dengue detection strategies and methods that are being developed or commercialized. We also discuss the state of art biosensing technologies, evaluated their performance and outline strategies to address challenges posed by the disease. Further, we outline future guidelines for the improved usage of diagnostic tools during recurrence or future outbreaks of DENV.

A Retrospective Study of Clinical and Laboratory Profile of Dengue Fever in Tertiary Care Hospital, Wardha, Maharashtra, India

Dengue disease is caused by dengue virus which is a vector born viral infection. The prevalence of dengue has increased dramatically from past few decades. The clinical symptoms vary from asymptomatic to severe hemorrhagic fever leads to high morbidity and mortality. Method- This retrospective study was carried out during January 2019 to December 2019. The laboratory test was done by using J Mitra & Co on Day 1 of their visit to the hospital which shows NS1, IgM and IgG reactivity towards dengue fever. The clinical profile information data was collected from patient records. Out of 640 samples 62.18% (398) was positive. The percentage of positive males and females were 60.78%, 64.23% respectively. The highest prevalence of dengue infection was observed more in age group between 31-40 years (81.69%) and least prevalence in age group 71-80 years (36.36%). Most of the patients were positive for NS1Ag121 (30.4%) followed by IgM positive 87 (21.9%) & 59 (14.8%) positive for both IgM and NS1 Ag The highest number of infections was seen during October (75.8%) post monsoon season. All patients had a fever, followed by head ache (82%) and body pains (66.4%), 64.84% stayed in the hospital less than 5 days. In tropical and sub-tropical regions dengue is still a leading public health problem especially during rainy and post monsoon seasons. Both NS1 Ag and IgM detection in early acute phase has potential diagnostic value. So, to reduce mortality there need to initiate community-based cohort studies to predict the pace of dengue spread based on clinical presentation and laboratory findings during epidemics in India. Aedesaegypti is a common vector for transmission of DENV, CHIKV and ZIKV, so there is a need to screen for these infections in endemic areas.

Responsive polymers for medical diagnostics

Stimulus-responsive polymers have been used in improving the efficacy of medical diagnostics through different approaches including enhancing the contrast in imaging techniques and promoting the molecular recognition in diagnostic assays. This review overviews the mechanisms of stimulus-responsive polymers in response to external stimuli including temperature, pH, ion, light, etc. The applications of responsive polymers in magnetic resonance imaging, capture and purification of biomolecules through protein-ligand recognition and lab-on-a-chip technology are discussed.

NS1 Recombinant Proteins Are Efficiently Produced in Pichia pastoris and Have Great Potential for Use in Diagnostic Kits for Dengue Virus Infections

Dengue is one of the major diseases causing global public health concerns. Despite technological advances in vaccine production against all its serotypes, it is estimated that the dengue virus is responsible for approximately 390 million infections per year. Laboratory diagnosis has been the key point for the correct treatment and prevention of this disease. Currently, the limiting factor in the manufacture of dengue diagnostic kits is the large-scale production of the non-structural 1 (NS1) antigen used in the capture of the antibody present in the infected patients' serum. In this work, we demonstrate the production of the non-structural 1 protein of dengue virus (DENV) serotypes 1-4 (NS1-DENV1, NS1-DENV2, NS1-DENV3, and NS1-DENV4) in the methylotrophic yeast Pichia pastoris KM71H. Secreted recombinant protein was purified by affinity chromatography and characterized by SDS-PAGE and ELISA. The objectives of this study were achieved, and the results showed that P. pastoris is a good heterologous host and worked well in the production of NS1DENV 1-4 recombinant proteins. Easy to grow and quick to obtain, this yeast secreted ready-to-use proteins, with a final yield estimated at 2.8-4.6 milligrams per liter of culture. We reached 85-91% sensitivity and 91-93% specificity using IgM as a target, and for anti-dengue IgG, 83-87% sensitivity and 81-93% specificity were achieved. In this work, we conclude that the NS1 recombinant proteins are efficiently produced in P. pastoris and have great potential for use in diagnostic kits for dengue virus infections. The transformed yeast obtained can be used for production in industrial-scale bioreactors.

Dengue Fever and Severe Dengue in Barbados, 2008-2016

Analysis of the temporal, seasonal and demographic distribution of dengue virus (DENV) infections in Barbados was conducted using national surveillance data from a total of 3994 confirmed dengue cases. Diagnosis was confirmed either by DENV-specific real time reverse transcriptase polymerase chain reaction (rRT-PCR), or non-structural protein 1 (NS1) antigen or enzyme linked immunosorbent assay (ELISA) tests; a case fatality rate of 0.4% (10/3994) was observed. The prevalence rate of dengue fever (DF) varied from 27.5 to 453.9 cases per 100,000 population among febrile patients who sought medical attention annually. DF cases occurred throughout the year with low level of transmission observed during the dry season (December to June), then increased transmission during rainy season (July to November) peaking in October. Three major dengue epidemics occurred in Barbados during 2010, 2013 and possibly 2016 with an emerging three-year interval. DF prevalence rate among febrile patients who sought medical attention overall was highest among the 10-19 years old age group. The highest DF hospitalisation prevalence rate was observed in 2013. Multiple serotypes circulated during the study period and Dengue virus serotype 2 (DENV-2) was the most prevalent serotype during 2010, whilst DENV-1 was the most prevalent serotype in 2013. Two DENV-1 strains from the 2013 DENV epidemic were genetically more closely related to South East Asian strains, than Caribbean or South American strains, and represent the first ever sequencing of DENV strains in Barbados. However, the small sample size (n = 2) limits any meaningful conclusions. DF prevalence rates were not significantly different between females and males. Public health planning should consider DENV inter-epidemic periodicity, the current COVID-19 pandemic and similar clinical symptomology between DF and COVID-19. The implementation of routine sequencing of DENV strains to obtain critical data can aid in battling DENV epidemics in Barbados.

Relationship of Non Structural Antigen 1 (NS1) Examination Results To Clinical Signs ,Symptoms and Routine Blood Examination In Patients Suspected Dengue Infections at inpatients Clinic of Vita Medika Kepung Kediri Districts

Early diagnosis of dengue infection is important because late diagnostic can be fatal to the patient, remembered the journey of the disease is very rapid. Currently there has been developed an examination of a non structural 1 dengue antigen (NS1) that can detect dengue viral infections earlier, even on the first day of fever. However, not all health care centers have adequate laboratory facilities for NS1 checks.Clinical symptoms and signs as well as a routine blood test are indicators that become the basis of diagnosis in health care facilities with limited facilities. This study aims to determine the relationship of NS1 examination result to clinical symptoms and signs as well as the result of routine blood tests in patients suspected dengue infection. This research uses observational analytic method with cross sectional approach. The research was conducted in clinic laboratory and inpatient clinic room of Vita Medika Kepung Kediri from November 2017 to February 2018.The number of research samples of 30 people was determined by the consecutive sampling technique. NS1 examination was done by using rapid immunochromatography test method with mono kits. Routine blood examination was done by using Micros 60. Chi square test on relationship between clinical sign and symptoms  examination of dengue with the results of NS1 examination obtained p= 0,310 (p > 0,005), while the results of chi square test on the relationship of routine blood examination results haemoglobine levels, amount of leucocyte, platelet count and hematocite of NS1 examination result obtained p value in a row p = 0,235 (p > 0,05) , p = 0,013(p < 0,05) , p = 0,028(p < 0,05)  dan p = 0,132 (p > 0,05). There was a significant correlation between leucocyte count and platelet count to NS1 antigen exanimation result , but there was no correlation between clinical signs and symptoms of dengue patients, haemoglobine level and haematocryt value on NS1 antigen examination result.

Dengue NS1 detection in pediatric serum using microfluidic paper-based analytical devices

The diagnosis of dengue infection is still a critical factor determining success in the clinical management and treatment of patients. Here, the development of microfluidic paper-based analytical devices (μPADs) utilizing a sandwich immunoassay on wax patterned paper functionalized with anti-dengue NS1 monoclonal antibodies for point-of-care detection of dengue NS1 (DEN-NS1-PAD) is reported. Various assay conditions, including the length of the channel and diluent, were optimized, and the response detected by the naked eye and digitized images within 20-30 min. The DEN-NS1-PAD was successfully tested in the field for detecting dengue NS1 in buffer, cell culture media, and human serum. The limit of detection (LoD) of the DEN-NS1-PAD obtained with the naked eye, scanner, and a smartphone camera was 200, 46.7, and 74.8 ng mL^-1, respectively. The repeatability, reproducibility, and stability of the DEN-NS1-PAD were also evaluated. High true specificity and sensitivity in the serum of pediatric patients were observed. These evaluation results confirm that the DEN-NS1-PAD can potentially be used in point-of-care dengue diagnostics, which can significantly impact on the spreading of mosquito-borne diseases, which are likely to become more prevalent with the effects of global warming. Graphical Abstract.

Definitive tests for dengue fever: when and which should I use?

Dengue is a mosquito-borne viral disease that has established itself globally in both endemic and epidemic transmission cycles. While diagnostic decision-making for dengue is often guided by clinical judgement, definitive laboratory tests, including rapid point-of-care tests, have many advantages in the primary care setting. These include providing epidemiological data and diagnostic clarity for atypical cases, as well as contributing to patient education and compliance. This article discussed the types of diagnostic methods for dengue, when to use them and the appropriateness of each test. Viral detection diagnostic methods such as NS1 antigen assays are generally used within the first week of illness onset, whereas dengue serology testing is most appropriate after that time frame. Locally available rapid point-of-care tests, which include both assays in one convenient test kit, can enhance dengue diagnosis in an endemic setting.

Development of peptide-based chemiluminescence enzyme immunoassay (CLEIA) for diagnosis of dengue virus infection in human

Dengue is the most prevalent mosquito-borne viral disease in tropical and subtropical regions worldwide. Since its clinical symptoms are non-specific and easily mistaken as other kinds of infection, laboratory diagnosis is required to confirm dengue infections. In this study, ten peptides (E1-E10) from the envelope protein of dengue virus (DENV) were first identified using bioinformatic tool. The screened peptides were then synthesized for the peptide-based chemiluminescence enzyme immunoassay (CLEIA). Two peptides, E1 and E7, were found as the best candidate antigen and therefore used as downstream application in the development of low-cost peptide-based anti-DENV immunoglobulin M antibodies (IgM) indirect CLEIA. 176 serum samples were used to study the presence of anti-DENV IgM antibodies to evaluate the diagnostic ability of IgM-CLEIA. Receiver operating characteristic curve (ROC) was used to estimate the diagnostic cut-off value. The sensitivity and the specificity reached 82.5% and 94.6% respectively when peptide E1 was used, but declined to 79.2% and 92.9% respectively when peptide E7 was used. Therefore, the combination of E1 and E7 was used to improve the sensitivity and the specificity to 85.0% and 96.4% respectively in 1.5 h assay time, providing a potentially practical use for the diagnosis of DENV infections in patients' serum.

Intravenous immunoglobulin for severe thrombocytopenia in secondary dengue

A 30-year-old woman with severe dengue presented on the sixth day of her illness with life-threatening thrombocytopenia, refractory to multiple platelet transfusions. Dengue IgM antibody and the non-structural-1 antigen tests as of day 3 were negative. The IgG antibody against the same was positive, suggesting a past episode of dengue. Since she had a history of menorrhagia prior to the current illness, a working diagnosis of idiopathic thrombocytopenic purpura was made, for which intravenous immunoglobulin (IVIg) was administered that led to a rapid rise in the platelet count with no adverse events. Subsequently, dengue IgM antibody repeated on day 6 came back positive, confirming dengue. This case report re-emphasises the potential use of IVIg in patients with severe thrombocytopenia in dengue.

Development of a portable and disposable NS1 based electrochemical immunosensor for early diagnosis of dengue virus

The present study represents fabrication of nonstructural antibody (NS1) based immunosensor coupled with bovine serum albumin (BSA) modified screen printed carbon electrodes (SPCE) as transducing substrate for the early diagnosis of dengue virus. The anti-NS1 monoclonal antibody was immobilized on electro grafted BSA surface of working electrode. The electrons transfer resistance before and after NS1 attachment was monitored as a function of its concentration to perform the qualitative and quantitative analysis. The as prepared impedimetric immunosensor successfully detected the dengue virus protein with enhanced limit of detection (0.3 ng/mL) and linear range (1-200 ng/mL). The selectivity of the designed device was further elaborated with several interfering analytes and was finally demonstrated with human serum samples. The extravagant selectivity, sensitivity and easier fabrication protocol corroborate the potential applications of such immunosensor for practical diagnosis of dengue virus.

Clinical and laboratory profile of dengue viral infections in and around Mangalore, India

BACKGROUND

Dengue (DEN) is being recognised as the world's major emerging tropical disease. Clinically, DEN may resemble other infections such as malaria, leptospirosis, and typhoid, and thus, laboratory investigations are required for definitive diagnosis. Secondary DEN infection, caused most often by dengue virus (DENV) serotypes 2 and 3, is known to present with severe disease manifestations. This study was undertaken to examine the clinical and laboratory profile of DEN viral infections and to determine the circulating serotypes in and around Mangalore, India.

MATERIALS AND METHODS

Serum samples from 285 clinically suspected cases of DEN in and around Mangalore between September 2013 and January 2014 were processed for detection of DEN IgM and IgG antibodies and nonstructural 1 (NS1) antigen using commercial ELISA kits. Detection of DEN viral RNA and serotyping was done by multiplex real-time reverse-transcriptase polymerase chain reaction (RT-PCR). The clinical and haematological profiles of the patients were analysed.

RESULTS

Serum samples from 83 (29%) patients were positive for DEN NS1 antigen and/or IgM antibodies. 33 (45%) out of 73 serum samples processed by multiplex real-time RT-PCR were positive for DEN viral RNA. DEN-1, -2 and -3 were the serotypes identified in this study. Fever was the most common presenting symptom followed by myalgia/arthralgia. Majority of the patients had thrombocytopaenia.

CONCLUSION

Early detection of DEN can be achieved effectively using NS1 ELISA and IgM capture ELISA. Circulating DENV serotypes should be closely monitored for prevention of fatal outcomes in secondary infections.

Inhibition of dengue virus infection by small interfering RNAs that target highly conserved sequences in the NS4B or NS5 coding regions

Dengue fever is one of the most common viral infections in the world. Although a vaccine against dengue virus (DENV) has been approved in several countries, this disease is still considered a public health priority worldwide. The ability of three small interfering RNAs (FG-siRNAs) targeting conserved sequences in the NS4B and NS5 regions of the DENV genome to inhibit DENV replication was tested in vitro in both Vero and C6/36 cells. The FG-siRNAs were effective against DENV-1, -3, and -4, but not DENV-2. A fourth siRNA specifically targeting the NS5 region of the DENV-2 genome (SG-siRNA) was designed and tested against two different DENV-2 strains, showing high levels of inhibition in both mammalian and insect cells.

Fatal Intracranial Hemorrhage in a Patient with Severe Dengue Fever

Dengue fever has been a major cause of morbidity and mortality in subtropical and tropical countries. We report a rare case of severe dengue with spontaneous intracranial hemorrhage. A search of literature through PubMed revealed that the largest series analyzed so far only included five cases. A 47-year-old man presented with 7 days history of fever, headache, myalgia, and vomiting with hematemesis. On the day of presentation, he had reduced consciousness and an episode of generalized tonic-clonic seizure. His Glasgow Coma Scale was E1V1M3 with anisocoria. Postresuscitation computed tomography of the brain revealed a right subdural and left thalamic hemorrhage. His blood investigations revealed thrombocytopenia, dengue virus type 1 nonstructural protein antigen test was positive, dengue IgM negative, and dengue IgG positive. A right decompressive craniectomy was done. Unfortunately, the patient died soon after. Spontaneous intracranial hemorrhage in patients with dengue fever is an uncommon entity but usually carry a grave prognosis. To date, there has been no clear management guideline for such cases, as both operative and nonoperative approaches have their own inherent risks.

NS 1 lasts longer than the dengue virus nucleic acid in the clinically suspected patients with dengue fever and dengue haemorrhagic fever

The objectives of the study were to compare the DENV NS1 and nucleic acid positivity in dengue fever (DF) and dengue haemorrhagic fever (DHF) patients and to evaluate the usefulness of these parameters in severe dengue. Blood samples were collected from 91 patients with DF or DHF (fever days 3-9) from Gampaha and Negombo General Hospitals, Sri Lanka and tested for DENV NS1 antigen and nucleic acid. On fever day 3, 67% of the DF and 33% of the DHF patients had DENV nucleic acid whereas 50% of the DF and 67% of the DHF patients had NS1. On fever day 4, 67% of the DF and 100% of the DHF patients had DENV nucleic acid whereas 83% of the DF and DHF patients had NS1. From fever day 5 in the DHF group, DENV nucleic acid declined but NS1 remained detectable even on day 9 (p < 0.0001). NS1 positivity did not correlate with the decrease in the WBC count in DF and DHF patients (p > 0.05) whereas NS1 positivity significantly correlated with the decrease in the platelet count in DF and DHF patients (p < 0.0001). NS1 is a useful marker to detect DENV infection even in the latter stages of DHF.

Seroprevalence of Asymptomatic Dengue Virus Infection and Its Antibodies Among Healthy/Eligible Saudi Blood Donors: Findings From Holy Makkah City

BACKGROUND

Threat to blood transfusion-transmitted dengue virus (DENV) and its antibodies has recently emerged worldwide. Dengue fever is an endemic disease in Saudi Arabia, particularly in its Western region. The aim of this study was to estimate the seroprevalence of asymptomatic DENV infection and its antibodies among eligible Saudi blood donors.

METHODS

Serum samples from 910 healthy/eligible adult male Saudi blood donors, who reside in Holy Makkah City of Saudi Arabia, were collected between March 2015 and August 2016 and screened for the detection of DENV nonstructural protein 1 (NS1) antigen and anti-DENV IgM and IgG antibodies using commercial enzyme-linked immunosorbent assay kits (Panbio, Brisbane, QLD, Australia).

RESULTS

Among the tested donors, 48 (5.3%) were seropositive for DENV-NS1 antigen, whereas 50 (5.5%) and 354 (38.9%) were seropositive for anti-DENV IgM and IgG antibodies, respectively. Seropositivity for DENV-NS1 antigen and/or anti-DENV IgM antibody among the tested donors reflects their ongoing asymptomatic viremic infectious stage with DENV during their donation time, whereas high prevalence of anti-DENV IgG seropositivity reflects the high endemicity of dengue disease in this region of Saudi Arabia.

CONCLUSIONS

These results show high prevalence of asymptomatic DENV infection and its antibodies among Saudi blood donors, raising the importance of establishing blood screening for dengue disease at different blood donation services and units in Saudi Arabia to improve the guarantee of blood transfusions and to control DENV dissemination.

Deadly intracranial bleed in patients with dengue fever: A series of nine patients and review of literature

INTRODUCTION

Dengue fever is a global pandemic threat with increasing incidence. To date, there are no cures and the effectiveness of dengue vaccines is still uncertain. World Heath Organization introduced expanded dengue syndrome to include unusual presentations of dengue fever including severe neurologic complications. One of the deadly complications is intracranial hemorrhage (ICH).

METHODOLOGY

We collected data of patients with ICH diagnosed via a plain computed tomography of the brain (CT brain) with thrombocytopenia and positive Dengue virus type 1 nonstructural protein (NS1) antigen test or positive dengue serology IgM from January 2014 till June 2015 at our center. Nine patients were included and all 20 other remaining patients reported in literature so far are discussed.

DISCUSSION

We found that all patients in our center requiring neurosurgical intervention died. Another interesting observation is that detection of Dengue IgG usually meant more severe ICH and poorer outcomes. From our series, platelet levels did not seem to influence the outcome.

CONCLUSION

We recommend that for early detection of ICH, Dengue IgG should be routinely screened and a high index of suspicion be maintained. Future research should be focused on determining predictors of ICH in patients with dengue fever so that preventive steps can be taken as mortality is high and no treatment seems beneficial at the moment once severe ICH occurs.

Is Reactive Dengue NS1Antigen Test a Warning Call for Hospital Admissions?

INTRODUCTION

Dengue fever is a major public health problem worldwide. The 2011 revised World Health Organization (WHO) guidelines have emphasized on early diagnosis and intervention to reduce the case fatality rate due to dengue fever. Rapid diagnostic tests like NS1 antigen assays have improved the detection of cases in early clinical phase of illness but its role as a predictor of severe dengue infection is not very clear.

AIM

To evaluate the utility of NS1 Ag assay as an early diagnostic marker and predictor of severe dengue infection.

MATERIALS AND METHODS

All children (0-12 years of age) diagnosed and confirmed with dengue fever at a tertiary care hospital in Puducherry between 01(st) August 2012 and 31(st) July 2015 were reviewed retrospectively from hospital case records as per the revised WHO guidelines for dengue fever. The diagnosis was confirmed by NS1antigen-based ELISA test or dengue serology for IgM and IgG antibodies and the data were analysed using SPSS 16.0 statistical software. After collecting all the data, all the variables were summarised by descriptive statistics. Categorical variables were expressed as frequencies and percentages, and then analysed by the χ(2) test or fishers exact test, where appropriate. Significance was taken at p-value< 0.05.

RESULTS

Among the 261 confirmed cases of dengue fever non-severe dengue and severe dengue infection was seen in 60.9% and 39.1% respectively. The mean age of presentation was 6.9 years and M:F ratio was 1.2:1. NS1 Ag was positive in 217 cases (83.1%) and among them non-severe dengue and severe dengue was seen in 65.9% and 34.1% cases respectively. A total of 44 cases (16.9%) were negative for NS1 Ag assay and positive for IgM MAC ELISA and among them 16 children (36.4%) had non-severe dengue infection where as 28 children (63.6%) had severe dengue infection. Secondary infection with (MAC-ELISA IgG) was seen in 17 cases (6.5%). NS1Ag assay was predominantly positive in acute phase sera, where as IgM/IgG MAC ELISA was predominantly positive in convalescent phase sera. There were six deaths (2.3%) and the common causes of poor outcome were multiorgan failure, encephalopathy and refractory shock.

CONCLUSION

NS1 Ag assay is a useful early diagnostic marker for dengue fever but cannot be used as an early predictor of severe dengue infection. The criteria for admission in hospitals of cases of dengue fever should be based on clinical warning signs rather than positive NS1 Antigen test.

Detection of dengue cases by serological testing in a dengue vaccine efficacy trial: Utility for efficacy evaluation and impact of future vaccine introduction

BACKGROUND

Dengue diagnosis confirmation and surveillance are widely based on serological assays to detect anti-dengue IgM or IgG antibodies since such tests are affordable/user-friendly. The World Health Organization identified serological based diagnosis as a potential tool to define probable dengue cases in the context of vaccine trials, while acknowledging that this may have to be interpreted with caution.

METHODS

In a phase IIb randomized, placebo-controlled trial assessing the efficacy of a tetravalent dengue vaccine (CYD-TDV) in Thai schoolchildren, case definition was based on virological confirmation by either serotype-specific RT-PCRs or by NS1-antigen ELISA (Clinicaltrials.gov NCT00842530). Here, we characterized suspected dengue cases using IgM and IgG ELISA to assess their utility in evaluating probable dengue cases in the context of vaccine efficacy trials, comparing virologically-confirmed and serologically diagnosed dengue in the vaccine and placebo groups. Serologically probable cases were defined as: (1) IgM positive acute- or convalescent-phase samples, or (2) IgG positive acute-phase sample and ≥4-fold IgG increase between acute and convalescent-phase samples.

RESULTS

Serological diagnosis had good sensitivity (97.1%), but low specificity (85.1%) compared to virological confirmation. A high level of false positivity through serology diagnosis particularly in the 2 months post-vaccination was observed, and is most likely related to detection of the immune response to the dengue vaccine. This lack of specificity and bias with vaccination demonstrates the limitation of using IgM and IgG antibody responses to explore vaccine efficacy.

CONCLUSION

Reliance on serological assessments would lead to a significant number of false positives during routine clinical practice and surveillance following the introduction of the dengue vaccine.

Evaluation of NS1 Antigen Detection for Early Diagnosis of Dengue in a Tertiary Hospital in Southern India

INTRODUCTION

Dengue is a mosquito-borne disease affecting mainly tropical and subtropical regions of the world. The early diagnosis of dengue is required for identifying an epidemic and also for implementing effective vector control measures.

AIM

To evaluate NS1 antigen assay as an alternative to RT-PCR for the early diagnosis of Dengue.

MATERIALS AND METHODS

A comparative study was conducted to evaluate NS1 antigen assay in clinically suspected dengue cases admitted to JIPMER hospital from January to November 2011. Serum samples were tested for NS1 antigen, IgM and IgG antibodies by ELISA and RT-PCR.

RESULTS

Out of total 112 clinically suspected dengue, 94 were laboratory-confirmed dengue cases (positive by one or more of the following tests - IgM ELISA, NS1 antigen ELISA and RT-PCR). NS1 was detectable from day 1 to day 12 of fever. The positive detection rate of NS1 antigen ELISA, RT-PCR and IgM ELISA were 80.9%, 68.1% and 47.9% respectively. NS1 antigen ELISA was evaluated using RT-PCR as the reference standard and showed a sensitivity of 96.8%, specificity of 53.3%, positive predictive value of 81.6% and negative predictive value of 88.9% with a likelihood ratio of 2.1 by Fisher's-exact test. The combination of NS1 and IgM had the highest sensitivity of 97.8%. DEN-3 was the serotype identified by RT-PCR for 24 randomly selected samples. NS1 antigen detection had the highest sensitivity in the early stages while IgM detection was more sensitive in the later half of the illness.

CONCLUSION

Both NS1 and RT-PCR are useful for early dengue diagnosis, although in terms of cost, ease of performance and rapidity, NS1 is superior to RT-PCR. NS1 in combination with IgM assay offers the most sensitive and cost-effective diagnostic modality for dengue.

Dengue Virus Transmission from Living Donor to Recipient in Liver Transplantation: A Case Report

Many infections are transmitted from a donor to a recipient through organ transplantations. The transmission of dengue virus from a donor to a recipient in liver transplantation is a rare entity, and currently, there is no recommendation for screening this virus prior to transplantation. We report a case of transmission of dengue virus from donor to recipient after liver transplantation. The recipient had a history of multiple admissions for hepatic encephalopathy and ascites. He was admitted in the ICU for 15 days for chronic liver disease, ascites, and acute kidney injury before transplantation. The donor was admitted 1 day before transplantation. The donor spiked fever on postoperative day 2 followed by thrombocytopenia and elevated liver enzymes. The donor blood test was positive for dengue NS1 antigen. The recipient also had a similar clinical picture on postoperative day 5 and his blood test was also positive for dengue NS1 antigen. Hence, the diagnosis for posttransplant donor-derived allograft-related transmission of dengue infection was made. Both recipient and donor were treated with supportive measures and discharged after their full recovery on postoperative days 9 and 18, respectively. The effect of immunosuppression on dengue presentation is still unclear and there is lack of literature available. In our case, the recipient developed dengue fever similar to general population without showing any feature of severe graft dysfunction. We have concluded that dengue virus can also be transmitted from donor to recipient, and immunosuppression did not have any adverse effect on the evolution of dengue fever within the recipient. Delhi being a hyperendemic zone, screening for donors (especially in season time) for dengue virus seems to be the best preventive method to control donor-derived transmission of dengue to recipient.

Cross-Reactivity of Rapid Salmonella Typhi IgM Immunoassay in Dengue Fever Without Co-Existing Infection

INTRODUCTION

Dengue fever is endemic in developing nations worldwide with as many as 500,000 annual cases of dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). A prompt and accurate diagnosis early in the disease course is essential for prompt identification and treatment of severe complications of the dengue virus infection (DVI). We identified cross-reactivity of a rapid IgM test for typhoid fever in patients with febrile illnesses that were determined to be due to dengue virus.

METHODS

All patients with documented DVI during a recent epidemic in Pakistan also underwent diagnostic testing for Salmonella enterica serovar Typhi. The diagnosis of DVI was made based on clinical findings and the positive results for dengue non-structural protein 1 antigen (NS1Ag) and/or dengue IgM antibody (anti-D IgM) during the acute phase of febrile illness. Patients with positive test results for Salmonella typhi (S. Typhi) IgM also had their blood cultures done.

RESULTS

In the group of 322 patients with clinical and serological evidence of DVI, 107 also tested positive for S. Typhi IgM. Blood cultures were negative for S. Typhi bacteria in all patients. Principal disease features included fever, headache, myalgia, retro-orbital pain, and a rash accompanied by thrombocytopenia and leukopenia. Comparisons of clinical and routine laboratory findings between the S. Typhi-positive and negative groups showed no significant differences. Patients testing positive for both NS1Ag and anti-D IgM were significantly more likely to test positive for S. Typhi IgM, even in the absence of typhoid fever. No routine antibiotics were used and all patients survived.

CONCLUSION

One-third of a large group of patients with primary DVI also demonstrated false positive results for typhoid fever. Cross-reactivity of a rapid immunoassay for typhoid fever has not been previously reported in DVI or any other flavivirus infections. Until these findings can be further evaluated, clinicians should be cautious in interpreting S. Typhi rapid immunoassays and have a high index of suspicion of DVI in dengue fever endemic areas.

Clinical evaluation of dengue RNA, NS1, and IgM for diagnosis of dengue in Southern China

In 2014, a large outbreak of dengue occurred in Guangzhou, China. This outbreak prompted us to evaluate NS1 and RNA for the early diagnosis of acute dengue infection, in addition to the combination with IgM antibody. We aimed to find the differences of three assays about dengue diagnosis. This study was an evaluation of diagnosis test. Based on WHO criteria 2009, dengue RNA, NS1, and IgM/IgG were detected from 294 patients (180 dengue patients, 114 non-dengue patients) by three diagnostic kits made in China. The χ(2) test, sensitivity, and specificity were used in statistical analysis. The ratios of dengue patients with low platelet counts (<100 × 10(9) /L 32.2%) or white blood cell counts (<4.0 × 10(9) /L 58.9%) were significantly higher compared to non-dengue patients (P < 0.05). Dengue NS1 was shown sensitive (93.9%) for diagnostic use. RNA had a better performance with 98.1% of sensitivity from day 1 to day 4 after illness onset. IgM performed better at day 5 or more with 74.0% of sensitivity. The diagnostic rate using a combination of RNA and IgM was 97.8% and 96.7% using NS1 and IgM. A patient with low platelet and white blood cell counts needs additional tests for dengue during an epidemic. RNA and NS1 were most valuable for early diagnosis of dengue, whereas IgM was best suited as a supplementary method for patients at day 5 or more after illness onset.

Development and clinical evaluation of a highly accurate dengue NS1 rapid test: from the preparation of a soluble NS1 antigen to the construction of an RDT

Early diagnosis of dengue virus (DENV) is important. There are numerous products on the market claiming to detect DENV NS1, but these are not always reliable. In this study, a highly sensitive and accurate rapid diagnostic test (RDT) was developed using anti-dengue NS1 monoclonal antibodies. A recombinant NS1 protein was produced with high antigenicity and purity. Monoclonal antibodies were raised against this purified NS1 antigen. The RDT was constructed using a capturing (4A6A10, Kd=7.512±0.419×10(-9)) and a conjugating antibody (3E12E6, Kd=7.032±0.322×10(-9)). The diagnostic performance was evaluated with NS1-positive clinical samples collected from various dengue endemic countries and compared to SD BioLine Dengue NS1 Ag kit. The constructed RDT exhibited higher sensitivity (92.9%) with more obvious diagnostic performance than the commercial kit (83.3%). The specificity of constructed RDT was 100%. The constructed RDT could offer a reliable point-of-care testing tool for the early detection of dengue infections in remote areas and contribute to the control of dengue-related diseases.

Dengue fever in a liver-transplanted patient: a case report

Introduction

Dengue fever is one of the commonest mosquito-borne diseases in the tropics, and Sri Lanka is no exception. Despite its commonness, dengue fever has rarely been described among patients who have undergone transplantation. We report the case of a patient with dengue fever after liver transplantation, which, to the best of our knowledge, is the first such reported case outside Brazil.

Case presentation

Our patient was a 46-year-old Sri Lakan man who presented to our institution two years after undergoing an ABO-compatible cadaveric liver transplant. At presentation, he had typical symptoms of dengue fever. He was taking prednisolone 5mg daily and tacrolimus 3mg twice daily as immunosuppression. Initial investigations showed thrombocytopenia and neutropenia that reached a nadir by day 7 of his illness. He had elevated liver enzymes as well. The diagnosis was confirmed on the basis of NS1 antigen detection by enzyme-linked immunosorbent assay. His blood cultures and polymerase chain reaction tests for cytomegalovirus were negative. He made an uneventful recovery and was discharged by day 9 of his illness. However, normalization of liver function took nearly two weeks. In three previously reported Brazilian cases of dengue after liver transplantation, the patients presented with dengue shock syndrome, in contrast to the relatively milder presentation of our patient. Because of the lack of case reports in the literature, it is difficult to ascertain the risk factors for severe dengue infection in transplants, but dengue fever reported in renal transplants sheds some light on them. High-dose steroids increase the risk of thrombocytopenia, whereas tacrolimus has been reported to prolong the duration of symptoms. Otherwise, dengue fever is a relatively mild illness in patients who have undergone renal transplantation, and renal allograft survival has been reported to be 86% following dengue fever.

Conclusion

Dengue is a rarely reported infection in patients who have undergone transplantation. A high degree of suspicion is required for diagnosis. Dengue NS1 antigen detection is a useful addition to the already existing methods of diagnosis. Steroids and tacrolimus have effects on the morbidity of the disease. Graft outcomes following the infection has been excellent in all reported cases.

Evaluation of dengue NS1 antigen rapid tests and ELISA kits using clinical samples

Background

Early diagnosis of dengue virus (DENV) infection can improve clinical outcomes by ensuring close follow-up, initiating appropriate supportive therapies and raising awareness to the potential of hemorrhage or shock. Non-structural glycoprotein-1 (NS1) has proven to be a useful biomarker for early diagnosis of dengue. A number of rapid diagnostic tests (RDTs) and enzyme-linked immunosorbent assays (ELISAs) targeting NS1 antigen (Ag) are now commercially available. Here we evaluated these tests using a well-characterized panel of clinical samples to determine their effectiveness for early diagnosis.

Methodology/Principal Findings

Retrospective samples from South America were used to evaluate the following tests: (i) “Dengue NS1 Ag STRIP” and (ii) “Platelia Dengue NS1 Ag ELISA” (Bio-Rad, France), (iii) “Dengue NS1 Detect Rapid Test (1^st Generation)” and (iv) “DENV Detect NS1 ELISA” (InBios International, United States), (v) “Panbio Dengue Early Rapid (1^st generation)” (vi) “Panbio Dengue Early ELISA (2^nd generation)” and (vii) “SD Bioline Dengue NS1 Ag Rapid Test” (Alere, United States). Overall, the sensitivity of the RDTs ranged from 71.9%–79.1% while the sensitivity of the ELISAs varied between 85.6–95.9%, using virus isolation as the reference method. Most tests had lower sensitivity for DENV-4 relative to the other three serotypes, were less sensitive in detecting secondary infections, and appeared to be most sensitive on Day 3–4 post symptom onset. The specificity of all evaluated tests ranged from 95%–100%.

Conclusions

ELISAs had greater overall sensitivity than RDTs. In conjunction with other parameters, the performance data can help determine which dengue diagnostics should be used during the first few days of illness, when the patients are most likely to present to a clinic seeking care.

Evaluation of a dengue NS1 antigen detection assay sensitivity and specificity for the diagnosis of acute dengue virus infection

BACKGROUND

Currently, no dengue NS1 detection kit has regulatory approval for the diagnosis of acute dengue fever. Here we report the sensitivity and specificity of the InBios DEN Detect NS1 ELISA using a panel of well characterized human acute fever serum specimens.

METHODOLOGY/PRINCIPAL FINDINGS

The InBios DENV Detect NS1 ELISA was tested using a panel composed of 334 serum specimens collected from acute febrile patients seeking care in a Bangkok hospital in 2010 and 2011. Of these patients, 314 were found to have acute dengue by either RT-PCR and/or anti-dengue IgM/IgG ELISA. Alongside the InBios NS1 ELISA kit, we compared the performance characteristics of the BioRad Platelia NS1 antigen kit. The InBios NS1 ELISA Ag kit had a higher overall sensitivity (86% vs 72.8%) but equal specificity (100%) compared to the BioRad Platelia kit. The serological status of the patient significantly influenced the outcome. In primary infections, the InBios NS1 kit demonstrated a higher sensitivity (98.8%) than in secondary infections (83.5%). We found significant variation in the sensitivity of the InBios NS1 ELISA kit depending on the serotype of the dengue virus and also found decreasing sensitivity the longer after the onset of illness, showing 100% sensitivity early during illness, but dropping below 50% by Day 7.

CONCLUSION/SIGNIFICANCE

The InBios NS1 ELISA kit demonstrated high accuracy when compared to the initial clinical diagnosis with greater than 85% agreement when patients were clinically diagnosed with dengue illness. Results presented here suggest the accurate detection of circulating dengue NS1 by the InBios DENV Detect NS1 ELISA can provide clinicians with a useful tool for diagnosis of early dengue infections.

NS1-based tests with diagnostic utility for confirming dengue infection: a meta-analysis

OBJECTIVES

Non-structural protein 1 (NS1)-based tests may offer a larger window of opportunity for dengue diagnosis and could constitute a very useful diagnostic tool. The aim of this study was to establish the overall accuracy of NS1-based tests for diagnosing dengue infection.

METHODS

A meta-analysis was conducted including 18 studies published up to October 1, 2012 identified using PubMed, ISI Web of Science, Google Scholar, and the Chinese National Knowledge Infrastructure (CNKI) database.

RESULTS

For the single NS1-based tests - ELISA (Panbio Dengue Early ELISA Kit, Dengue NS1 Ag ELISA Kit, and Platelia Dengue NS1 Ag-ELISA Kit) and immunochromatography (Dengue NS1 Ag STRIP Kit and SD BIOLINE Dengue Duo Strip Kit) - the summarized sensitivities and specificities were 67% (95% confidence interval (CI) 59-74%) and 99% (95% CI 97-99%), and 71% (95% CI 61-79%) and 99% (95% CI 98-100%), respectively. The hierarchical summary receiver operating characteristics (HSROCs) were 0.92 and 0.96, respectively. For NS1 combined with an anti-dengue-specific IgM test, the summarized sensitivity, specificity, and HSROC were 83% (95% CI 68-92%), 86% (95% CI 79-91%), and 0.91 (95% CI 0.89-0.93), respectively. The accuracy for serotypes was 50.0-90.9% for DENV-1, 38.5-85.7% for DENV-2, 46.7-91.3% for DENV-3, and 21.7-87.0% for DENV-4.

CONCLUSIONS

These results support the use of single NS1-based tests; they have good diagnostic utility for confirming dengue and for distinguishing serotypes DENV-1 and 3 from DENV-2 and 4, while they can be used as a screening tool when combined with an IgM test. Moreover, the Dengue NS1 Ag STRIP Kit appears to be the best for confirming and serotyping dengue infection.