Potential Misdiagnosis between COVID-19 and Dengue Infection Using Rapid Serological Test

Cross-reactivity between dengue virus and SARS-CoV-2 antibodies: Confirmation study using specimens from dengue-infected patients before the COVID-19 pandemic

Background

The simultaneous occurrence of the COVID-19 pandemic and a dengue outbreak has posed significant challenges for governments and medical personnel in dengue-endemic countries like Indonesia. Several studies in dengue-endemic countries have reported cases of misdiagnosis between COVID-19 and dengue. Therefore, it is crucial to evaluate the potential cross-reactivity between SARS-CoV-2 antibodies and dengue.

Methods

This study aimed to confirm the serological cross-reaction between dengue virus and SARS-CoV-2 in Surabaya, East Java, which is a highly dengue-endemic city in Indonesia. In total, 238 serum samples with confirmed dengue that were collected before the emergence of COVID-19 were tested to detect the presence of reacting IgG and IgM antibodies (Abs) against SARS-CoV-2 via a rapid detection test (RDT) and enzyme-linked immunosorbent assay (ELISA). Samples from patients with dengue infection collected during the pandemic, from healthy volunteers predating the pandemic, and from patients with COVID-19 were used for comparison.

Results and conclusion

Few (6.7 %) of the pre-COVID-19 dengue Ab-positive serum samples showed reactive on SARS-CoV-2 in the RDT, with significantly lower IgG and IgM levels detected in ELISA compared with the dengue samples collected during the pandemic and the COVID-19 samples (P < 0.005). A comparable anti-SARS-CoV-2 IgG concentration was observed in the pre-COVID-19 dengue samples and healthy volunteers (P = 0.56), which also indicated other possibilities. In conclusion, our results suggested a low risk of cross-reactivity between dengue virus and SARS-CoV-2. However, they highlighted the need for caution when using and interpreting data obtained stemming from serological methods, to prevent false-positive results. Further studies are needed to evaluate the cross-reactivity between dengue virus, SARS-CoV-2, and other common human pathogens, as well as its effect on the serosurveys, treatment of these diseases, or vaccine efficacy.

Enhanced Assessment of Cross-Reactive Antigenic Determinants within the Spike Protein

Despite successful vaccination efforts, the emergence of new SARS-CoV-2 variants poses ongoing challenges to control COVID-19. Understanding humoral responses regarding SARS-CoV-2 infections and their impact is crucial for developing future vaccines that are effective worldwide. Here, we identified 41 immunodominant linear B-cell epitopes in its spike glycoprotein with an SPOT synthesis peptide array probed with a pool of serum from hospitalized COVID-19 patients. The bioinformatics showed a restricted set of epitopes unique to SARS-CoV-2 compared to other coronavirus family members. Potential crosstalk was also detected with Dengue virus (DENV), which was confirmed by screening individuals infected with DENV before the COVID-19 pandemic in a commercial ELISA for anti-SARS-CoV-2 antibodies. A high-resolution evaluation of antibody reactivity against peptides representing epitopes in the spike protein identified ten sequences in the NTD, RBD, and S2 domains. Functionally, antibody-dependent enhancement (ADE) in SARS-CoV-2 infections of monocytes was observed in vitro with pre-pandemic Dengue-positive sera. A significant increase in viral load was measured compared to that of the controls, with no detectable neutralization or considerable cell death, suggesting its role in viral entry. Cross-reactivity against peptides from spike proteins was observed for the pre-pandemic sera. This study highlights the importance of identifying specific epitopes generated during the humoral response to a pathogenic infection to understand the potential interplay of previous and future infections on diseases and their impact on vaccinations and immunodiagnostics.

The effects of the COVID-19 pandemic on dengue cases in Malaysia

Background

Globally, the COVID-19 pandemic has affected the transmission dynamics and distribution of dengue. Therefore, this study aims to describe the impact of the COVID-19 pandemic on the geographic and demographic distribution of dengue incidence in Malaysia.

Methods

This study analyzed dengue cases from January 2014 to December 2021 and COVID-19 confirmed cases from January 2020 to December 2021 which was divided into the pre (2014 to 2019) and during COVID-19 pandemic (2020 to 2021) phases. The average annual dengue case incidence for geographical and demographic subgroups were calculated and compared between the pre and during the COVID-19 pandemic phases. In addition, Spearman rank correlation was performed to determine the correlation between weekly dengue and COVID-19 cases during the COVID-19 pandemic phase.

Results

Dengue trends in Malaysia showed a 4-year cyclical trend with dengue case incidence peaking in 2015 and 2019 and subsequently decreasing in the following years. Reductions of 44.0% in average dengue cases during the COVID-19 pandemic compared to the pre-pandemic phase was observed at the national level. Higher dengue cases were reported among males, individuals aged 20-34 years, and Malaysians across both phases. Weekly dengue cases were significantly correlated (ρ = -0.901) with COVID-19 cases during the COVID-19 pandemic.

Conclusion

There was a reduction in dengue incidence during the COVID-19 pandemic compared to the pre-pandemic phase. Significant reductions were observed across all demographic groups except for the older population (>75 years) across the two phases.

Performance of VIDAS® Diagnostic Tests for the Automated Detection of Dengue Virus NS1 Antigen and of Anti-Dengue Virus IgM and IgG Antibodies: A Multicentre, International Study

Dengue is a serious mosquito-transmitted disease caused by the dengue virus (DENV). Rapid and reliable diagnosis of DENV infection is urgently needed in dengue-endemic regions. We describe here the performance evaluation of the CE-marked VIDAS® dengue immunoassays developed for the automated detection of DENV NS1 antigen and anti-DENV IgM and IgG antibodies. A multicenter concordance study was conducted in 1296 patients from dengue-endemic regions in Asia, Latin America, and Africa. VIDAS® dengue results were compared to those of competitor enzyme-linked immunosorbent assays (ELISA). The VIDAS® dengue assays showed high precision (CV ≤ 10.7%) and limited cross-reactivity (≤15.4%) with other infections. VIDAS® DENGUE NS1 Ag showed high positive and negative percent agreement (92.8% PPA and 91.7% NPA) in acute patients within 0–5 days of symptom onset. VIDAS® Anti-DENGUE IgM and IgG showed a moderate-to-high concordance with ELISA (74.8% to 90.6%) in post-acute and recovery patients. PPA was further improved in combined VIDAS® NS1/IgM (96.4% in 0–5 days acute patients) and IgM/IgG (91.9% in post-acute patients) tests. Altogether, the VIDAS® dengue NS1, IgM, and IgG assays performed well, either alone or in combination, and should be suitable for the accurate diagnosis of DENV infection in dengue-endemic regions.

Cross-reactivity of SARS-CoV-2 with other pathogens, especially dengue virus: A historical perspective

Dengue is a vector-borne viral disease caused by a Flavivirus whereas the COVID-19 pandemic was caused by a highly contagious virus, SARS-CoV-2 belonging to the family Coronaviridae. However, COVID-19 severity was observably less in dengue-endemic countries and vice versa especially during the active years of the pandemic (2019-2021). We observed that dengue virus (DENV) antibodies (Abs) could cross-react with SARS-CoV-2 spike antigen. This resulted in SARS-CoV-2 false positivity by rapid Ab test kits. DENV Abs binding to SARS-CoV-2 receptor-binding domain (and the reverse scenario), as revealed by docking studies further validated DENV and SARS-CoV-2 cross-reactivity. Finally, SARS-CoV-2 Abs were found to cross-neutralize DENV1 and DENV2 in virus neutralization test (VNT). Abs to other pathogens like Plasmodium were also cross-reactive but non-neutralizing for SARS-CoV-2. Here, we analyze the existing data on SARS-CoV-2 cross-reactivity with other pathogens, especially dengue to assess its impact on health (cross-protection?) and differential sero-diagnosis/surveillance.

Dengue amid COVID-19 pandemic

The increasing in dengue cases nowadays is a global threat concern. Fifty per cent of the world's population is vulnerable to dengue infection with Asia contributing over two-thirds of the global burden. The double trouble of Coronavirus disease 2019 (COVID-19) arising from novel severe respiratory syndrome coronavirus (SARS-CoV-2) and dengue virus is a major challenge, particularly in developing countries due to overburdened public health systems and economic constraints including the ability to diagnose. The objective of this study was to analyze the prevalence of dengue in Thailand during the outbreak of COVID-19. We studied data on dengue cases reported at epidemiological information centers, the Bureau of Epidemiology, and the Ministry of Public Health, Thailand during 2019 to 2021. Patients can be observed across all age groups, particularly adolescents and adults. Dengue was seen year-round, with highest incidence in the rainy seasons between June and September. Total number of cases was markedly declined by nearly 93 percentage from 2019 to 2011. Taken together, Thailand is still at risk of spreading of dengue in the midst of COVID-19 pandemic. Continuous status updates on dengue patients in Thailand should be incorporated into global health advisory on preventive measures before travelling.

Capacitive immunosensor for COVID-19 diagnosis

COVID-19 has spread worldwide and early detection has been the key to controlling its propagation and preventing severe cases. However, diagnostic devices must be developed using different strategies to avoid a shortage of supplies needed for tests' fabrication caused by their large demand in pandemic situations. Furthermore, some tropical and subtropical countries are also facing epidemics of Dengue and Zika, viruses with similar symptoms in early stages and cross-reactivity in serological tests. Herein, we reported a qualitative immunosensor based on capacitive detection of spike proteins of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of COVID-19. The sensor device exhibited a good signal-to-noise ratio (SNR) at 1 kHz frequency, with an absolute value of capacitance variation significantly smaller for Dengue and Zika NS1 proteins (|ΔC| = 1.5 ± 1.0 nF and 1.8 ± 1.0 nF, respectively) than for the spike protein (|ΔC| = 7.0 ± 1.8 nF). Under the optimized conditions, the established biosensor is able to indicate that the sample contains target proteins when |ΔC| > 3.8 nF, as determined by the cut-off value (CO). This immunosensor was developed using interdigitated electrodes which require a measurement system with a simple electrical circuit that can be miniaturized to enable point-of-care detection, offering an alternative for COVID-19 diagnosis, especially in areas where there is also a co-incidence of Zika and Dengue.

Anti-Arbovirus Antibodies Cross-React With Severe Acute Respiratory Syndrome Coronavirus 2

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is found in regions where dengue (DENV) and chikungunya (CHIKV) viruses are endemic. Any serological cross-reactivity between DENV, CHIKV, and SARS-CoV-2 is significant as it could lead to misdiagnosis, increased severity, or cross-protection. This study examined the potential cross-reactivity of anti-DENV and CHIKV antibodies with SARS-CoV-2 using acute and convalescent-phase samples collected before the SARS-CoV-2 pandemic. These included healthy, normal human (NHS, n = 6), CHIKV-positive (n = 14 pairs acute and convalescent), primary DENV-positive (n = 20 pairs), secondary DENV-positive (n = 20 pairs), and other febrile illnesses sera (n = 23 pairs). Samples were tested using an in-house SARS-CoV-2 and a EUROIMMUN IgA and IgG ELISAs. All NHS samples were negative, whereas 3.6% CHIKV, 21.7% primary DENV, 15.7% secondary DENV, and 10.8% febrile diseases sera resulted as anti-SARS-CoV-2 antibody positive. The EUROIMMUN ELISA using spike 1 as the antigen detected more positives among the primary DENV infections than the in-house ELISA using spike 1-receptor binding domain (RBD) protein. Among ELISA-positive samples, four had detectable neutralizing antibodies against SARS-CoV-2 reporter virus particles yet none had detectable neutralizing antibodies against the live Wuhan strain of SARS-CoV-2. These data demonstrated the SARS-CoV-2 diagnostic cross-reactivity, but not neutralizing antibody cross-reactivity, among dengue seropositive cases. IMPORTANCE SARS-CoV-2 continues to cause significant morbidity globally, including in areas where DENV and CHIKV are endemic. Reports using rapid diagnostic and ELISAs have demonstrated that serological cross-reactivity between DENV and SARS-CoV-2 can occur. Furthermore, it has been observed that convalescent DENV patients are at a lower risk of developing COVID-19. This phenomenon can interfere with the accuracy of serological testing and clinical management of both DENV and COVID-19 patients. In this study, the cross-reactivity of primary/secondary anti-DENV, CHIKV, and other febrile illness antibodies with SARS-CoV-2 using two ELISAs has been shown. Among ELISA-positive samples, four had detectable levels of neutralizing antibodies against SARS-CoV-2 reporter virus particles. However, none had detectable neutralizing antibodies against the live Wuhan strain of SARS-CoV-2. These data demonstrated SARS-CoV-2 diagnostic cross-reactivity, but not neutralizing antibody cross-reactivity, among dengue seropositive cases. The data discussed here provide information regarding diagnosis and may help guide appropriate public health interventions.

SARS-CoV-2 and Dengue Virus Coinfection in a Mexican Pediatric Patient: A Case Report from Early Molecular Diagnosis

Mexico is an endemic region for dengue virus (DENV). The increase in this disease coincides with outbreaks of COVID-19, both of which are single-stranded positive RNA viruses. These characteristics make it difficult to distinguish each disease because they share clinical and laboratory features, which can consequently result in misdiagnoses. This is why the use of precision confirmatory tests (qRT-PCR) are crucial for early diagnosis. We herein report a pediatric patient who presented a coinfection for DENV and COVID-19, “SARS-CoV-2/Dengue”. This patient initially presented a fever, cough, and headache and, three days later, developed generalized pain and epistaxis. Blood studies revealed thrombocytopenia and leukopenia, and the patient was admitted to the hospital for a probable DENV infection. Within 48 h, qRT-PCR tests specific for SARS-CoV-2 and DENV were performed and resulted as positive. The patient immediately received pharmacological treatment with azithromycin, oseltamivir, and metamizole. During hospitalization (9 days), the patient had no signs of respiratory distress and maintained normal body temperature and normal blood oxygen saturation. This case warns of the need for early diagnosis and adequate clinical and pharmacological management in the face of a “SARS-CoV-2/Dengue” coinfection. Early molecular detection of both viruses and timely treatment helped the patient to achieve a favorable recovery.

Dengue & COVID-19: A Comparison and the Challenges at Hand

The COVID-19 pandemic caused by SARS-CoV-2 spread across many countries between 2020 and 2022. The similarities in clinical presentation with other endemic diseases pose a challenge to physicians in effectively diagnosing and treating the infection. Approximately 129 nations have a risk of dengue infection, and more than 100 of those are endemic to dengue. During the COVID-19 pandemic, the number of dengue cases decreased in many countries owing to the isolation measures followed. However, the common clinical presentation between them has led to misdiagnosis. Both COVID-19 and dengue fever cause a surge in pro-inflammatory cytokines and chemokines, thus sharing a common pathophysiology. False positive serological test results also posed difficulty differentiating between COVID-19 and dengue fever. This review aims to compare the clinical features, pathophysiology, and immune response between dengue and COVID-19, to benefit public health management during the pandemic.

Coinfection and cross-reaction of dengue and COVID-19: a case series analysis

BACKGROUND

The risk of possible cross-reactions between serological tests, together with the clinical similarities between dengue fever and COVID-19, can delay diagnosis and increase the risk of both COVID-19 transmission and worsening. The present study aimed to determine the possibility of cross-reactions among rapid serological tests based on clinical symptoms.

METHODS

Patients with COVID-19, confirmed by RT-PCR and clinical criteria for diagnosing dengue, were recruited consecutively between September 2020 and August 2021 and underwent rapid immunochromatographic diagnostic (RID) tests for AgNS1, IgM, and IgG. Patients who tested positive for acute-phase dengue IgM and AgNS1 underwent a follow-up test after 12-30 days for diagnostic confirmation.

RESULTS

A total of 43 patients were included, 38 of whom required hospital admission, and 8 received intensive care. Seven patients tested positive on the RID tests, comprising 2 NS1 positive (coinfection), one reactive for IgM and IgG (coinfection), three reactive for IgM not confirmed (false-positive), and one reactive for IgG due to previous infection. Two of the 3 patients with coinfection died. Fever, myalgia, headache, and cough were the most common clinical symptoms, while lymphopenia was the most prevalent laboratory finding.

CONCLUSIONS

Cross-reactivity was found in only three patients and coinfection in another three patients, two of whom died of severe COVID-19 manifestations.

Antibodies against the SARS-CoV-2 S1-RBD cross-react with dengue virus and hinder dengue pathogenesis

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread globally since December 2019. Several studies reported that SARS-CoV-2 infections may produce false-positive reactions in dengue virus (DENV) serology tests and vice versa. However, it remains unclear whether SARS-CoV-2 and DENV cross-reactive antibodies provide cross-protection against each disease or promote disease severity. In this study, we confirmed that antibodies against the SARS-CoV-2 spike protein and its receptor-binding domain (S1-RBD) were significantly increased in dengue patients compared to normal controls. In addition, anti-S1-RBD IgG purified from S1-RBD hyperimmune rabbit sera could cross-react with both DENV envelope protein (E) and nonstructural protein 1 (NS1). The potential epitopes of DENV E and NS1 recognized by these antibodies were identified by a phage-displayed random peptide library. In addition, DENV infection and DENV NS1-induced endothelial hyperpermeability in vitro were inhibited in the presence of anti-S1-RBD IgG. Passive transfer anti-S1-RBD IgG into mice also reduced prolonged bleeding time and decreased NS1 seral level in DENV-infected mice. Lastly, COVID-19 patients’ sera showed neutralizing ability against dengue infection in vitro. Thus, our results suggest that the antigenic cross-reactivity between the SARS-CoV-2 S1-RBD and DENV can induce the production of anti-SARS-CoV-2 S1-RBD antibodies that cross-react with DENV which may hinder dengue pathogenesis.

Addressing the COVID-19 pandemic challenges for operational adaptations of a cluster randomized controlled trial on dengue vector control in Malaysia

INTRODUCTION

The COVID-19 pandemic placed an unprecedented overload on healthcare system globally. With all medical resources being dedicated to contain the spread of the disease, the pandemic may have impacted the burden of other infectious diseases such as dengue, particularly in countries endemic for dengue fever. Indeed, the co-occurrence of COVID-19 made dengue diagnosis challenging because of some shared clinical manifestations between the two pathogens. Furthermore, the sudden emergence and novelty of this global public health crisis has forced the suspension or slow-down of several research trials due to the lack of sufficient knowledge on how to handle the continuity of research trials during the pandemic. We report on challenges we have faced during the COVID-19 pandemic and measures that were implemented to continue the iDEM project (intervention for Dengue Epidemiology in Malaysia).

METHODS

This randomized controlled trial aims to assess the effectiveness of Integrated Vector Management (IVM) on the incidence of dengue in urban Malaysia by combining: targeted outdoor residual spraying (TORS), deployment of auto-dissemination devices (ADDs), and active community engagement (CE). Our operational activities started on February 10, 2020, a few weeks before the implementation of non-pharmaceutical interventions to contain the spread of COVID-19 in Malaysia.

RESULTS

The three main issues affecting the continuity of the trial were: ensuring the safety of field workers during the interventions; ensuring the planned turnover of TORS application and ADD deployment and services; and maintaining the CE activities as far as possible.

CONCLUSIONS

Even though the pandemic has created monumental challenges, we ensured the safety of field workers by providing complete personal protective equipment and regular COVID-19 testing. Albeit with delay, we maintained the planned interval time between TORS application and ADDs services by overlapping the intervention cycles instead of having them in a sequential scheme. CE activities continued remotely through several channels (e.g., phone calls and text messages). Sustained efforts of the management team, significant involvement of the Malaysian Ministry of Health and a quick and smart adaptation of the trial organisation according to the pandemic situation were the main factors that allowed the successful continuation of our research.

TRIAL REGISTRATION

Trial registration number: ISRCTN-81915073 . Date of registration: 17/04/2020, 'Retrospectively registered'.

Coinfection With SARS-CoV-2 and Dengue Virus: A Case Report Highlighting Diagnostic Challenges

Background

Since its emergence in China, SARS-CoV-2 has infected more than 240 million people worldwide, including in regions where dengue virus (DENV) is hyperendemic such as Latin America and Southeast Asia, including Indonesia. Diagnosis of COVID-19 in dengue endemic regions as well as DENV and SARS-CoV-2 co-infection can be challenging.

Case Presentation

We describe a 68-year-old woman with diabetes mellitus type II who was admitted to the Tangerang District Hospital on 14 April 2020. She lived in a neighborhood where a few people were contracting dengue fever. She presented with five days of fever, malaise, anorexia, nausea, myalgia, and arthralgia. Hematology revealed anemia, thrombocytopenia, normal leukocyte count, increased neutrophil proportion, and decreased lymphocyte proportion and absolute lymphocytes. Her chest X-ray showed right pericardial infiltrates. Although dengue was clinically suspected, she was also tested for SARS-CoV-2 infection as she met screening criteria. After being confirmed SARS-CoV-2 positive by RT-PCR, she was treated with ceftriaxone, paracetamol, azithromycin, oseltamivir, and chloroquine. She was clinically improved four days later and discharged from the hospital on 25 April 2020 after SARS-CoV-2 RT-PCR was negative on two consecutive samples. Dengue was diagnosed retrospectively based on sero-conversion of dengue IgM and a very high dengue IgG index (ELISA, Focus Diagnostics®, Cypress, CA, USA), and sero-conversion of dengue IgM and positive IgG (Rapid test, PanBio ®Dengue duo cassette, Inverness Medical Innovations, QLD, AU), which was equivalent to high Hemagglutination Inhibition (HI) antibody titer (≥1280) found in secondary dengue infection.

Conclusion

The overlapping clinical presentations of COVID-19 and dengue; limited diagnostic capacity of laboratories in resource constrained settings; and complexities of interpreting results make identification of COVID-19 in the dengue endemic setting challenging. Clinicians in endemic areas must be aware of diagnostic challenges and maintain a high index of suspicion for COVID-19 coinfection with DENV and other tropical pathogens.

Devastating dengue outbreak amidst COVID-19 pandemic in Bangladesh: an alarming situation

Dengue fever is a viral infection caused by Aedes mosquitoes that has recently expanded fast in many of the WHO member states globally. Female mosquitoes, mostly Aedes aegypti and, to a smaller degree, Aedes albopictus, disseminate dengue virus. Dengue fever has been more common in recent decades all across the world, and Bangladesh is no exception. As the COVID-19 outbreak wreaks havoc, the following rise in dengue illnesses has been a source of considerable concern. As the health care has been stretched thin in these dangerous times, the vulnerable population has been left at the mercy of these two viral infections. Lack of knowledge, major legislative changes, poor eradication initiatives, and a lack of financing resources have all contributed to the increase in numbers. Stakeholders and policymakers must begin taking meaningful actions and implementing well-thought-out adjustments immediately, or the situation will worsen, resulting in the loss of thousands of innocent lives.