Atypical Manifestations of Dengue Fever (DF) - Where Do We Stand Today?

Detection of viral antigen and inflammatory mediators in fatal pediatric dengue: a study on lung immunopathogenesis

Introduction

The dengue virus (DENV) is the etiological agent that causes dengue fever illness, an arbovirus with a major endemic potential that has become increasingly prevalent in Brazil and has already been associated with fatal cases in children. DENV has tropism for several organs, including lungs causing pulmonary complications. The aim of this article was to evaluate the inflammatory and histopathological profile of the lung tissue of three fatal cases of children infected with DENV, which represents a group more susceptible to fatality due to its incomplete development.

Methods

Histopathological analysis was carried out using Hematoxylin and Eosin staining and special stains. While the characterization of the inflammatory response and cellular expression was done by marking the viral protein, macrophages, lymphocytes and pro-inflammatory cytokines.

Results and discussion

The results confirm that vascular dysfunctions such as hemorrhage, vascular congestion and edema associated with a mononuclear infiltrate were observed in all three cases. In addition, the presence of viral replication and increased expression of inflammatory markers were also observed. Such findings contribute to the study and description of dengue, especially its effects on lung tissue.

Liver immunopathogenesis in fatal cases of dengue in children: detection of viral antigen, cytokine profile and inflammatory mediators

Introduction

Dengue virus (DENV), the etiologic agent of dengue fever illness, represents a global public health concern, mainly in tropical and subtropical areas across the globe. It is well known that this acute viral disease can progress to severe hemorrhagic stages in some individuals, however, the immunopathogenic basis of the development of more severe forms by these patients is yet to be fully understood.

Objective

In this context, we investigated and characterized the histopathological features as well as the cytokine profile and cell subpopulations present in liver tissues from three fatal cases of DENV in children.

Methods

Hematoxylin and Eosin, Periodic Acid Schiff and Picro Sirius Red staining were utilized for the histopathological analysis. Immunohistochemistry assay was performed to characterize the inflammatory response and cell expression patterns.

Results

Vascular dysfunctions such as hemorrhage, vascular congestion and edema associated with a mononuclear infiltrate were observedin all three cases. Liver tissues exhibited increased presence of CD68+ and TCD8+ cells as well as high expression of MMP-9, TNF-a, RANTES, VEGFR-2 mediators. Viral replication was confirmed by the detection of NS3 protein.

Conclusion

Taken together, these results evidenced key factors that may be involved in the development of severe alterations in liver tissues of children in response to DENV infection.

Dengue presenting as a case of acute pancreatitis-A rare case report

Atypical presentations may be presented with the common symptoms in Dengue. We, hereby, present a case of Dengue who was admitted in our hospital with the complaints of fever, upper abdominal pain, and vomiting, literally diagnosed as a case of acute pancreatitis.

Assessing the burden of dengue among household members in Alaminos, Laguna, the Philippines: a prospective cohort study

Background

The incidence of dengue is increasing rapidly and is a challenging health issue in the Philippines. Epidemiological data are largely based on a passive-surveillance reporting system, which leads to substantial under-reporting of cases.

Objectives

To estimate dengue infection and disease incidence prospectively at the community level in an endemic area of the Philippines using an active surveillance strategy.

Methods

We implemented active surveillance in the highly endemic community of Alaminos, Laguna. The study consisted of a 1-year follow-up with 2 visits scheduled at the start and end of the study, as well as regular active surveillance in between and unscheduled visits for suspected cases. Blood samples were collected and analyzed to detect dengue during the first scheduled visit and all unscheduled visits, and clinical examination was performed at all visits (registered at clinicaltrials.gov NCT02766088).

Results

We enrolled 500 participants, aged from 6 months to 50 years; 76.2% were found positive for immunoglobulin G (95% confidence interval [CI], 71.9-80.0), with 92.0% among those aged 9-17 years. Active (weekly) surveillance identified 4 virologically confirmed cases of dengue (incidence proportion 0.8; 95% CI 0.3-2.1); all in participants aged ≤14 years.

Conclusions

Routine surveillance programs such as sentinel sites are needed to characterize the entire clinical spectrum of symptomatic dengue, disease incidence, and transmission in the community.

Incidence of dengue illness in Mexican people aged 6 months to 50 years old: A prospective cohort study conducted in Jalisco

BACKGROUND AND OBJECTIVES

The burden of dengue virus (DENV), a mosquito-borne pathogen, remains difficult to assess due to misdiagnosis and underreporting. Moreover, the large proportion of asymptomatic dengue cases impairs comprehensive assessment of its epidemiology even where effective surveillance systems are in place. We conducted a prospective community-based study to assess the incidence of symptomatic dengue cases in Zapopan and neighboring municipalities in the state of Jalisco, Mexico.

METHODS

Healthy subjects aged 6 months to 50 years living in households located in the Zapopan and neighboring municipalities were enrolled for a 24-month follow-up study (NCT02766088). Serostatus was determined at enrolment and weekly contacts were conducted via phone calls and home visits. Participants had to report any febrile episode lasting for at least two days. Suspected dengue cases were tested by reverse-transcriptase quantitative polymerase chain reaction (RT-qPCR), detection of non-structural protein 1 (NS1), anti-DENV immunoglobulin G and M (IgG and IgM) assays.

RESULTS

A total of 350 individuals from 87 households were enrolled. The overall seroprevalence of anti-DENV IgG at enrolment was 19.4% (95% confidence interval [CI] 14.5-25.6) with the highest seroprevalence rate observed in the adult group. Over the 27-month study period from July 2016 to September 2018, a total of 18 suspected dengue cases were reported. Four cases were confirmed by RT-qPCR and serotyped as DENV-1. A fifth case was confirmed by the NS1 assay. The 13 remaining suspected cases were tested negative by these assays. Based on the 5 virologically confirmed cases, symptomatic dengue incidence proportion of 1.4% (95%CI 0.5-3.8) was estimated. No severe cases or hospitalizations occurred during the study.

CONCLUSION

Community-based active surveillance was shown as efficient to detect symptomatic dengue cases.

CLINICAL TRIAL REGISTRATION

NCT02766088.

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.

Dengue with Hemorrhagic Manifestations and Acute Pancreatitis: Case Report and Review

Dengue fever is an acute viral disease transmitted by arthropods, which has become a major public health problem, especially in tropical and subtropical areas. We found 17 reported cases of dengue complicated with pancreatitis in the world literature, 13 cases were found in Asia, one in Europe, and two in Latin America. This is the first and an unusual case of dengue with hemorrhagic manifestations complicated with acute pancreatitis in Panama.

A 37-year-old woman with an unknown past medical history presented to Santo Tomas Hospital (Panama City, Panama) with sudden abdominal pain in the epigastrium and left hypochondrium, described as a burning-like pain radiating towards the back. Five days before the admission, the patient had fever, chills, headache, retro-orbital pain, dizziness, arthralgia, loss of appetite, and fatigue. In the emergency room, a diagnosis of acute pancreatitis was made and the patient was hospitalized. Physical examination showed bleeding gums, and laboratory tests show leukopenia and thrombocytopenia, which suggested an infection caused by the dengue virus. The dengue infection was confirmed using quantitative polymerase chain reaction (qPCR) and enzyme-linked immunosorbent assay (ELISA). The patient received supportive treatment and the symptoms resolved. She was discharged on the ninth day of hospitalization without any sequela. The final diagnosis was hemorrhagic dengue complicated by acute pancreatitis.

Clinical Profile and Outcome of Dengue Fever in Multidisciplinary Intensive Care Unit of a Tertiary Level Hospital in India

Background

India is one of the seven identified countries in South-East Asia region regularly reporting dengue fever (DF)/dengue hemorrhagic fever (DHF) outbreaks. Even though the dengue prodrome and evolution of illness are most often similar in many patients, progress and outcome may differ significantly depending on the severity of illness as well as treatment instituted. We studied the clinical manifestations, outcome and factors predicting mortality of serology confirmed dengue fever cases admitted in Multidisciplinary Intensive Care Unit (MICU) of a high acuity healthcare facility in India.

Methodology

All patients with serology proven dengue fever admitted to MICU between 1st July 2015 and1st December 2015 were included in the study. Clinical presentation, laboratory findings, severity of illness scores and outcome were recorded.

Results

Majority of the patients (58.4%) belonged to 21–40 year age group. Hepatic (96.8%) followed by hematological (79.2%) involvement were the most common findings. CNS involvement observed among 27%. Survival to hospital discharge was 78.9%. Respiratory and gastrointestinal system involvement was associated with increased mortality. Acute respiratory distress syndrome (ARDS), acute kidney injury (AKI) and shock were the clinical syndromes associated with mortality. Serum lactate, aspartate transaminase (AST) and alanine transaminase (ALT) were significantly elevated among non survivors. Significant difference in sequential organ failure assessment (SOFA) and acute physiology and chronic health evaluation (APACHE) scores was also observed among survivors and non survivors.

Conclusion

Organ system involvement and higher disease severity scores are strong predictors of mortality. High index of suspicion for atypical manifestations of dengue is warranted.

How to cite this article

Padyana M, Karanth S, Vaidya S, Gopaldas JA. Clinical Profile and Outcome of Dengue Fever in Multidisciplinary Intensive Care Unit of a Tertiary Level Hospital in India. Indian J Crit Care Med 2019;23(6):270–273.

Beyond thrombocytopaenia, haemorrhage and shock: the expanded dengue syndrome

Dengue infection classically presents with fever, thrombocytopaenia, and varying degrees of plasma leakage, giving rise to shock. However, a myriad of other manifestations, involving the cardiovascular system, the nervous system, the liver, the kidneys, the gut and the haematological system have been reported in dengue. This review summarizes these varied presentations.

Dengue infection in India: A systematic review and meta-analysis

INTRODUCTION

Dengue is the most extensively spread mosquito-borne disease; endemic in more than 100 countries. Information about dengue disease burden, its prevalence, incidence and geographic distribution is critical in planning appropriate control measures against dengue fever. We conducted a systematic review and meta-analysis of dengue fever in India.

METHODS

We searched for studies published until 2017 reporting the incidence, the prevalence or case fatality of dengue in India. Our primary outcomes were (a) prevalence of laboratory confirmed dengue infection among clinically suspected patients, (b) seroprevalence in the general population and (c) case fatality ratio among laboratory confirmed dengue patients. We used binomial-normal mixed effects regression model to estimate the pooled proportion of dengue infections. Forest plots were used to display pooled estimates. The metafor package of R software was used to conduct meta-analysis.

RESULTS

Of the 2285 identified articles on dengue, we included 233 in the analysis wherein 180 reported prevalence of laboratory confirmed dengue infection, seven reported seroprevalence as evidenced by IgG or neutralizing antibodies against dengue and 77 reported case fatality. The overall estimate of the prevalence of laboratory confirmed dengue infection among clinically suspected patients was 38.3% (95% CI: 34.8%-41.8%). The pooled estimate of dengue seroprevalence in the general population and CFR among laboratory confirmed patients was 56.9% (95% CI: 37.5-74.4) and 2.6% (95% CI: 2-3.4) respectively. There was significant heterogeneity in reported outcomes (p-values<0.001).

CONCLUSIONS

Identified gaps in the understanding of dengue epidemiology in India emphasize the need to initiate community-based cohort studies representing different geographic regions to generate reliable estimates of age-specific incidence of dengue and studies to generate dengue seroprevalence data in the country.

Análisis descriptivo del compromiso de órganos en niños con dengue grave en Neiva, Colombia

Introducción. La infección por dengue puede comprometer órganos como el miocardio y el hígado. Tal hecho puede agravar la evolución clínica, por ello estos órganos han sido considerados en la clasificación revisada de la Organización Mundial de la Salud (OMS) para esta enfermedad.Objetivo. Describir la presencia de afectación por dengue en órganos como miocardio, hígado y sistema nervioso central (SNC) en niños de Neiva, ColombiaMateriales y métodos. Este estudio analizó 930 niños con diagnóstico de dengue confirmado que ingresaron al Hospital Universitario Hernando Moncaleano Perdomo de Neiva entre enero de 2009 y diciembre de 2010. Para el diagnóstico y estratificación clínica se usó la clasificación revisada de la OMS. La infección por dengue se confirmó por detección plasmática de NS1 o IgM específica. Se realizó seguimiento clínico y paraclínico diario durante toda la hospitalización.Resultados. De los 930 niños, 105 fueron clasificados como dengue grave (DG) y, de estos, 19 presentaron órganos afectados. El miocardio fue el más comprometido (14 casos), seguido por el hígado (4 casos) y el SNC (1 caso).Conclusión. El compromiso clínico del miocardio, el hígado o el SNC se observó en el 18% de los casos de niños con DG. Es necesario un diagnóstico y tratamiento oportuno de esta patología en niños.

Incidence and Clinical Outcome of Acute Liver Failure Caused by Dengue in a Hospital for Tropical Diseases, Thailand

Acute liver failure is an atypical manifestation of dengue with a high mortality. We performed a retrospective cohort study at the Hospital for Tropical Diseases, Bangkok, Thailand. In total, 1,926 patients with serologically confirmed dengue were enrolled in the study from 2011 to 2015. Of these, six patients presented with acute liver failure, four died, and two survived. The incidence of dengue-associated acute liver failure was 0.31%. Dengue-associated acute liver failure was most common among young adults (median age, 29 years). The median duration from onset of fever to development of acute liver failure was 7.5 days. Patients with the severe stage of dengue had a higher risk of developing acute liver failure (P < 0.001). The baseline risk factors associated with the development of acute liver failure were an age of ≤ 40 years (odds ratio [OR] = 1.5, 95% confidence interval [CI] = 1.1-2.0, P < 0.05), a > 10% ratio of atypical lymphocytes (OR = 2.3, 95% CI = 1.8-3.0, P < 0.001), and a platelet count of < 50,000 mm³ (OR = 2.8, 95% CI = 2.2-3.6, P < 0.001). The incidence of acute liver failure in patients with dengue was quite low, but its impact on morbidity, mortality, and poor clinical outcomes was significant. In summary, this study indicates that various baseline risk factors are associated with acute liver failure in patients with dengue.

Dengue virus induces apoptosis in SH-SY5Y human neuroblastoma cells

INTRODUCTION

Dengue is a human disease caused by a virus with the same name, which is transmitted by the bite of Aedes mosquitoes. The infection has a wide range of clinical presentations ranging from asymptomatic to fatal cases, with the pediatric population being the most susceptible. According to the new classification of the disease, the neurological manifestations are considered a criterion for the diagnosis of severe dengue. 

OBJECTIVE

To evaluate the possible mechanisms involved in the onset of neurological signs in a cell line of human neurons as a model of infection with dengue virus type 2 (DENV-2). 

MATERIALS AND METHODS

Susceptibility and permissiveness of the SH-SY5Y line to infection by DENV-2 was analyzed, showing that the proportions of viral infection and production are similar to those of primate cells used as positive control for infection. 

RESULTS

Infection induced a cytopathic effect on the neuroblastoma line characterized by apoptotic cell death process, increasing the proportion of annexin V and TUNEL positive cells and an upregulation of TNF-α. Treatment with anti-TNF-α antibody increased slightly cell survival of infected cells. The addition of exogenous TNF-α to the infected cultures enhanced cell death. 

CONCLUSION

These results as a whole suggest that the upregulation of TNF-α could be part of the process that induces cell damage and death in cases of dengue encephalitis.

Dengue death with evidence of hemophagocytic syndrome and dengue virus infection in the bone marrow

INTRODUCTION

HPS is a potentially life-threatening histiocytic disorder that has been described in various viral infections including dengue. Its involvement in severe and fatal dengue is probably more common but is presently under recognized.

CASE DESCRIPTION

A 38-year-old female was admitted after 5 days of fever. She was deeply jaundiced, leukopenic and thrombocytopenic. Marked elevation of transaminases, hyperbilirubinemia and hypoalbuminemia were observed. She had deranged INR values and prolonged aPTT accompanied with hypofibrinogenemia. She also had splenomegaly. She was positive for dengue IgM. Five days later she became polyuric and CT brain image showed gross generalized cerebral edema. Her conditions deteriorated by day 9, became confused with GCS of 9/15. Her BMAT showed minimal histiocytes. Her serum ferritin level peaked at 13,670.00 µg/mL and her sCD163 and sCD25 values were markedly elevated at 4750.00 ng/mL and 4191.00 pg/mL, respectively. She succumbed to the disease on day 10 and examination of her tissues showed the presence of dengue virus genome in the bone marrow.

DISCUSSION AND EVALUATION

It is described here, a case of fatal dengue with clinical features of HPS. Though BMAT results did not show the presence of macrophage hemophagocytosis, other laboratory features were consistent with HPS especially marked elevation of ferritin, sCD163 and sCD25. Detection of dengue virus in the patient's bone marrow, fifteen days after the onset of fever was also consistent with the suggestion that the HPS is associated with dengue virus infection.

CONCLUSIONS

The findings highlight HPS as a possible complication leading to severe dengue and revealed persistent dengue virus infection of the bone marrow. Detection of HPS markers; ferritin, sCD163 and sCD25, therefore, should be considered for early recognition of HPS-associated dengue.

Complete heart block in dengue complicating management of shock due to both bleeding and leakage: a case report

Background

The spread of Dengue virus infection is reaching pandemic proportions. Dengue is usually dreaded for causing shock due to capillary leakage. However the clinical spectrum of dengue is vast and the newly incorporated expanded dengue syndrome introduces a wide range of presentations that are rarely observed and appreciated but nevertheless have the potential to cause significant morbidity and even mortality. Cardiac involvement in dengue is one such example.

Case presentation

A 26 year old South-Asian female presented in a state of haemodynamic shock with a history of fever and use of non-steroidal anti inflammatory drugs. Dengue was suspected clinically and later confirmed. Following stabilization and while still in the febrile phase the patient developed bradycardia with dynamic electrocardiogram changes which evolved into complete heart block. However there was no circulatory compromise. Clinical picture was further complicated by the development of dengue haemorhaghic fever and cautious fluid resuscitation was carried out in correlation to clinical and haematological parameters. Impaired coagulation profile necessitated administration of activated factor seven on the backdrop of low platelets and bleeding. Cardiac pacing could be avoided due to maintenance of vitals within acceptable parameters.

Conclusion

Expanded dengue syndrome should be given greater appreciation as not all may be benign. Cardiovascular system involvement in dengue has the potential to cause significant morbidity and mortality. Careful interpretation of clinical parameters will help in the institution of the appropriate management and help avoid unnecessary invasive interventions. Screening of dengue patients with timely electrocardiographs would be useful to detect cardiac involvement. Guidance on managing atypical manifestations of dengue expanded syndrome should available to help clinicians dictate treatment.