Concurrent infections of dengue viruses serotype 2 and 3 in patient with severe dengue from Jakarta, Indonesia

Flying under the radar - impact and factors influencing asymptomatic DENV infections

The clinical outcome of DENV and other Flaviviruses infections represents a spectrum of severity that ranges from mild manifestations to severe disease, which can ultimately lead to death. Nonetheless, most of these infections result in an asymptomatic outcome that may play an important role in the persistent circulation of these viruses. Also, although little is known about the mechanisms that lead to these asymptomatic infections, they are likely the result of a complex interplay between viral and host factors. Specific characteristics of the infecting viral strain, such as its replicating efficiency, coupled with host factors, like gene expression of key molecules involved in the immune response or in the protection against disease, are among crucial factors to study. This review revisits recent data on factors that may contribute to the asymptomatic outcome of the world's widespread DENV, highlighting the importance of silent infections in the transmission of this pathogen and the immune status of the host.

Diagnosis of Acute Dengue Virus Infection Using Enzyme-Linked Immunosorbent Assay and Real-Time PCR

Dengue fever is a viral infection caused by the dengue virus and is a growing concern for public health worldwide, particularly in tropical and subtropical regions. This study aimed to assess the diagnostic accuracy of a commercially available NS1 ELISA kit for dengue fever in Pakistan using multiplex qRT-PCR as the gold standard. The study recruited 1236 suspected cases of dengue fever admitted to public sector hospitals in Lahore, Pakistan. Of the suspected cases, 610 (49.3%) were confirmed positive for DENV infection through qRT-PCR, with all four serotypes detected. DENV-2 was the most prevalent serotype, detected in 95.7% of cases. The NS1 ELISA kit detected 71.1% of the positive cases. However, the diagnostic accuracy of the NS1 ELISA kit was found to be only 64.89%. Of the 610 confirmed cases, 68% were male and 32% were female, with a median age of 30 years. Dengue fever was diagnosed in 91.8% of cases, while 8.2% were diagnosed with dengue hemorrhagic fever (DHF). DHF patients had a higher prevalence of abdominal pain, hemorrhagic manifestations, and thrombocytopenia. The cocirculation of all four DENV serotypes in Lahore is concerning and could lead to more severe forms of the disease, such as DHF or dengue shock syndrome, in the future. The study highlights the low diagnostic accuracy of commercially available NS1 ELISA kits and emphasizes the importance of using molecular methods to confirm acute dengue infections. Given the increasing prevalence of dengue fever in developing countries like Pakistan, more accurate and reliable diagnostic tools are needed for effective disease management and control.

Morphological Aspects and Viremia Analysis of BALB/c Murine Model Experimentally Infected with Dengue Virus Serotype 4

Ever since its brief introduction in the Brazilian territory in 1981, dengue virus serotype 4 (DENV-4) remained absent from the national epidemiological scenario for almost 25 years. The emergence of DENV-4 in 2010 resulted in epidemics in most Brazilian states. DENV-4, however, remains one of the least studied among the four DENV serotypes. Despite being known as a mild serotype, DENV-4 is associated with severe cases and deaths and deserves to be investigated; however, the lack of suitable experimental animal models is a limiting factor for pathogenesis studies. Here, we aimed to investigate the susceptibility and potential tropism of DENV-4 for liver, lung and heart of an immunocompetent mice model, and to evaluate and investigate the resulting morphological and ultrastructural alterations upon viral infection. BALB/c mice were inoculated intravenously with non-neuroadapted doses of DENV-4 isolated from a human case. The histopathological analysis of liver revealed typical alterations of DENV, such as microsteatosis, edema and vascular congestion, while in lung, widespread areas of hemorrhage and interstitial pneumonia were observed. While milder alterations were present in heart, characterized by limited hemorrhage and discrete presence of inflammatory infiltrate, the disorganization of the structure of the intercalated disc is of particular interest. DENV-4 RNA was detected in liver, lung, heart and serum of BALB/c mice through qRT-PCR, while the NS3 viral protein was observed in all of the aforementioned organs through immunohistochemistry. These findings indicate the susceptibility of the model to the serotype and further reinforce the usefulness of BALB/c mice in studying the many alterations caused by DENV.

Dengue and Chikungunya virus co-infection in major metropolitan cities of provinces of Punjab and Khyber Pakhtunkhwa: A multi-center study

Dengue has become endemic in Pakistan with annual recurrence. A sudden increase in the dengue cases was reported from Rawalpindi in 2016, while an outbreak occurred for the first time in Peshawar in 2017. Therefore, a multi-center study was carried out to determine the circulating dengue virus (DENV) serotypes and Chikungunya virus (CHIKV) co-infection in Lahore, Rawalpindi, and Peshawar cities in 2016–18. A hospital-based cross-sectional study was carried out in Lahore and Rawalpindi in 2016–18, while a community-based study was carried out in Peshawar in 2017. The study participants were tested for dengue NS1 antigen using an immunochromatographic device while anti-dengue IgM/IgG antibodies were detected by indirect ELISA. All NS1 positive samples were used for DENV serotyping using multiplex real-time PCR assay. Additionally, dengue samples were tested for CHIKV co-infection using IgM/IgG ELISA. A total of 6291 samples were collected among which 8.11% were NS1 positive while 2.5% were PCR positive. DENV-2 was the most common serotype (75.5%) detected, followed by DENV-1 in 16.1%, DENV-3 in 3.9% and DENV-4 in 0.7% while DENV-1 and DENV-4 concurrent infections were detected in 3.9% samples. DENV-1 was the predominant serotype (62.5%) detected from Lahore and Rawalpindi, while DENV-2 was the only serotype detected from Peshawar. Comorbidities resulted in a significant increase (p-value<0.001) in the duration of hospital stay of the patients. Type 2 diabetes mellitus substantially (p-value = 0.004) contributed to the severity of the disease. Among a total of 590 dengue positive samples, 11.8% were also positive for CHIKV co-infection. Co-circulation of multiple DENV serotypes and CHIKV infection in Pakistan is a worrisome situation demanding the urgent attention of the public health experts to strengthen vector surveillance.

Mosquitoes are responsible for the transmission of many different types of infectious pathogens and parasites to humans. Some of these pathogens include viruses like dengue and chikungunya viruses which cause diseases in humans. Dengue virus has four different types (1, 2, 3, and 4) present in nature. In this study, we detected all four dengue virus types in hospitalized patients in Lahore and Rawalpindi. While only dengue virus type-2 was detected from Peshawar city. The secondary infections with different dengue virus types than the previous one might result in a more severe form of the disease. Therefore, the population of Peshawar is at risk of developing a severe form of dengue fever in the future in case of infection from another dengue virus type. The data of hospitalized patients showed that other diseases in addition to dengue fever result in an increased hospital stay. Comorbidities like diabetes also increase the risk of developing a more severe form of dengue fever. Combined infections of both dengue and chikungunya viruses were detected from Lahore, Rawalpindi, and Peshawar. The transmission of dengue and chikungunya viruses and the co-circulation of multiple dengue virus types not only impose public health burden but also result in economic losses.

Flavivirus: From Structure to Therapeutics Development

Flaviviruses are still a hidden threat to global human safety, as we are reminded by recent reports of dengue virus infections in Singapore and African-lineage-like Zika virus infections in Brazil. Therapeutic drugs or vaccines for flavivirus infections are in urgent need but are not well developed. The Flaviviridae family comprises a large group of enveloped viruses with a single-strand RNA genome of positive polarity. The genome of flavivirus encodes ten proteins, and each of them plays a different and important role in viral infection. In this review, we briefly summarized the major information of flavivirus and further introduced some strategies for the design and development of vaccines and anti-flavivirus compound drugs based on the structure of the viral proteins. There is no doubt that in the past few years, studies of antiviral drugs have achieved solid progress based on better understanding of the flavivirus biology. However, currently, there are no fully effective antiviral drugs or vaccines for most flaviviruses. We hope that this review may provide useful information for future development of anti-flavivirus drugs and vaccines.

Molecular investigation of the dengue outbreak in Karnataka, South India, reveals co-circulation of all four dengue virus serotypes

The growing incidence of dengue outbreaks in the state of Karnataka prompted us to study the circulating dengue virus (DENV) and their proportion among the suspected cases of dengue patients during the disease outbreak at Mysuru district of Southern India. The presence of the DENV in a patient's serum sample was identified by RT-PCR using previously published primer pairs targeting CprM gene. DENV serotyping was carried out by semi-nested multiplex PCR using serotype-specific primers and nucleotide sequencing. Three hundred fifty-five samples of serum from suspected dengue cases were collected, and 203 samples (57.18%) were found positives. In 2016, DENV-4 (97.87%) was found to be the most dominant DENV serotype either alone or as co-infection, followed by DENV-2 (8.51%) and DENV-3 (4.25%). In 47 positive cases, co-infection with more than one serotype was detected in 4 cases (8.51%). The analysis of the dengue cases in 2017, DENV-4 was dominating serotype (33.97%), followed by the emergence of DENV-2 (32.05%), DENV-3 (25.64%), and DENV-1 (25.00%). Our study also reports the circulation of all four DENV serotypes in the Mysuru district of Southern India, with concurrent infections rate of 16.66% in 2017. The present study provides information regarding the genetic variation among the circulating DENV serotype in an Indian state of Karnataka. The need for the studying genetic diversity of DENV will be useful during the continuous monitoring for disease burden as well as the development of appropriate prophylactic measures to control the spread of dengue infection.

Comparison of Dengue Predictive Models Developed Using Artificial Neural Network and Discriminant Analysis with Small Dataset

In Indonesia, dengue has become one of the hyperendemic diseases. Dengue consists of three clinical phases—febrile phase, critical phase, and recovery phase. Many patients have died in the critical phase due to the lack of proper and timely treatment. Therefore, we developed models that can predict the severity level of dengue based on the laboratory test results of the corresponding patients using Artificial Neural Network (ANN) and Discriminant Analysis (DA). In developing the models, we used a very small dataset. It is shown that ANN models developed using logistic and hyperbolic tangent activation function with 70% training data yielded the highest accuracy (90.91%), sensitivity (91.11%), and specificity (95.51%). This is the proposed model in this research. The proposed model will be able to help physicians in predicting the severity level of dengue patients before entering the critical phase. Furthermore, it will ease physicians in treating dengue patients early, so fatal cases or deaths can be avoided.

Dengue viral infection in Indonesia: Epidemiology, diagnostic challenges, and mutations from an observational cohort study

BACKGROUND

Dengue virus (DENV) infection is a major cause of acute febrile illness in Indonesia. Diagnostic inaccuracy may occur due to its varied and non-specific presentation. Characterization of DENV epidemiology, clinical presentation, and virology will facilitate appropriate clinical management and public health policy.

METHODOLOGY/PRINCIPAL FINDINGS

A multicenter observational cohort study was conducted in Indonesia to assess causes of acute fever requiring hospitalization. Clinical information and specimens were collected at enrollment, 14-28 days, and 3 months from 1,486 children and adults. Total of 468 (31.9%) cases of DENV infection were confirmed by reference laboratory assays. Of these, 414 (88.5%) were accurately diagnosed and 54 had been misdiagnosed as another infection by sites. One hundred initially suspected dengue cases were finally classified as 'non-dengue'; other pathogens were identified in 58 of those cases. Mortality of DENV infection was low (0.6%). Prior DENV exposure was found in 92.3% of subjects >12 years. DENV circulated year-round in all cities, with higher incidence from January to March. DENV-3 and DENV-1 were the predominant serotypes. This study identified DENV-1 with TS119(C→T) substitution in the serotyping primer annealing site, leading to failure of serotype determination.

CONCLUSIONS/SIGNIFICANCE

DENV is a common etiology of acute febrile illness requiring hospitalization in Indonesia. Diagnostic accuracy at clinical sites merits optimization since misdiagnosis of DENV infection and over-estimation of dengue can negatively impact management and outcomes. Mutation at the annealing site of the serotyping primer may confound diagnosis. Clinicians should consider following diagnostic algorithms that include DENV confirmatory testing. Policy-makers should prioritize development of laboratory capacity for diagnosis of DENV.

Phylogenetic analysis revealed the co-circulation of four dengue virus serotypes in Southern Thailand

Dengue fever is caused by dengue viruses (DENV) from the Flavivirus genus and is the most prevalent arboviral disease. DENV exists in four immunogenically distinct and genetically-related serotypes (DENV-1 to 4), each subdivided in genotypes. Despite the endemicity of all four DENV serotypes in Thailand, no prior study has characterized the circulation of DENV in the southern provinces of the country. To determine the genetic diversity of DENV circulating in Southern Thailand in 2015 and 2016, we investigated 46 viruses from 182 patients' sera confirmed positive for DENV by serological and Nested RT-PCR tests. Our dataset included 2 DENV-1, 20 DENV-2, 9 DENV-3 and 15 DENV-4. Phylogenetic analysis was performed on viral envelop sequences. This revealed that part of the identified genotypes from DENV-1 and DENV-4 had been predominant in Asia (genotype I for both serotypes), while genotype II for DENV-4 and the Cosmopolitan genotype DENV-2 were also circulating. Whereas DENV-3 genotype II had been predominantly detected in South East Asia during the previous decades, we found genotype III and genotype I in Southern Thailand. All DENV genotype identified in this study were closely related to contemporary strains circulating in Southeast Asian countries, emphasizing the regional circulation of DENV. These results provide new insights into the co-circulation of all four DENV serotypes in Southern Thailand, confirming the hyperendemicity of DENV in the region. These findings also suggest a new trend of dissemination for some DENV serotypes with a possible shift in genotype distribution; as recently observed in other Asian countries.

Concurrent infections of dengue virus serotypes in Bali, Indonesia

Objective

To describe cases of dengue virus (DENV) concurrent infections in patients from both local and international traveler visiting Bali, Indonesia.

Results

During a hospital-based study, 260 patients (from 161 local and 99 international traveler patients) were recruited. Among them, 190 were positive by DENV RT-PCR in which eight patients (five local and three international travelers) detected as having concurrent infections by two different DENV serotypes. Among the eight patients, the common dengue symptoms diagnosed were fever, headache, and myalgia. Six cases (75%) were diagnosed with dengue fever (DF) while two cases (25%) manifested with bleeding and were diagnosed with dengue hemorrhagic fever (DHF) grade 1. The DENVs concurrent infections involved all four DENV serotypes known to be circulating in Bali. Although cases of DENV concurrent infections have been implicated with severe manifestation, we observed that most of concurrent infections cases in our study were of mild clinical manifestation, that may be related to the changing of DENV serotype predominance which is occurring in Bali, Indonesia.

DNA Switch: Toehold-Mediated DNA Isothermal Amplification for Dengue Serotyping

The inherent ability of nucleic acids to recognize a complementary pair has gained wide popularity in DNA sensor applications. DNA molecules can be produced in bulk and easily incorporated with various nanomaterials for sensing applications. More complex designs and sophisticated DNA sensors have been reported over the years to allow DNA detection in a faster, cheaper, and more convenient manner. Here, we report a DNA sensor designed to function like a switch to turn “on” silver nanocluster (AgNC) generation in the presence of a specific DNA target. By defining the probe region sequence, we are able to tune the color of the AgNC generated in direct relation to the different targets. As a proof of concept, we used dengue RNA-dependent RNA polymerase conserved sequences from all four serotypes as targets. This method was able to distinguish each dengue serotype by generating the serotype-respective AgNCs. The DNA switch was also able to identify and amplify the correct target in a mixture of targets with good specificity. This strategy has a detection limit of between 1.5 and 2.0 µM depending on the sequence of AgNC. The DNA switch approach provides an attractive alternative for single-target or multiplex DNA detection.

Diversity of Dengue Virus Serotype in Endemic Region of South Sulawesi Province

The objective of this research was to investigate serotype diversity pattern of dengue hemorrhagic fever virus by using real-time-polymerase chain reaction (RT-PCR) method. It was an explorative laboratory research in endemic dengue fever area in South Sulawesi Province, Indonesia, that is, Makassar municipality and Maros and Gowa region. Serological examination was carried out using real-time-polymerase chain reaction (RT-PCR) method to determine the serotype of dengue virus. The data showed that, of 30 patients, 20 patients (66.67%) were from Makassar municipality: 10 patients (33.33%) from Gowa region and 10 patients (33.33%) from Maros region. The serotypes found were DENV-2 and DENV-4 and no DENV-1 and DENV-3 serotypes were found. Makassar municipality and Gowa region have higher infection with serotype DENV-2, that is, 40% of cases compared with Maros, which is 20.0%. Statistical test results showed no significant differences between the three endemic areas. Maros region has the highest infection with serotype DENV-4, that is, 40% of cases compared with Makassar municipality (5.0%) and Gowa region (0%). Statistical test results showed significant differences between the three endemic areas. This result revealed that serotypes obtained in endemic areas of dengue fever in South Sulawesi are DENV-2 and DENV-4 and not serotypes DENV-1 and DENV-3. Makassar municipality has DENV-2 and DENV-4 serotype, infection dominated by DENV-2, while Maros region also has DENV-2 and DENV-4, but DENV-4 is the dominant serotype. Gowa municipality only has DENV-2 serotype infection.

Molecular characterization of dengue viruses isolated from patients in Central Java, Indonesia

BACKGROUND

Dengue is hyper-endemic in Indonesia. Purwokerto city in Central Java province is routinely ravaged by the disease. Despite the endemicity of dengue in this city, there is still no data on the virological aspects of dengue in the city. We conducted a molecular surveillance study of the circulating dengue viruses (DENV) in Purwokerto city to gain information on the virus origin, serotype and genotype distribution, and phylogenetic characteristics of DENV.

METHODS

A cross-sectional dengue molecular surveillance study was conducted in Purwokerto. Sera were collected from dengue-suspected patients attending three hospitals in the city. Diagnosis was performed using dengue NS1 antigen and IgG/IgM antibodies detection. DENV serotyping was performed using Simplexa Dengue real-time RT-PCR. Sequencing was conducted to obtain full-length DENV Envelope (E) gene sequences, which were then used in phylogenetic and genotypic analyses. Patients' clinical and demographic data were collected and analyzed.

RESULTS

A total of 105 dengue-suspected patients' sera were collected, in which 80 (76.2%) were positive for IgM and/or IgG, and 57 (54.2%) were confirmed as dengue by NS1 antigen and/or DENV RNA detection using RT-PCR. Serotyping was successful for 47 isolates. All four serotypes circulated in the area with DENV-3 as the predominant serotype. Phylogenetic analyses grouped the isolates into Genotype I for DENV-1, Cosmopolitan genotype for DENV-2, and Genotype I and II for DENV-3 and -4, respectively. The analyses also revealed the close relatedness of Purwokerto isolates to other DENV strains from Indonesia and neighboring countries.

CONCLUSION

We reveal the molecular and virological characteristics of DENV in Purwokerto, Banyumas regency, Central Java. The genotype and phylogenetic analyses indicate the endemicity of the circulating DENV in the city. Our serotype and genotype data provide references for future dengue molecular epidemiology studies and disease management in the region.

Phylogenetic and evolutionary analyses of dengue viruses isolated in Jakarta, Indonesia

Dengue has affected Indonesia for the last five decades and become a major health problem in many cities in the country. Jakarta, the capital of Indonesia, reports dengue cases annually, with several outbreaks documented. To gain information on the dynamic and evolutionary history of dengue virus (DENV) in Jakarta, we conducted phylogenetic and evolutionary analyses of DENV isolated in 2009. Three hundred thirty-three dengue-suspected patients were recruited. Our data revealed that dengue predominantly affected young adults, and the majority of cases were due to secondary infection. A total of 171 virus isolates were successfully serotyped. All four DENV serotypes were circulating in the city, and DENV-1 was the predominant serotype. The DENV genotyping of 17 isolates revealed the presence of Genotypes I and IV in DENV-1, while DENV-2 isolates were grouped into the Cosmopolitan genotype. The grouping of isolates into Genotype I and II was seen for DENV-3 and DENV-4, respectively. Evolutionary analysis revealed the relatedness of Jakarta isolates with other isolates from other cities in Indonesia and isolates from imported cases in other countries. We revealed the endemicity of DENV and the role of Jakarta as the potential source of imported dengue cases in other countries. Our study provides genetic information regarding DENV from Jakarta, which will be useful for upstream applications, such as the study of DENV epidemiology and evolution and transmission dynamics.

Trends of Dengue Disease Epidemiology

Dengue disease is an emerging mosquito-borne viral infection transmitted between humans by Aedes spp. that are distributed mainly in the tropical and subtropical region along with chikungunya and zika diseases. The distribution of dengue disease is influenced by local variation, such as geography, rainfall, temperature, and rapid urbanization or migration. The epidemy of mosquito-borne infection significantly led to increased number of cases and hyperendemicity which induce a more severe form of dengue accompanied by cocirculation of chikungunya and zika. The rapid global spreading of dengue disease created public health burdens that are presently unfulfilled by the absence of specific therapy, simple diagnosis tool for the early phase, and effective and efficient vector control system. This review highlights the current situation of dengue distribution, epidemiology, and new strategies for early dengue diagnosis and risk prediction of severity that can be used to improve oversight and alleviate the heavy burden of the disease.

Co-circulation of the dengue with chikungunya virus during the 2013 outbreak in the southern part of Lao PDR

Background

During the 2013 outbreak, 4638 infection cases and 32 deaths have been recorded in the southern part of Laos. In recent years, the chikungunya virus (CHIKV) emerged in the part of the country bordering Cambodia. Dengue virus (DENV) and CHIKV are transmitted by common mosquito vectors. Both diseases have similar clinical presentations; therefore, CHIKV infections might go undiagnosed in DENV-endemic areas. Thus, rapid detection and accurate diagnosis are crucial for differentiating between the two viruses (DENV and CHIKV). In this study, we demonstrated that CHIKV and two serotypes of DENV are circulating in Laos. In addition, we encountered patients that had been concurrently infected with multiple DENV serotypes or DENV and CHIKV.

Methods

Plasma samples were collected from 40 patients with suspected DENV infections during an outbreak between July and August 2013. The reverse transcription polymerase chain reaction was performed to detect the four DENV serotypes and CHIKV using specific primers. Specifically, the complete envelope gene sequences of the viruses were sequenced and subjected to phylogenetic analysis.

Results

Forty acute-phase plasma samples from patients with suspected dengue infections were tested for the presence of DENV viral RNA using molecular methods. Among the 40 samples, 14 samples were positive for DENV, 2 samples were positive for both viruses (DENV-2 and DENV-3), whereas DENV-1 and DENV-4 were not detected during the study period. We also encountered 10 samples that were positive for CHIKV. Of the 10 CHIKV-positive samples, 3 samples were co-infected by DENV-2, and 2 samples were co-infected by DENV-3. Phylogenetic analysis revealed that the 2013 dengue outbreak in Laos involved DENV-2 genotype Asian I and DENV-3 genotype II. Moreover, the Laotian CHIKV strains grouped together with those isolated during outbreaks on the Indian Ocean Islands within the East Central South African genotype.

Conclusions

These findings revealed that two serotypes (DENV-2 and DENV-3) and CHIKV were detected. Furthermore, infection of multiple DENV serotypes and CHIKV was also observed in the 2013 dengue outbreak. This is the first documented evidence of co-infection with CHIKV and one of two DENV serotypes.