Effectiveness of corticosteroid in the treatment of dengue - A systemic review

Time-Varying Effects of Glucocorticoid Treatment in Critically III Patients with Severe Fever with Thrombocytopenia Syndrome: An Inverse Probability of Treatment Weighting Analysis

Purpose

To evaluate the efficacy of glucocorticoid treatment in critically ill patients with severe fever with thrombocytopenia syndrome (SFTS) and to assess whether glucocorticoid use increases the risk of fungal infections.

Patients and Methods

A retrospective cohort study was conducted involving confirmed SFTS patients from a tertiary hospital. After applying the Inverse Probability of Treatment Weights (IPTW), multivariable Cox regression and logistic regression analyses were utilized to assess the impact of glucocorticoids on the 28-day mortality rate and the risk of fungal infections. Additionally, landmark analysis and time-varying Cox regression were employed to evaluate the effects of glucocorticoids on mortality across different time intervals.

Results

The study included 112 patients with severe SFTS, comprising 67 patients in the glucocorticoid (GC) group and 45 in the non-glucocorticoid (non-GC) group. While glucocorticoid treatment did not significantly alter the overall 28-day mortality in severe SFTS (aHR 0.92, 95% CI 0.44-1.93, P = 0.828), it was associated with a notable reduction in mortality within the first 7 days of hospitalization (aHR 0.35, 95% CI 0.15-0.82, P = 0.016) and an increased mortality risk between days 7 and 28 (aHR 4.92, 95% CI 1.30-18.67, P = 0.019). Furthermore, glucocorticoid use was linked to a significantly higher risk of developing fungal infections (aOR 15.22, 95% CI 4.04-57.38, P < 0.001).

Conclusion

The effects of glucocorticoid treatment in severe SFTS patients vary depending on the disease stage, suggesting that the timing of glucocorticoid administration is crucial. Additionally, the increased risk of fungal infections warrants careful consideration when prescribing glucocorticoids in this population.

Pathogenesis and clinical management of arboviral diseases

Arboviral diseases are viral infections transmitted to humans through the bites of arthropods, such as mosquitoes, often causing a variety of pathologies associated with high levels of morbidity and mortality. Over the past decades, these infections have proven to be a significant challenge to health systems worldwide, particularly following the considerable geographic expansion of the dengue virus (DENV) and its most recent outbreak in Latin America as well as the difficult-to-control outbreaks of yellow fever virus (YFV), chikungunya virus (CHIKV), and Zika virus (ZIKV), leaving behind a substantial portion of the population with complications related to these infections. Currently, the world is experiencing a period of intense globalization, which, combined with global warming, directly contributes to wider dissemination of arbovirus vectors across the globe. Consequently, all continents remain on high alert for potential new outbreaks. Thus, this review aims to provide a comprehensive understanding of the pathogenesis of the four main arboviruses today (DENV, ZIKV, YFV, and CHIKV) discussing their viral characteristics, immune responses, and mechanisms of viral evasion, as well as important clinical aspects for patient management. This includes associated symptoms, laboratory tests, treatments, existing or developing vaccines and the main associated complications, thus integrating a broad historical, scientific and clinical approach.

Diagnostic challenges in a patient with dengue shock syndrome presenting with acute meningoencephalitis

Dengue is a systemic viral infection, and clinical findings vary from asymptomatic to life-threatening, including shock and neurological complications. Despite efforts in vector control, the disease continues to spread worldwide, and the number of annual dengue infections is estimated to be 390 million. For patients with severe dengue, early diagnosis is important; however, owing to the wide range of symptoms and severity, diagnosis can be difficult. Herein, we report the case of a 24-year-old man from Vietnam who was found to have dengue shock syndrome complicated by meningoencephalitis, even though he did not show the typical clinical manifestations of dengue infection. He was transported to our hospital by ambulance because of fever and altered mental status. Brain magnetic resonance imaging revealed hyperintensities in the bilateral thalamus and brainstem on the T2 sequence. After hospitalization, polymerase chain reaction testing of cerebrospinal fluid, serum, and urine revealed the presence of dengue virus serotype 2. This confirmed the diagnosis of dengue encephalitis. The patient was discharged on day 49 with impaired abduction of the left eye and urinary retention. In this case, the initial differential diagnosis was broad because the patient was unable to provide any medical history owing to altered mental status. In addition, the fact that he did not show the characteristic symptoms of dengue infection initially made the diagnosis very difficult. In conclusion, dengue fever should always be considered as a part of the differential diagnosis when a patient from an endemic area presents with fever and impaired consciousness.

Dengue induced acute liver failure: A meta summary of case reports

BACKGROUND

Dengue fever is the most common cause of viral hemorrhagic fever, with more than 400 million cases being reported annually, worldwide. Even though hepatic involvement is common, acute liver failure (ALF) is a rare complication of dengue fever.

AIM

To analyze the demographic profile, symptomology, hospital course and outcomes of patients presenting with ALF secondary to dengue infection by reviewing the published case reports.

METHODS

A systematic search was performed from multiple databases including PubMed, Reference Citation Analysis, Science Direct, and Google Scholar. The search terms used were "dengue" OR "severe dengue" OR "dengue shock syndrome" OR "dengue haemorrhagic syndrome" OR "dengue fever" AND "acute liver failure" OR "hepatic failure" OR "liver injury". The inclusion criteria were: (1) Case reports or case series with individual patient details; (2) Reported acute liver failure secondary to dengue infection; and (3) Published in English language and on adult humans. The data were extracted for patient demographics, clinical symptomatology, clinical interventions, hospital and intensive care unit course, need for organ support and clinical outcomes.

RESULTS

Data from 19 case reports fulfilling the predefined inclusion criteria were included. The median age of patients was 38 years (inter quartile range: Q3-Q1 26.5 years) with a female preponderance (52.6%). The median days from diagnosis of dengue to development of ALF was 4.5 d. The increase in aspartate aminotransferase was higher than that in alanine aminotransferase (median 4625 U/L vs 3100 U/L). All the patients had one or more organ failure, with neurological failure present in 73.7% cases. 42.1% patients required vasopressor support and hepatic encephalopathy was the most reported complication in 13 (68.4%) cases. Most of the patients were managed conservatively and 2 patients were taken up for liver transplantation. Only 1 death was reported (5.3%).

CONCLUSION

Dengue infection may rarely lead to ALF. These patients may frequently require intensive care and organ support. Even though most of these patients may improve with supportive care, liver transplantation may be a therapeutic option in refractory cases.

Cytokine Storm Syndrome Associated with Hemorrhagic Fever and Other Viruses

A wide variety of infections can trigger cytokine storm syndromes including those caused by bacteria, viruses, fungi and parasites. The most frequent viral trigger is Epstein-.Barr virus which is covered in Chapter 16. CSS associated with COVID-19 is also discussed separately (Chapter 22). This chapter will focus on other viruses including the hemorrhagic fever viruses, influenza, parainfluenza, adenovirus, parvovirus, hepatitis viruses, measles, mumps, rubella, enterovirus, parechovirus, rotavirus, human metapneumovirus and human T-lymphotropic virus. The published literature consists of many single case reports and moderate-sized case series reporting CSS, in most circumstances meeting the 2004 diagnostic criteria for hemophagocytic lymphohistiocytosis (HLH). There is no published clinical trial evidence specifically for management of HLH associated with these viruses. In some situations, patients received supportive therapy and blood product transfusions only but in most cases, they were treated with one or more of intravenous corticosteroids, intravenous immunoglobulin and/or etoposide. These were successful in many patients although in significant numbers progression of infection to CSS was associated with mortality.

Severe dengue in the intensive care unit

Dengue fever is considered the most prolific vector-borne disease in the world, with its transmission rate increasing more than eight times in the last two decades. While most cases present mild to moderate symptoms, 5% of patients can develop severe disease. Although the mechanisms are yet not fully comprehended, immune-mediated activation leading to excessive cytokine expression is suggested as a cause of the two main findings in critical patients: increased vascular permeability that may shock and thrombocytopenia, and coagulopathy that can induce hemorrhage. The risk factors of severe disease include previous infection by a different serotype, specific genotypes associated with more efficient replication, certain genetic polymorphisms, and comorbidities such as diabetes, obesity, and cardiovascular disease. The World Health Organization recommends careful monitoring and prompt hospitalization of patients with warning signs or propensity for severe disease to reduce mortality. This review aims to update the diagnosis and management of patients with severe dengue in the intensive care unit.

Dengue overview: An updated systemic review

Dengue is caused by the dengue virus (DENVs) infection and clinical manifestations include dengue fever (DF), dengue hemorrhagic fever (DHF), or dengue shock syndrome (DSS). Due to a lack of antiviral drugs and effective vaccines, several therapeutic and control strategies have been proposed. A systemic literature review was conducted according to PRISMA guidelines to select proper references to give an overview of DENV infection. Results indicate that understanding the virus characteristics and epidemiology are essential to gain the basic and clinical knowledge as well as dengue disseminated pattern and status. Different factors and mechanisms are thought to be involved in the presentation of DHF and DSS, including antibody-dependent enhancement, immune dysregulation, viral virulence, host genetic susceptibility, and preexisting dengue antibodies. This study suggests that dissecting pathogenesis and risk factors as well as developing different types of therapeutic and control strategies against DENV infection are urgently needed.

Computer-aided identification of dengue virus NS2B/NS3 protease inhibitors: an integrated molecular modelling approach for screening of phytochemicals

Globally, dengue (DENV) fever has appeared as the most widespread vector-borne disease, affecting more than 100 million individuals annually. No approved anti-DENV therapy or preventive vaccine is available yet. DENV NS3 protein is associated with protease activity and is essential for viral replication process within the host cell. NS2B is linked with NS3 protein as a cofactor. Hence, NS3/NS2B is a potential druggable target for developing inhibitors against dengue virus. In the present study, a dataset of Beta vulgaris L.-based natural compounds was developed. Virtual ligand screening of 30 phytochemicals was carried out to find novel inhibitors against the NS2B/NS3 protein. Spatial affinity, drug-likeness, and binding behaviors of selected phytochemicals were analyzed. Post-simulation analysis, including Principal Component Analysis (PCA), MMGBSA, and Co-relation analysis, was also performed to provide deep insight for elucidating protein-ligand complexes. This computer-aided screening scrutinized four potent phytochemicals, including betavulgaroside II, vitexin xyloside, epicatechin, and isovitexin2-O-xyloside inhibitors exhibiting optimal binding with viral NS3/NS2B protein. Our study brings novel scaffolds against DENV NS2B/NS3 of serotype-2 to act as lead molecules for further biological optimization. In future, this study will prompt the exploration and development of adjuvant anti-DENV therapy based on natural compounds.Communicated by Ramaswamy H. Sarma.

Case of steroid refractory dengue myositis responsive to intravenous immunoglobulins

Dengue is an arbovirus infection that usually presents with the symptoms of high-grade fever, myalgia and rash. Dengue is spread by the Aedes aegypti mosquito and frequent outbreaks are being reported in regions like Pakistan, India and Sri Lanka. Although muscle ache is quite common with dengue fever, overt myositis is of very rare occurrence. Here, we report a case of a young girl who presented to us with serologically confirmed dengue infection, and having bilateral upper and lower limb weakness. Her raised creatine kinase, along with her electromyography pattern was suggestive of myositis. Her condition was steroid-resistant and responded only to intravenous immunoglobulin. She was discharged in a stable condition.

Targeting the Annexin A1-FPR2/ALX pathway for host-directed therapy in dengue disease

Host immune responses contribute to dengue's pathogenesis and severity, yet the possibility that failure in endogenous inflammation resolution pathways could characterise the disease has not been contemplated. The pro-resolving protein Annexin A1 (AnxA1) is known to counterbalance overexuberant inflammation and mast cell (MC) activation. We hypothesised that inadequate AnxA1 engagement underlies the cytokine storm and vascular pathologies associated with dengue disease. Levels of AnxA1 were examined in the plasma of dengue patients and infected mice. Immunocompetent, interferon (alpha and beta) receptor one knockout (KO), AnxA1 KO, and formyl peptide receptor 2 (FPR2) KO mice were infected with dengue virus (DENV) and treated with the AnxA1 mimetic peptide Ac_2-26 for analysis. In addition, the effect of Ac_2-26 on DENV-induced MC degranulation was assessed in vitro and in vivo. We observed that circulating levels of AnxA1 were reduced in dengue patients and DENV-infected mice. Whilst the absence of AnxA1 or its receptor FPR2 aggravated illness in infected mice, treatment with AnxA1 agonistic peptide attenuated disease manifestationsatteanuated the symptoms of the disease. Both clinical outcomes were attributed to modulation of DENV-mediated viral load-independent MC degranulation. We have thereby identified that altered levels of the pro-resolving mediator AnxA1 are of pathological relevance in DENV infection, suggesting FPR2/ALX agonists as a therapeutic target for dengue disease.

COVID-19 with dengue shock syndrome in a child: coinfection or cross-reactivity?

COVID-19, caused by SARS-CoV-2, has spread globally. Coinfection with other endemic viruses is likely to complicate the clinical presentation and outcome. Information on clinical manifestations and management strategies on COVID-19 coinfection with endemic diseases in children is yet to evolve. The risk of dengue infection exists in 129 countries and it is endemic in more than 100 countries. The SARS-CoV-2 pandemic might overlap with the dengue epidemics in tropical countries. We report the first paediatric case to the best of our knowledge of COVID-19 encephalitis with dengue shock syndrome. This clinical syndrome could be attributed to serological cross-reactivity, incidental coinfection or perhaps a warning for dengue-endemic regions to face the unique challenge of differentiating and managing two disease entities together. Enhanced understanding of potential COVID-19 and dengue coinfection warrants immediate attention of researchers and international health policy makers.

Acute liver failure and death predictors in patients with dengue-induced severe hepatitis

BACKGROUND

Liver injury in patients with dengue infection is common. Most patients have mild and transient hepatitis. Acute liver failure (ALF) in dengue infection is rare but results in an extremely poor prognosis.

AIM

To identify prognostic predictors of ALF and death in patients with dengue-induced severe hepatitis (DISH).

METHODS

We retrospectively reviewed 2311 serologically confirmed adolescent and adult dengue patients who were hospitalized during a 12-year study period (between 2007 and 2019) at the university hospital of King Chulalongkorn Memorial Hospital, Bangkok, Thailand. Patients with DISH [n = 134 (5.80%)], defined as a baseline transaminase > 10 times the normal reference cut-off level, and DISH with subsequent ALF as defined by the American Association for the Study of the Liver Diseases 2011 criteria [n = 17 (0.74%)], were included. Predictors of ALF and in-hospital death were identified using logistic regression analysis.

RESULTS

Of the 151 dengue-infected patients with severe liver injury or ALF, 51% were female, with a mean age of 27.9 ± 14.5 years. Capillary leakage syndrome (CLS) occurred in 68.2% (n = 103) of DISH and 100% of ALF patients. The mortality rate was low in DISH patients (0.8%) but was remarkably high if ALF developed (58.8%). In univariate analysis, age, sex, hematocrit, white blood count, atypical lymphocyte count, platelet count, international normalized ratio (INR), bilirubin, serum glutamate-oxaloacetate transaminase, serum glutamate-pyruvate transaminase, alkaline phosphatase, albumin, creatinine, Model for End-Stage Liver Disease (MELD) score, presence of liver comorbidity and presence of CLS were identified as potential prognostic parameters for ALF or death. In multivariate analysis, the MELD score remained the only predictor of ALF with an adjusted odds ratio (aOR) of 1.3 [95% confidence interval (CI): 1.1-1.5; P = < 0.001]. An initial MELD score ≥ 15 was associated with ALF from DISH with an area under the receiver operating characteristic (AUROC) of 0.91, 88.2% sensitivity and 87.3% specificity. Regarding mortality prediction, the deterioration of liver function to ALF was the most significant factor related to death in DISH patients (aOR 108.5, 95%CI: 5.5-2145.4, P = 0.002). Other independent factors associated with death included baseline INR (aOR 10.4, 95%CI: 2.6-40.5, P = 0.001). An INR ≥ 1.5 predicted death from DISH with an AUROC of 0.83 (81.8% sensitivity and 86.8% specificity).

CONCLUSION

The MELD score is the best predictor of ALF in DISH patients, a complication from dengue that is associated with high mortality. The presence of ALF and the baseline INR level are independent markers of death in DISH patients.

Structure-Based Design of Antivirals against Envelope Glycoprotein of Dengue Virus

Dengue virus (DENV) presents a significant threat to global public health with more than 500,000 hospitalizations and 25,000 deaths annually. Currently, there is no clinically approved antiviral drug to treat DENV infection. The envelope (E) glycoprotein of DENV is a promising target for drug discovery as the E protein is important for viral attachment and fusion. Understanding the structure and function of DENV E protein has led to the exploration of structure-based drug discovery of antiviral compounds and peptides against DENV infections. This review summarizes the structural information of the DENV E protein with regards to DENV attachment and fusion. The information enables the development of antiviral agents through structure-based approaches. In addition, this review compares the potency of antivirals targeting the E protein with the antivirals targeting DENV multifunctional enzymes, repurposed drugs and clinically approved antiviral drugs. None of the current DENV antiviral candidates possess potency similar to the approved antiviral drugs which indicates that more efforts and resources must be invested before an effective DENV drug materializes.

Current Understanding of West Nile Virus Clinical Manifestations, Immune Responses, Neuroinvasion, and Immunotherapeutic Implications

West Nile virus (WNV) is the most common mosquito-borne virus in North America. WNV-associated neuroinvasive disease affects all ages, although elderly and immunocompromised individuals are particularly at risk. WNV neuroinvasive disease has killed over 2300 Americans since WNV entered into the United States in the New York City outbreak of 1999. Despite 20 years of intensive laboratory and clinical research, there are still no approved vaccines or antivirals available for human use. However, rapid progress has been made in both understanding the pathogenesis of WNV and treatment in clinical practices. This review summarizes our current understanding of WNV infection in terms of human clinical manifestations, host immune responses, neuroinvasion, and therapeutic interventions.

Impact of Dengue Rapid Diagnostic Tests on the Prescription of Antibiotics and Anti-Inflammatory Drugs by Physicians in an Endemic Area in Colombia

There is insufficient evidence on whether dengue rapid diagnostic tests (dRDTs) influence clinical decisions in endemic areas. Therefore, our objective was to evaluate the impact of dRDTs on the prescription of antibiotics and anti-inflammatory drugs by physicians in a dengue-endemic area in Colombia. A retrospective cohort study was conducted with 330 patients in Cali, Colombia, between January 2012 and December 2017. The exposure was defined by the result of the dRDT. The outcomes were prescription of antibiotics and anti-inflammatory drugs after results of dRDT. Incidence and RR with 95% CIs were estimated. Multivariate logistic regression models were fitted separately for each outcome. Antibiotics were prescribed in 3% exposed and 14% unexposed. Anti-inflammatory drugs were prescribed in 1.2% exposed and 7.9% unexposed. A positive dRDT reduced the prescription of anti-inflammatories (AdjOR: 0.06, 95% CI: 0.008-0.5) but, by itself, had no effect on antibiotics (AdjOR: 1.1, 95% CI: 0.2-6); however, in hospitalized patients, a positive result reduced the probability of antibiotic prescription (AdjOR: 0.02, 95% CI: 0.00-0.8). Despite limitations of current dRDTs, they influence treatment decisions. Further studies are needed to assess the effect of dRDTs in patient outcomes and health-care costs.

Lazarus Effect of High Dose Corticosteroids in a Patient With West Nile Virus Encephalitis: A Coincidence or a Clue?

West Nile virus (WNV) causes severe neuroinvasive disease in humans characterized by meningitis, encephalitis, and acute flaccid paralysis (poliomyelitis variant). In neuroinvasive disease, WNV infection of neurons resulting in neuronal loss is generally presumed to be the anatomical substrate for the high morbidity and mortality. However, on a molecular level, WNV infection also results in a significant upregulation of important proinflammatory molecules that have been reported to promote neuroinflammation and cytotoxicity. Currently, there is no specific treatment for the neurological complications of WNV infection. We present a 71-year-old woman who developed WNV infection that rapidly progressed to severe generalized weakness and encephalitis manifesting with bulbar signs (dysphagia, dysarthria) and persistent delirium and stupor. Consciousness remained impaired for 9 days and then she received a 5-day course of high-dose intravenous methylprednisolone (1,000 mg daily). After the first day, voluntary movement and spontaneous eye-opening increased and by the end of the second day, she was awake and responding to commands. Thereafter, she remained awake and responsive. Although the rapid improvement from stupor to wakefulness following treatment with an anti-inflammatory immunosuppressant could merely be coincidence, since these observations are of one patient, it may also provide a clue that in some cases of WNV neuroinvasive disease a post-infectious pro-inflammatory state, rather than neuronal loss, may also contribute to morbidity. Further clinical trials are warranted to determine if high dose corticosteroids and other drugs that can alter this neuro-inflammatory cascade may be potentially beneficial in the treatment of WNV neuroinvasive disease.