Dengue hemorrhagic fever and shock syndromes

Clinical Management and Outcomes of Dengue Fever and Enteric Fever

BACKGROUND

Dengue fever and enteric fever, two prevalent infectious diseases in tropical and subtropical regions, pose significant public health challenges due to their overlapping clinical manifestations and distinct therapeutic approaches. This study aims to evaluate hospitalization and management protocols for both illnesses, assessing their adherence to clinical guidelines and examining patient outcomes across diverse healthcare settings.

METHODOLOGY

A retrospective cross-sectional study was conducted by reviewing hospital records over a five-year period (April 2019-April 2024). A total of 218 individuals diagnosed with enteric fever (n=98) and dengue fever (n=120) were included in the study. Data were retrospectively collected using standardized forms from hospital records, laboratory reports, and discharge summaries to capture demographics, clinical presentations, lab findings, treatments, complications, and outcomes for patients with dengue or enteric fever. Statistical analysis was conducted using SPSS, Version 26 (IBM Corp., Armonk, NY), applying descriptive statistics, chi-square test, t-test, logistic regression, and Cox modeling to evaluate associations between treatment protocols and patient outcomes, with significance set at p<0.05.

RESULTS

Dengue and enteric fever showed distinct clinical patterns: rash and headache were more common in dengue fever, while abdominal pain and diarrhea predominated in enteric fever. Although demographic differences in age, sex, and residence were observed, they were not statistically significant. Improved outcomes in dengue fever were significantly associated with fluid replacement (n=110, 91.67%, p=0.02), reflecting the collective effect of standard supportive care measures. In contrast, antibiotic therapy (n=98, 100.00%, p=0.01) was central to favorable outcomes in enteric fever. Dengue fever was primarily diagnosed through serological testing (n=115, 95.83%), while enteric fever relied on blood cultures (n=78, 79.59%) (χ²=126.98, p<0.0001, OR=0.02). Hospitalization durations were significantly longer in enteric fever, patients staying ≥5 days compared to dengue fever patients (χ²=8.76, p=0.0031, OR=0.39). Recovery without complications was slightly more frequent in dengue fever (n=112, 93.33%) than in enteric fever (n=88, 89.80%), though this difference was not statistically significant (χ²=0.49, p=0.483, OR=0.60). These findings apply to general dengue fever cases only; patients with dengue hemorrhagic fever were managed separately due to differing clinical protocols.

CONCLUSION

This study highlights the necessity of tailored treatment protocols for enteric and dengue fever, emphasizing the importance of strict adherence to established clinical guidelines to optimize patient outcomes, particularly in resource-limited healthcare settings. While appropriate management, such as antibiotic therapy for enteric fever and supportive care for dengue, is well defined, differentiating between these conditions based solely on clinical presentation remains a significant challenge due to overlapping symptoms with other febrile illnesses. This diagnostic ambiguity underscores the urgent need for more robust, accessible, and rapid diagnostic tools. Furthermore, ongoing education and capacity building for healthcare professionals are essential to enhance clinical judgment, ensure early recognition, and improve compliance with evolving evidence-based practices in the management of febrile illnesses.

Dengue epidemiology and molecular characterization of vector mosquitoes; Aedes aegypti and Aedes albopictus in Mizoram, Northeast India

BACKGROUND

Dengue is the most important arboviral disease, and Aedes aegypti and Aedes albopictus are the major vectors. It is one of the most recent emerging diseases in Mizoram state with a fast-growing burden over the years. The present study aimed to explore the epidemiological patterns of dengue in Mizoram, and to identify vector mosquito species.

METHODS

In the present study, two years secondary data of dengue disease in Mizoram was studied. Dengue vector mosquitoes and dengue virus serotypes circulating in vector mosquitoes in Aizawl City were identified by sequence analysis of COX1 and C-prM genes respectively.

RESULTS

In Mizoram State, the annual case prevalence of dengue was found to be 300.45 per 100,000 persons. Seasonality of the disease was also noted, with the peak season occurring from July to December. There is a significant positive relationship between age and the disease prevalence (p < 0.05, r = 0.909). DENV was detected in 10 pools of Ae. aegypti with a minimum infection rate (MIR) of 18.05, and 8 pools of Ae. albopictus with a minimum infection rate of 16.03. The viral isolates were found to correspond to serotypes 2 (DENV2) and 3 (DENV3). A total of 6 pools of Aedes aegypti and 4 pools of Aedes albopictus tested positive with DENV2 serotype, while 4 pools of Aedes aegypti and 3 pools of Aedes albopictus tested positive with DENV3 serotype. DENV2 serotype was more common, and multiple serotypes (DENV2 and DENV3) were also detected in two pools from one locality.

CONCLUSIONS

There is an increasing trend in dengue infection in Mizoram, and seasonality of the disease was observed with the peak season during July to December. The higher incidence rate among the adults indicated that outdoor activities may be related to the high risk of the infection. However, lack of immunity among the older people may also be a possible reason of higher disease incidence rather than the activity pattern. Early identification and frequent monitoring of infected vector mosquitoes will yield an early warning indicator for forecasting dengue epidemics in the future.

Susceptibility to childhood sepsis, contemporary management, and future directions

Sepsis disproportionally affects children across all health-care settings and is one of the leading causes of morbidity and mortality in neonatal and paediatric age groups. As shown in the first paper in this Series, the age-specific incidence of sepsis is highest during the first years of life, before approaching adult incidence rates during adolescence. In the second paper in this Series, we focus on the unique susceptibility of paediatric patients to sepsis and how the underlying dysregulated host response relates to developmental aspects of children's immune system, genetic, perinatal, and environmental factors, and comorbidities and socioeconomic determinants of health, which often differ between children and adults. State-of-the-art clinical management of paediatric sepsis is organised around three treatment pillars-diagnosis, early resuscitation, and titration of advanced care-and we examine available treatment guidelines and the limitations of their supporting evidence. Serious evidence gaps remain in key areas of paediatric sepsis care, especially surrounding recognition, common interventions, and survivor support, and to this end we offer a research roadmap for the next decade that could accelerate targeted diagnostics and personalised use of immunomodulation. However, improving outcomes for children with sepsis relies fundamentally on systematic quality improvement in both recognition and treatment, which is the theme of the third paper in this Series. Digital health, as shown in the fourth and final paper of this Series, holds promising potential in breaking down the barriers that hinder progress in paediatric sepsis care and, ultimately, global child health.

The Development of New Primer Sets for the Amplification and Sequencing of the Envelope Gene of All Dengue Virus Serotypes

Dengue virus (DENV) poses a significant threat to global health, infecting approximately 390 million people annually. This virus comprises four serotypes capable of causing severe disease. Genetic analyses are crucial for understanding the epidemiology, evolution, and spread of DENV. Although previous studies have focused on the envelope protein-coding (E) gene, only a few primers can efficiently detect and amplify the viral genes from multiple endemic countries simultaneously. In this study, we designed degenerate primer pairs for each DENV serotype to amplify and sequence the entire E gene, using globally representative sequences for each serotype. These primers were validated using DENV isolates from various Asian countries and demonstrated broad-spectrum detection capabilities and high-quality sequences. The primers provide effective tools for genetic analysis in the regions affected by dengue, aiding strain identification and epidemiological studies during outbreaks.

Demographic and clinical features of dengue fever infection in Pakistan: a cross-sectional epidemiological study

BACKGROUND

Dengue fever caused by dengue virus is a tropical disease and is among the deadliest vector-borne diseases. The humid and hot summers of Pakistan support the probation of the vectors responsible for the transmission of viral and other parasitic diseases.

METHODOLOGY

A retrospective study, from 2012- 2019, of dengue infected individuals from the Punjab province of Pakistan was carried out to analyze epidemiology, clinical and laboratory findings of subjects with dengue virus infection. Data was derived from National Institute of Health (NIH) followed by Dengue control program of Pakistan, covering the incidence rate in 36 districts of Punjab and Islamabad Capital Territory (ICT) respectively. Patients data including the presence of dengue specific antigen or/and antibodies such as NS1 and IgG/IgM were observed. The study also included the analysis of demographic data, geographic data, and the month-wise distribution of dengue cases to examine seasonal trends.

RESULTS

We analyzed 25,682 dengue infected individuals. The statistical analysis revealed a significant association between genders in which male population was more affected by dengue than females. It was also noted that the middle age group was the most affected age group while the highest number of cases were reported in October. Rawalpindi and Lahore were the most affected cities in Punjab province while Islamabad represented the highest number of cases during the recent outbreak in 2019. The IgM and IgG antibodies were highly prevalent among the infected patients.

CONCLUSION

Dengue is endemic in Pakistan, circulating throughout the year. Highest number of cases were observed in the month of October, September and November respectively. Association between climate change and vector-borne diseases need to be investigated in Pakistan as they significantly influence the timing and intensity of dengue and other disease outbreaks. Further exploration of hematological parameters is required to better diagnose and treat the disease. For the effective control of dengue outbreaks, awareness campaigns on sewage management and vector control along with social factors are strongly recommended for better control and eradication of the disease.

Dengue havoc: overview and eco-friendly strategies to forestall the current epidemic

Dengue fever is a mosquito-borne viral illness that affects over 100 nations around the world, including Africa, America, the Eastern Mediterranean, Southeast Asia, and the Western Pacific. Those who get infected by virus for the second time are at greater risk of having persistent dengue symptoms. Dengue fever has yet to be treated with a long-lasting vaccination or medication. Because of their ease of use, mosquito repellents have become popular as a dengue prevention technique. However, this has resulted in environmental degradation and harm, as well as bioaccumulation and biomagnification of hazardous residues in the ecosystem. Synthetic pesticides have caused a plethora of serious problems that were not foreseen when they were originally introduced. The harm caused by the allopathic medications/synthetic pesticides/chemical mosquito repellents has paved the door to employment of eco-friendly/green approaches in order to reduce dengue cases while protecting the integrity of the nearby environment too. Since the cases of dengue have become rampant these days, hence, starting the medication obtained from green approaches as soon as the disease is detected is advisable. In the present paper, we recommend environmentally friendly dengue management strategies, which, when combined with a reasonable number of vector control approaches, may help to avoid the dengue havoc as well as help in maintaining the integrity of the ecosystem.

Haemodynamic support for paediatric septic shock: a global perspective

Septic shock is a leading cause of hospitalisation, morbidity, and mortality for children worldwide. In 2020, the paediatric Surviving Sepsis Campaign (SSC) issued evidence-based recommendations for clinicians caring for children with septic shock and sepsis-associated organ dysfunction based on the evidence available at the time. There are now more trials from multiple settings, including low-income and middle-income countries (LMICs), addressing optimal fluid choice and amount, selection and timing of vasoactive infusions, and optimal monitoring and therapeutic endpoints. In response to developments in adult critical care to trial personalised haemodynamic management algorithms, it is timely to critically reassess the current state of applying SSC guidelines in LMIC settings. In this Viewpoint, we briefly outline the challenges to improve sepsis care in LMICs and then discuss three key concepts that are relevant to management of children with septic shock around the world, especially in LMICs. These concepts include uncertainties surrounding the early recognition of paediatric septic shock, choices for initial haemodynamic support, and titration of ongoing resuscitation to therapeutic endpoints. Specifically, given the evolving understanding of clinical phenotypes, we focus on the controversies surrounding the concepts of early fluid resuscitation and vasoactive agent use, including insights gained from experience in LMICs and high-income countries. We outline the key components of sepsis management that are both globally relevant and translatable to low-resource settings, with a view to open the conversation to the large variety of treatment pathways, especially in LMICs. We emphasise the role of simple and easily available monitoring tools to apply the SSC guidelines and to tailor individualised support to the patient's cardiovascular physiology.

Recent Dengue Infection in Bangladesh: A Seasonal Endemic Progressing to Year-long Serious Health Concern

Dengue represents one of the most dangerous mosquito-borne viral diseases. Although the disease has been prevalent around the globe over the centuries, recent outbreaks of dengue have devasted the healthcare delivery system of many countries. Being a global infection, dengue virus (DENV) is endemically present mainly in Latin America and Caribbean countries as well as countries in South Asia. The recent outbreak of DENV infection has indicated an exceptional outbreak of DENV in some countries in South Asia. There has been a serious endemic of DENV during 2019. After a heterogeneous pause, another severe outbreak of DENV was reported in some Asian countries in 2023. Among the Asian countries, Bangladesh has reported an acute upsurge of DENV infection in 2023 with record numbers of fatalities. However, this pattern of DENV has not been detected in neighbors of Bangladesh, such as India or other countries in Southeast Asia. This provides an emergent task of dissecting the present DENV infection in Bangladesh from different angles to get insights for future containment of the DENV infection, not only in Bangladesh but also in other DENV endemic areas or DENV-native areas.

How to cite this article

Akbar SMF, Khan S, Mahtab M, et al. Recent Dengue Infection in Bangladesh: A Seasonal Endemic Progressing to Year-long Serious Health Concern. Euroasian J Hepato-Gastroenterol 2023;13(2):145-151.

DDPM: A Dengue Disease Prediction and Diagnosis Model Using Sentiment Analysis and Machine Learning Algorithms

The aedes mosquito-borne dengue viruses cause dengue fever, an arboviral disease (DENVs). In 2019, the World Health Organization forecasts a yearly occurrence of infections from 100 million to 400 million, the maximum number of dengue cases ever testified worldwide, prompting WHO to label the virus one of the world’s top ten public health risks. Dengue hemorrhagic fever can progress into dengue shock syndrome, which can be fatal. Dengue hemorrhagic fever can also advance into dengue shock syndrome. To provide accessible and timely supportive care and therapy, it is necessary to have indispensable practical instruments that accurately differentiate Dengue and its subcategories in the early stages of illness development. Dengue fever can be predicted in advance, saving one’s life by warning them to seek proper diagnosis and treatment. Predicting infectious diseases such as dengue is difficult, and most forecast systems are still in their primary stages. In developing dengue predictive models, data from microarrays and RNA-Seq have been used significantly. Bayesian inferences and support vector machine algorithms are two examples of statistical methods that can mine opinions and analyze sentiment from text. In general, these methods are not very strong semantically, and they only work effectively when the text passage inputs are at the level of the page or the paragraph; they are poor miners of sentiment at the level of the sentence or the phrase. In this research, we propose to construct a machine learning method to forecast dengue fever.

Fluid management in children with severe dengue: a narrative review

Dengue is a mosquito-borne arboviral infection of increasing public health importance. Globally, children account for a significant proportion of infections. No pathogen-specific treatment currently exists, and the current approach to reducing disease burden is focused on preventative strategies such as vector control, epidemiological interventions, and vaccination in selected populations. Once infected, the mainstay of treatment is supportive, of which appropriate fluid management is a cornerstone. The timely provision of fluid boluses has historically been central to the management of septic shock. However, in patients with dengue shock, particular emphasis is placed on judicious fluid administration. Certain colloids such as hydroxyethyl starches and dextran, despite no longer being used routinely in intensive care units due to concerns of acute kidney injury and impairment of coagulation, are still commonly used in dengue shock syndrome. Current guidelines recommend initial crystalloid therapy, with consideration of colloids for severe or recalcitrant shock in patients with dengue. In this review, we discuss the pathophysiology of septic shock, and consider whether any differences in dengue exist that may warrant a separate approach to fluid therapy. We critically review the available evidence for fluid management in dengue, including the role of colloids. In dengue, there is increasing recognition of the importance of tailoring fluid therapy to phases of disease, with attention to the need for fluid "deresuscitation" once the critical phase of vascular leak passes.

Learning meaningful latent space representations for patient risk stratification: Model development and validation for dengue and other acute febrile illness

Background

Increased data availability has prompted the creation of clinical decision support systems. These systems utilise clinical information to enhance health care provision, both to predict the likelihood of specific clinical outcomes or evaluate the risk of further complications. However, their adoption remains low due to concerns regarding the quality of recommendations, and a lack of clarity on how results are best obtained and presented.

Methods

We used autoencoders capable of reducing the dimensionality of complex datasets in order to produce a 2D representation denoted as latent space to support understanding of complex clinical data. In this output, meaningful representations of individual patient profiles are spatially mapped in an unsupervised manner according to their input clinical parameters. This technique was then applied to a large real-world clinical dataset of over 12,000 patients with an illness compatible with dengue infection in Ho Chi Minh City, Vietnam between 1999 and 2021. Dengue is a systemic viral disease which exerts significant health and economic burden worldwide, and up to 5% of hospitalised patients develop life-threatening complications.

Results

The latent space produced by the selected autoencoder aligns with established clinical characteristics exhibited by patients with dengue infection, as well as features of disease progression. Similar clinical phenotypes are represented close to each other in the latent space and clustered according to outcomes broadly described by the World Health Organisation dengue guidelines. Balancing distance metrics and density metrics produced results covering most of the latent space, and improved visualisation whilst preserving utility, with similar patients grouped closer together. In this case, this balance is achieved by using the sigmoid activation function and one hidden layer with three neurons, in addition to the latent dimension layer, which produces the output (Pearson, 0.840; Spearman, 0.830; Procrustes, 0.301; GMM 0.321).

Conclusion

This study demonstrates that when adequately configured, autoencoders can produce two-dimensional representations of a complex dataset that conserve the distance relationship between points. The output visualisation groups patients with clinically relevant features closely together and inherently supports user interpretability. Work is underway to incorporate these findings into an electronic clinical decision support system to guide individual patient management.

Maternal and foetal-neonatal outcomes of dengue virus infection during pregnancy

OBJECTIVE

Given that women of reproductive age in dengue-endemic areas are at risk of infection, it is necessary to determine whether dengue virus (DENV) infection during pregnancy is associated with adverse outcomes. The aim of this systematic review and meta-analysis is to investigate the consequences of DENV infection in pregnancy on various maternal and foetal-neonatal outcomes.

METHODS

A systematic literature search was undertaken using PubMed, Google Scholar, and Embase till December 2021. Mantel-Haenszel risk ratios were calculated to report overall effect size using random effect models. The pooled prevalence was computed using the random effect model. All statistical analyses were performed on MedCalc Software.

RESULT

We obtained data from 36 studies involving 39,632 DENV-infected pregnant women. DENV infection in pregnancy was associated with an increased risk of maternal mortality (OR = 4.14 [95% CI, 1.17-14.73]), stillbirth (OR = 2.71 [95% CI, 1.44-5.10]), and neonatal deaths (OR = 3.03 [95% CI, 1.17-7.83]) compared with pregnant women without DENV infection. There was no significant statistical association established between maternal DENV infection and the outcomes of preterm birth, maternal bleeding, low birth weight in neonates, and risk of miscarriage. Pooled prevalences were 14.9% for dengue shock syndrome, 14% for preterm birth, 13.8% for maternal bleeding, 10.1% for low birth weight, 6% for miscarriages, and 5.6% for stillbirth.

CONCLUSION

DENV infection in pregnant women may be associated with adverse outcomes such as maternal mortality, stillbirth, and neonatal mortality. Hence, pregnant women should be considered an at-risk population for dengue management programmes.

The Potential of Purinergic Signaling to Thwart Viruses Including SARS-CoV-2

A long-shared evolutionary history is congruent with the multiple roles played by purinergic signaling in viral infection, replication and host responses that can assist or hinder viral functions. An overview of the involvement of purinergic signaling among a range of viruses is compared and contrasted with what is currently understood for SARS-CoV-2. In particular, we focus on the inflammatory and antiviral responses of infected cells mediated by purinergic receptor activation. Although there is considerable variation in a patient's response to SARS-CoV-2 infection, a principle immediate concern in Coronavirus disease (COVID-19) is the possibility of an aberrant inflammatory activation causing diffuse lung oedema and respiratory failure. We discuss the most promising potential interventions modulating purinergic signaling that may attenuate the more serious repercussions of SARS-CoV-2 infection and aspects of their implementation.

Early Predictors of Mortality in Children with Severe Dengue Fever: A Prospective Study

OBJECTIVE

The aim of the study was to identify early predictors of mortality in children with severe dengue fever admitted to pediatric intensive care unit (PICU).

MATERIALS AND METHODS

All consecutive children with laboratory-confirmed severe dengue fever were enrolled in this prospective observational study. Besides demographic data, disease severity and organ dysfunction scores, laboratory investigations and interventions are done in PICU were recorded and analyzed.

RESULTS

During the study period of 42 months, 172 patients with dengue fever were admitted to PICU. A total of 78 (45.3%) patients with severe dengue fever were included and analyzed. There were 20 (25.6%) deaths. There were significant differences in disease severity and organ dysfunction scores, transaminases, blood lactate level and serum creatinine between survivors and nonsurvivors. A significantly higher number of nonsurvivors required interventions in first 24 hours of admission. Platelet counts (P value 0.22) and hematocrit (P value 0.47) were not statistically different in 2 groups. There was a significantly high vasopressor-inotrope score (VIS) (<0.001) and positive fluid balance >10% (0.002) in nonsurvivors. Multivariate stepwise logistic regression analysis identified serum glutamic pyruvic transaminases (≥ 284 IU/L; odds ratio [OR] 1.002, 95% confidence interval [CI]: 1.001-1.003), blood lactate level (≥2.73 mmol/L; OR 2.08, 95% CI: 1.354-3.202), Pediatric Risk of Mortality score at 12 hours (≥14.5; OR 1.35, 95% CI: 1.077-1.693), VIS (≥22.5, OR 1.129, 95% CI: 1.059-1.204) and positive fluid balance >10% (OR 22.937, 95% CI: 2.393-219.84) at 24 hours of admission as independent predictors of mortality.

CONCLUSION

Disease severity, hyperlactatemia at admission, need for multiple vasoactive drugs and positive fluid balance are predictors of mortality in severe dengue infection in children admitted to PICU.

Clinical characteristics and risk factors for intracranial hemorrhage or infarction in patients with dengue

BACKGROUND

Intracranial hemorrhage (ICH) or infarction in dengue cases is rare but very challenging for clinicians. We report these uncommon complications of dengue patients and focused on the significant factors associated with ICH or infarction in dengue patients.

METHODS

This investigation was a retrospective study of 182 adult dengue patients who received brain computed tomography at three Taiwan hospitals during the 2014 and 2015 dengue outbreaks. This included 13 hemorrhage cases, 26 infarction cases and 143 cases without brain infarction or hemorrhage.

RESULTS

Among them, 13 (7.14%) suffered from ICH (6 had subdural hemorrhage, 3 had subarachnoid hemorrhage, 1 had subdural and subarachnoid hemorrhage, and 3 had intracerebral hemorrhage) and 26 (14.3%) had brain infarction. The overall mortality rate was 4/13 (30.8%) in the ICH group and 3/26 (11.5%) in the infarction group. The significant variables from the univariate analysis, including difference between 2014 and 2015, age, history of cerebrovascular accident, bone pain, arthralgia, dizziness, altered consciousness, and a higher Charlson comorbidity score. Multivariate analysis revealed that significant risk factors for ICH/infarction in dengue cases were the year of occurrence, 2014 vs. 2015 (p < 0.0001, OR = 25.027, 95% CI = 8.205-76.336), Charlson score >4 (p = 0.01, OR = 3.764, 95% CI = 1.364-10.386) and altered consciousness (p < 0.0001, OR = 6.3, 95% CI = 2.242-17.7). The factors physicians should notice in dengue endemic regions for brain infarction or ICH include altered consciousness and a Charlson score >4, especially in the year that a higher frequency of infarction/ICH was observed.

Micronutrient Supplementation and Clinical Outcomes in Patients with Dengue Fever

Dengue fever (DF) is a viral infection that is common in tropical countries and represents a significant cause of global morbidity and mortality. Despite its prevalence and severity, treatment options for DF remain limited and consist primarily of supportive measures. Several recent studies have concluded that micronutrient supplementation may improve clinical outcomes in patients with DF, but no review has summarized and synthesized these findings. We conducted a literature review to identify articles investigating the effect of micronutrient supplementation on clinical outcomes among patients with DF. We found several studies which indicated that supplemental vitamin C, vitamin D, vitamin E, and zinc may be useful adjuncts in DF treatment. Folic acid supplementation did not appear to affect clinical outcomes. The reviewed studies have significant limitations including small sample sizes and limited data about the baseline nutritional status of study subjects. We identify a need for additional high-quality randomized trials to elucidate the role of micronutrient supplementation in DF treatment.

Factors associated with thrombocytopenia in patients with dengue fever: a retrospective cohort study

OBJECTIVE

Some patients with dengue fever tend to develop thrombocytopenia during the course of infection and are thus vulnerable to haemorrhagic manifestations and other complications. However, the factors associated with the development of thrombocytopenia are unknown. We aimed to identify factors associated with an increased risk of thrombocytopenia and haematological changes in patients with confirmed dengue fever.

DESIGN

Retrospective cohort study.

SETTING

Brazilian multicentre primary care databases.

PARTICIPANTS

387 patients had positive laboratory serological confirmation of dengue infection during 2014. The data were identified from two databases: Notification of Injury Information System (SINAN) and Municipal Laboratory.

MAIN OUTCOME MEASURE

The presence of thrombocytopenia (platelet count <1 50×10⁹/L). The associations of factors that predisposed patients to thrombocytopenia and haematological changes were analysed using logistic regression. ORs and 95% CIs were calculated.

RESULTS

Among 387 patients, 156 had both dengue and thrombocytopenia. The risk factors associated with thrombocytopenia included male sex (OR: 1.77, 95% CI: 1.16 to 2.71, p=0.007), age of 46-64 years (OR: 2.20, 95% CI: 1.15 to 4.21, p=0.009) or ≥65 years (OR: 3.02, 95% CI: 1.40 to 6.50, p=0.002), presence of leucopenia (OR: 6.85, 95% CI: 4.27 to 10.99, p<0.001) and high mean corpuscular haemoglobin (MCH) levels (OR: 2.00, 95% CI: 1.29 to 3.12, p=0.005).

CONCLUSION

Older age, male sex, presence of leucopenia and high MCH levels were identified as risk factors associated with the development of thrombocytopenia in this population.

Seropositivity to dengue and associated risk factors among non-malarias acute febrile patients in Arba Minch districts, southern Ethiopia

BACKGROUND

Dengue fever is an arthropod vector-borne disease transmitted to humans by infected Aedes mosquitoes. Ethiopia has a favorable ecology for arthropods and report high burden of acute febrile illnesses. However, the contribution of arboviral infections to the burden of acute febrile illnesses is barely known. In this study the seropositivity to dengue virus infection and associated risk factors were assessed in Arba Minch districts, southern Ethiopia.

METHODS

An institution based cross-sectional study was conducted in a consecutive group of 529 acute febrile patients between May to August 2016. Socio-demographic data, residence place and clinical signs and symptoms were collected using structured questionnaires. Sera were tested for anti-dengue IgG and IgM using Euroimmune indirect immunofluorescent assay. Data analysis was done using SPSS V-20 (IBM Corp, 2012). P-value < 0.05 was taken as statistically significant.

RESULT

Seropositivity was 25.1% (133/529) and 8.1% (43/529) for anti- IgG and IgM respectively.

CONCLUSION

The high IgM prevalence detected indicate the probability of active transmission with a potential of public health significance that calls for a proactive follow up of the communities in the study area to forecast and avert the risk.

Characterization of a novel STAT 2 knock-out hamster model of Crimean-Congo hemorrhagic fever virus pathogenesis

Crimean-Congo hemorrhagic fever virus (CCHFV) is a tick-borne pathogen causing a febrile illness in humans, which can progress to hemorrhagic manifestations, multi-organ failure, and death. Current mouse models of CCHFV infection reliably succumb to virus challenge but vary in their ability to reflect signs of disease similar to humans. In this study, we established a signal transducer and activator of transcription 2 (STAT2) knockout hamster model to expand the repertoire of animal models of CCHFV pathogenesis that can be used for therapeutic development. These hamsters demonstrated a systemic and lethal disease in response to infection. Hallmarks of human disease were observed including petechial rash, blood coagulation dysfunction, and various biochemistry and blood cell count abnormalities. Furthermore, we also demonstrated the utility of this model for anti-CCHFV therapeutic evaluation. The STAT2 knock-out hamster model of CCHFV infection may provide some further insights into clinical disease, viral pathogenesis, and pave the way for testing of potential drug and vaccine candidates.

Lower risk of primary Sjogren's syndrome in patients with dengue virus infection: a nationwide cohort study in Taiwan

The data concerning the association between dengue viruses (DV) infection and autoimmune diseases (ADs) remain unclear and are scarce. This nationwide population-based cohort study assessed the risk of ADs among patients with DV infection. We analyzed Taiwanese medical data from the Registry of the National Notifiable Disease Reporting System of Taiwan’s Centers for Disease Control between 1998 and 2015 and identified patients with DV infection. From the entire general population data in the National Health Insurance Research Database, we randomly selected a comparison cohort that was individual matching by age, sex, residence, and index date. We analyzed the risk of ADs using a Cox proportional hazards regression model stratified by sex, age, and residence. We enrolled 29,365 patients with DV infection (50.68% men; mean age, 44.13 years) and 117,460 age-, sex-, and residence-matched controls in the present study. The incidence rates of organ-specific ADs were nonsignificantly higher in the DV cohort than in the non-DV control cohort. An approximately 70% lower risk of primary Sjogren syndrome (pSS) was evident in the DV cohort than in the non-DV control cohort with an adjusted hazard ratio of 0.30 (95% confidence interval 0.13–0.67) after adjusting for comorbidities in matched design. By contrast, the other systemic ADs were nonsignificantly lower in the DV cohort than in the non-DV control cohort. This nationwide long-term cohort study demonstrated that patients with DV infection had a lower risk of primary Sjogren syndrome than those without DV infection.

Key Points • This retrospective, longitudinal cohort observational study shows that patients with DV infection had a lower risk of pSS than those without DV infection. • The DV cohort had an approximately 70% lower risk of pSS than the control group, with a multivariate-adjusted HR of 0.30. • On the basis of this result, we contended that DV infection has a protective effect that reduces the risk of pSS.

Roles of Macrophage Migration Inhibitory Factor in Dengue Pathogenesis: From Pathogenic Factor to Therapeutic Target

Dengue virus (DENV) infection is the most prevalent mosquito-borne viral infection and can lead to severe dengue hemorrhagic fever (DHF) and even life-threatening dengue shock syndrome (DSS). Although the cytokine storm has been revealed as a critical factor in dengue disease, the limited understanding of dengue immunopathogenesis hinders the development of effective treatments. Macrophage migration inhibitory factor (MIF) is a pleiotropic proinflammatory cytokine that mediates diverse immune responses, and the serum level of MIF positively correlates with disease severity in patients with dengue. MIF is involved in DENV replication and many pathological changes, such as vascular leakage, during DENV infection. In this paper, the pathogenic roles of MIF and the regulation of MIF secretion during DENV infection are reviewed. Furthermore, whether MIF is a potential therapeutic target against DENV infection is also discussed.

DenvInD: dengue virus inhibitors database for clinical and molecular research

Dengue virus (DENV) researchers often face challenges with the highly time-consuming process of collecting and curating information on known inhibitors during the standard drug discovery process. To this end, however, required collective information is not yet available on a single platform. Hence, we have developed the DenvInD database for experimentally validated DENV inhibitors against its known targets presently hosted at https://webs.iiitd.edu.in/raghava/denvind/. This database provides comprehensive information, i.e. PubChem IDs, SMILES, IC50, EC50, CC50, and wherever available Ki values of the 484 compounds in vitro validated as inhibitors against respective drug targets of DENV. Also, the DenvInD database has been linked to the user-friendly web-based interface and accessibility features, such as simple search, advanced search and data browsing. All the required data curation was conducted manually from the reported scientific literature and PubChem. The collected information was then organized into the DenvInD database using sequence query language under user interface by hypertext markup language. DenvInD is the first useful repository of its kind which would augment the DENV drug discovery research by providing essential information on known DENV inhibitors for molecular docking, computational screening, pharmacophore modeling and quantitative structure-activity relationship modeling.

A Coupled Mathematical Model of the Intracellular Replication of Dengue Virus and the Host Cell Immune Response to Infection

Dengue virus (DV) is a positive-strand RNA virus of the Flavivirus genus. It is one of the most prevalent mosquito-borne viruses, infecting globally 390 million individuals per year. The clinical spectrum of DV infection ranges from an asymptomatic course to severe complications such as dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS), the latter because of severe plasma leakage. Given that the outcome of infection is likely determined by the kinetics of viral replication and the antiviral host cell immune response (HIR) it is of importance to understand the interaction between these two parameters. In this study, we use mathematical modeling to characterize and understand the complex interplay between intracellular DV replication and the host cells' defense mechanisms. We first measured viral RNA, viral protein, and virus particle production in Huh7 cells, which exhibit a notoriously weak intrinsic antiviral response. Based on these measurements, we developed a detailed intracellular DV replication model. We then measured replication in IFN competent A549 cells and used this data to couple the replication model with a model describing IFN activation and production of IFN stimulated genes (ISGs), as well as their interplay with DV replication. By comparing the cell line specific DV replication, we found that host factors involved in replication complex formation and virus particle production are crucial for replication efficiency. Regarding possible modes of action of the HIR, our model fits suggest that the HIR mainly affects DV RNA translation initiation, cytosolic DV RNA degradation, and naïve cell infection. We further analyzed the potential of direct acting antiviral drugs targeting different processes of the DV lifecycle in silico and found that targeting RNA synthesis and virus assembly and release are the most promising anti-DV drug targets.

Severe dengue categories as research endpoints-Results from a prospective observational study in hospitalised dengue patients

Severe dengue was perceived as one clinical disease entity until the WHO 2009 classification stratified it into severe vascular leakage, severe bleeding, and severe organ dysfunction. The objectives of this study were to investigate the potential use of severe dengue categories as endpoints for intervention research. 271 patients with severe dengue among 1734 confirmed dengue patients were followed prospectively in this hospital-based observational study in Latin America and Asia. We compared the distribution of severe dengue categories according to gender and age (below/above 15y), and determined the relative frequency and the overlap of severe dengue categories in the same patients. In a next step, we extended the analysis to candidate moderate severity categories, based on recently suggested definitions which were adapted for our purposes. Severe vascular leakage occurred in 244 (90%), severe bleeding in 39 (14%), and severe organ dysfunction in 28 (10%) of 271 severe dengue patients. A higher frequency of severe leakage was seen in children or adolescents (<15y) compared to adults. More than 80% of the severe leakage cases, and 30-50% of the cases with severe bleeding or severe organ dysfunction, were defined as severe on the basis of that feature alone. In 136 out of 213 patients with severe leakage alone, neither moderate bleeding manifestation nor hepatic involvement was recorded. On the other hand, moderate leakage manifestations were detected in 4 out of 12 cases that were classified as severe based on bleeding alone. A major proportion of severe dengue patients exhibited clinical manifestations of severe vascular leakage only, which may constitute a useful endpoint for intervention research or pathophysiology studies. Severe bleeding and severe organ manifestation were recorded less frequently and exhibited a higher degree of overlap with severe leakage. Severe bleeding without leakage may be associated with individual predisposition or the presence of comorbidities. More detailed assessments are needed to explore this hypothesis. Candidate moderate disease endpoints were investigated and need to be further validated.

Forecast of Dengue Cases in 20 Chinese Cities Based on the Deep Learning Method

Dengue fever (DF) is one of the most rapidly spreading diseases in the world, and accurate forecasts of dengue in a timely manner might help local government implement effective control measures. To obtain the accurate forecasting of DF cases, it is crucial to model the long-term dependency in time series data, which is difficult for a typical machine learning method. This study aimed to develop a timely accurate forecasting model of dengue based on long short-term memory (LSTM) recurrent neural networks while only considering monthly dengue cases and climate factors. The performance of LSTM models was compared with the other previously published models when predicting DF cases one month into the future. Our results showed that the LSTM model reduced the average the root mean squared error (RMSE) of the predictions by 12.99% to 24.91% and reduced the average RMSE of the predictions in the outbreak period by 15.09% to 26.82% as compared with other candidate models. The LSTM model achieved superior performance in predicting dengue cases as compared with other previously published forecasting models. Moreover, transfer learning (TL) can improve the generalization ability of the model in areas with fewer dengue incidences. The findings provide a more precise forecasting dengue model and could be used for other dengue-like infectious diseases.

Significance of Autophagy in Dengue Virus Infection: A Brief Review

Dengue virus (DENV) causes asymptomatic to severe life-threatening infections and affects millions of people worldwide. Autophagy, a cellular degradative pathway, has both proviral and antiviral functions. Dengue virus triggers the autophagy pathway for the successful replication of its genome. However, the exact mechanism and the viral factors involved in activating this pathway remain unclear. This review summarizes the existing knowledge on the mechanism of autophagy induction and its significance during DENV infection.

Electroporation-Mediated Immunization of a Candidate DNA Vaccine Expressing Dengue Virus Serotype 4 prM-E Antigen Confers Long-Term Protection in Mice

Dengue fever, caused by dengue viruses (DENVs), is a widespread mosquito-borne zoonotic disease; however, there is no available anti-dengue vaccine for worldwide use. In the current study, a DNA vaccine candidate (pV-D4ME) expressing prM-E protein of DENV serotype 4 (DENV-4) was constructed, and its immunogenicity and protection were evaluated in immunocompetent BALB/c mice. The pV-D4ME candidate vaccine induced effective humoral and cellular immunity of mice against DENV-4 in vivo when administered both at 50 μg and 5 μg through electroporation. Two weeks after receiving three immunizations, both doses of pV-D4ME DNA were shown to confer effective protection against lethal DENV-4 challenge. Notably, at 6 months after the three immunizations, 50 μg, but not 5 μg, of pV-D4ME could provide stable protection (100% survival rate) against DENV-4 lethal challenge without any obvious clinical signs. These results suggest that immunization with 50 μg pV-D4ME through electroporation could confer effective and long-term protection against DENV-4, offering a promising approach for development of a novel DNA vaccine against DENVs.

Increased Carotid Intima-Media Thickness in Children with a History of Dengue Hemorrhagic Fever

We assessed carotid intima-media thickness (cIMT) and arterial stiffness in 28 children and adolescents with previous dengue hemorrhagic fever (DHF) (mean interval between DHF and cardiovascular assessment, 8.4 years), and 34 controls in a low-resource setting. Participants with previous DHF had an adjusted increased cIMT of 42.6 µm (95% confidence interval [CI]: 10.0-75.3, P = 0.01), and 61.7 µm (95% CI: 21.5-102.0, P < 0.01) in a subgroup analysis on dengue shock syndrome. There were no differences in arterial stiffness. In this first exploratory study, children and adolescents with a history of DHF had an increased cIMT, which may be modulated by dengue severity.

An open-label, randomized prospective study to evaluate the efficacy and safety of Carica papaya leaf extract for thrombocytopenia associated with dengue fever in pediatric subjects

Objective

Thrombocytopenia in dengue fever (DF) is a well-known complication in both adults and pediatric subjects. Management of DF primarily includes symptomatic and intensive supportive care. There are studies available on the efficacy and safety of Carica papaya leaf extract (CPLE) in adult patients with DF. However, there are no published studies available on the efficacy and safety of CPLE in the pediatric age group. Hence, this study was conducted.

Methodology

A prospective, open-label, randomized controlled study was conducted in subjects aged between 1 and 12 years having thrombocytopenia associated with DF (NS-1 antigen positive) or dengue hemorrhagic fever (DHF) grades I and II. All participants were randomized into the intervention group (n =147, CPLE syrup + standard therapy) and the control group (n=147, received only standard therapy). All subjects were followed up daily for 5 days with monitoring of blood counts.

Results

A total of 285 subjects were finally evaluated for efficacy, and nine dropped out (seven in the control group and two in the intervention group). However, all 294 subjects were evaluated for safety. CPLE (Caripill) syrup increased the platelet count significantly compared to the control group (P<0.05). In the intervention group, the platelet count increased from day 3 onward: platelet count on day 3 (mean platelet count =89,739.31, P=0.030), day 4 (mean platelet count =120,788.96, P=0.019), and day 5 (mean platelet count =168,922.75 P=0.023). Two children complained of nausea in the intervention group. Overall, Caripill syrup was well tolerated.

Conclusion

CPLE syrup significantly increases the platelet count in pediatric DF patients and is well tolerated.

Dengue Outbreak in Peshawar: Clinical Features and Laboratory Markers of Dengue Virus Infection

BACKGROUND

Dengue is a tropical disease caused by dengue virus (DENV). It is one of the most significant arthropod-borne viral infection.

OBJECTIVES

The aim of the current study was to characterize epidemiological, clinical features and laboratory markers of dengue infection during the recent epidemic in Peshawar, KP.

METHODS

During the prospective hospital-based observational study, 2000 dengue suspected cases were serologically examined at Lady Reading Hospital (LRH) Peshawar. Dengue NS1 antigen and Dengue IgG and IgM antibody ELISA tests were conducted for the confirmation of dengue infection. Data regarding the clinical features, platelet count and liver function tests were also recorded for the dengue positive patients.

RESULTS

Out of total samples 415 (21%) cases including 309 (74%) male and 106 (25%) female were detected positive for the dengue infection. In the dengue positive patients, the highest prevalence was observed in the age group of 21-40years with 160 (38%) followed by the age group of 1-20years with 89 (21%) patients. Fever was recorded in 100% of the dengue patients followed by a headache and fatigue in 73% and liver abnormality observed in 70% of the cases. During laboratory examinations IgM antibody was detected in 180 cases, followed by IgG antibody in 87, NS1 antigen in 43, NS1 antigen along with IgG and IgM antibodies in 41 dengue positive cases. Another combine detection of NS1 antigen with IgM antibody, NS1 antigen with IgG antibody and both IgG and IgM antibodies was observed in 21, 21, 22 dengue cases respectively.

CONCLUSION

It was concluded that the dengue infection can be early diagnosed on the basis of described clinical features and with the detection of dengue-specific NS1 antigen along with antibodies such as IgG and IgM.

Purinergic Signaling: A New Pharmacological Target Against Viruses?

Viral diseases represent a major global problem in human health, with high morbidity and mortality. Despite recent progress in antiviral treatments, several viral diseases are still not controlled and millions suffer from them every year. It has recently emerged that purinergic signaling participates in viral infection and replication. Furthermore, stimulation of purinergic receptors in infected cells also induces inflammatory and antiviral responses, thus contributing to the host antiviral defense. Here we review the multiple roles played by the purinergic signaling network in cell-virus interactions that can lead either to viral maintenance in the cells or, by contrast, to stronger antiviral responses, and discuss potential future applications of purinergic signaling modulation for the treatment of viral diseases.

Molecular characterization and phylogenetic analysis of a dengue virus serotype 3 isolated from a Chinese traveler returned from Laos

BACKGROUND

Dengue virus (DENV) infection caused by international visitors has become a public health concern in China. Although sporadic imported cases of DENV have been documented in Yunnan, China since 2000, a complete genome sequence of dengue virus serotype 3 (DENV-3) imported from Laos is still not available. Here, we report the first complete genome sequence and genomic characterization of a DENV-3 strain (YNPE3) isolated from a patient returned from Laos.

METHODS

Viral isolation from the patient's serum was performed using mosquitoes C6/36 cells. Reverse transcriptase polymerase chain reaction (RT-PCR) was used for identification and serotyping of the virus. The complete sequence was determined by Sanger dideoxy sequencing. Homology analysis was implemented by NCBI-BLAST. Multiple sequence alignment was performed using MegAlign module of the Lasergene 7 software package DNASTAR. MFOLD software was used to predict the RNA secondary structure of 5' untranslated region (UTR) and 3' UTR. Phylogenetic analysis, which was based on envelope gene and complete coding sequence, was performed by Maximum-Likelihood method.

RESULTS

RT-PCR analysis confirmed that the virus belonged to dengue virus serotype 3, which was named YNPE3 strain. The full-length genome of the YNPE3 strain was 10,627 nucleotides (nts) with an open reading frame (ORF) encoding 3390 amino acids. Strain YNPE3 shared 98.6-98.8% nucleotide identity with the closely related strains isolated in India (JQ922556, KU216209, KU216208). We observed the deletion of about 40 nts in the 5' UTR and 3' UTR of strain YNPE3, and 11 nts (ACGCAGGAAGT) insertion that was present in the 3' UTR of YNPE3. Compared with prototype strain H87, abundant amino acid substitutions in the YNPE3 strain were observed. Phylogenetic analysis revealed that the YNPE3 strain belonged to genotype III of DENV-3, and that it might be closely related with genotype III strains isolated in Laos and India.

CONCLUSIONS

This is the first report of the complete genome sequence and molecular characterization of a DENV-3 isolate imported from Laos. The presented results can further promote disease surveillance, and epidemiological and evolutionary studies of the DENV-3 in Yunnan province of China.

Dengue Infection Spectrum in Guangzhou: A Cross-Sectional Seroepidemiology Study among Community Residents between 2013 and 2015

The majority of dengue virus infections are asymptomatic, which could potentially facilitate the transmission of dengue fever and increase the percentage of sever dengue fever manifestations. This cross-sectional study explored the sero-prevalence of dengue virus infection in Guangzhou to clarify the infection spectrum. In total, 2085 serum samples were collected from residents of 34 communities. All samples were selected from a 200,000-sample database holding serum collected from community residents living in Liwan and Yuexiu districts of Guangzhou between September 2013 and August 2015, and 17 to 28 individuals of each age group were chosen per month. Dengue immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies were tested by enzyme-linked immunosorbent assay. Symptomatic infected individuals were identified via follow-up questionnaires. Among 2085 serum samples, anti-dengue IgG and IgM positive rates were 11.80% and 3.98%, respectively. The IgG antibody positive rate increased with age and was higher in poorly educated people than in highly educated people and in married individuals than in single individuals. Approximately 96.71% of dengue virus infections and an estimated 13.68% of the whole population were asymptomatic. Such high asymptomatic-infection rates have an impact on the local spread of dengue fever. Stricter surveillance, such as a network of rapid diagnostic laboratories, screening of residents in the epidemic season, and other integrated control measures are necessary.

Genomics, proteomics and evolution of dengue virus

The genome of a pathogenic organism possesses a specific order of nucleotides that contains not only information about the synthesis and expression of proteomes, which are required for its growth and survival, but also about its evolution. Inhibition of any particular protein, which is required for the survival of that pathogenic organism, can be used as a potential therapeutic target for the development of effective drugs to treat its infections. In this review, the genomics, proteomics and evolution of dengue virus have been discussed, which will be helpful in better understanding of its origin, growth, survival and evolution, and may contribute toward development of new efficient anti-dengue drugs.

Exploring the in vitro potential of celecoxib derivative AR-12 as an effective antiviral compound against four dengue virus serotypes

Objectives

With no clinically effective antiviral options available, infections and fatalities associated with dengue virus (DENV) have reached an alarming level worldwide. We have designed this study to evaluate the efficacy of the celecoxib derivative AR-12 against the in vitro replication of all four DENV serotypes.

Methods

Each 24-well plate of Vero cells infected with all four DENV serotypes, singly, was subjected to treatments with various doses of AR-12. Following 48 h of incubation, inhibitory efficacies of AR-12 against the different DENV serotypes were evaluated by conducting a virus yield reduction assay whereby DENV RNA copy numbers present in the collected supernatant were quantified using qRT-PCR. The underlying mechanism(s) possibly involved in the compound's inhibitory activities were then investigated by performing molecular docking on several potential target human and DENV protein domains.

Results

The qRT-PCR data demonstrated that DENV-3 was most potently inhibited by AR-12, followed by DENV-1, DENV-2 and DENV-4. Our molecular docking findings suggested that AR-12 possibly exerted its inhibitory effects by interfering with the chaperone activities of heat shock proteins.

Conclusions

These results serve as vital information for the design of future studies involving in vitro mechanistic studies and animal models, aiming to decipher the potential of AR-12 as a potential therapeutic option for DENV infection.

Analysis of dengue virus burden and serotypes pattern in Faisalabad, 2016–2017

Dengue is the fastest growing mosquito-borne viral infection and has become a public epidemic in Pakistan. This cross-sectional study was carried out to explore the prevalence and characterization of dengue virus serotypes in Faisalabad, Pakistan during 2016–2017. Aim: To determine most prevalent dengue serotype in Faisalabad, Pakistan. Methodology: Cross-sectional study of stored serum specimens for dengue virus genotype by multiplex real time (RT)-PCR, antidengue IgM, IgG and NS1.Results: Viral RNA detection of 42 patients revealed positive results in 125 (34.4%) samples. DENV-3 (76%) was the predominant genotype followed by DENV-2 (17%) and 7% of DENV1. None of the samples were positive for DENV-4. Conclusion: DENV-3 is the most prevalent serotype of dengue virus observed in Faisalabad, Pakistan.

Targeted Interventions in Critically Ill Children with Severe Dengue

Background:

The World Health Organization guidelines provide suggestions on early recognition and treatment of severe dengue (SD); however, mortality in this group can be high and is related both to disease severity and the treatment complications.

Subjects and Methods:

In this prospective observational study, we report our results where standard therapy (ST) was enhanced by Intensive Care Unit (ICU) supportive measures that have proven beneficial in other conditions that share similar pathophysiology of capillary leak and fluid overload. These include early albumin for crystalloid-refractory shock, proactive monitoring for symptomatic abdominal compartment syndrome (ACS), application of a high-risk intubation management protocol, and other therapies. We compared outcomes in a matched retrospective cohort who received ST.

Results:

We found improved outcomes using these interventions in patients with the most devastating forms of dengue (ST+ group). We could demonstrate decreased positive fluid balance on days 1–3 and less symptomatic ACS that necessitated invasive percutaneous drainage (7.7% in ST+ group vs. 30% in ST group, P = 0.025). Other benefits in ST+ group included lower intubation and positive pressure ventilation requirements (18.4% in ST+ vs. 53.3% in ST, P = 0.003), lower incidence of major hemorrhage and acute kidney injury, and reduced pediatric ICU stays and mortality (2.6% in ST+ group vs. 26% in ST group, P = 0.004).

Conclusion:

Children with SD with refractory shock are at extremely high mortality risk. We describe the proactive application of several targeted ICU supportive interventions in addition to ST and could show that these interventions resulted in decreased resuscitation morbidity and improved outcomes in SD.

Pharmacophore anchor models of flaviviral NS3 proteases lead to drug repurposing for DENV infection

Background

Viruses of the flaviviridae family are responsible for some of the major infectious viral diseases around the world and there is an urgent need for drug development for these diseases. Most of the virtual screening methods in flaviviral drug discovery suffer from a low hit rate, strain-specific efficacy differences, and susceptibility to resistance. It is because they often fail to capture the key pharmacological features of the target active site critical for protein function inhibition. So in our current work, for the flaviviral NS3 protease, we summarized the pharmacophore features at the protease active site as anchors (subsite-moiety interactions).

Results

For each of the four flaviviral NS3 proteases (i.e., HCV, DENV, WNV, and JEV), the anchors were obtained and summarized into ‘Pharmacophore anchor (PA) models’. To capture the conserved pharmacophore anchors across these proteases, were merged the four PA models. We identified five consensus core anchors (CEH1, CH3, CH7, CV1, CV3) in all PA models, represented as the “Core pharmacophore anchor (CPA) model” and also identified specific anchors unique to the PA models. Our PA/CPA models complied with 89 known NS3 protease inhibitors. Furthermore, we proposed an integrated anchor-based screening method using the anchors from our models for discovering inhibitors. This method was applied on the DENV NS3 protease to screen FDA drugs discovering boceprevir, telaprevir and asunaprevir as promising anti-DENV candidates. Experimental testing against DV2-NGC virus by in-vitro plaque assays showed that asunaprevir and telaprevir inhibited viral replication with EC₅₀ values of 10.4 μM & 24.5 μM respectively. The structure-anchor-activity relationships (SAAR) showed that our PA/CPA model anchors explained the observed in-vitro activities of the candidates. Also, we observed that the CEH1 anchor engagement was critical for the activities of telaprevir and asunaprevir while the extent of inhibitor anchor occupation guided their efficacies.

Conclusion

These results validate our NS3 protease PA/CPA models, anchors and the integrated anchor-based screening method to be useful in inhibitor discovery and lead optimization, thus accelerating flaviviral drug discovery.

Electronic supplementary material

The online version of this article (10.1186/s12859-017-1957-5) contains supplementary material, which is available to authorized users.

An Evidence-Based Algorithm for Early Prognosis of Severe Dengue in the Outpatient Setting

Background

Early prediction of severe dengue could significantly assist patient triage and case management.

Methods

We prospectively investigated 7563 children with ≤3 days of fever recruited in the outpatient departments of 6 hospitals in southern Vietnam between 2010 and 2013. The primary endpoint of interest was severe dengue (2009 World Health Organization Guidelines), and predefined risk variables were collected at the time of enrollment to enable prognostic model development.

Results

The analysis population comprised 7544 patients, of whom 2060 (27.3%) had laboratory-confirmed dengue; nested among these were 117 (1.5%) severe cases. In the multivariate logistic model, a history of vomiting, lower platelet count, elevated aspartate aminotransferase (AST) level, positivity in the nonstructural protein 1 (NS1) rapid test, and viremia magnitude were all independently associated with severe dengue. The final prognostic model (Early Severe Dengue Identifier [ESDI]) included history of vomiting, platelet count, AST level. and NS1 rapid test status.

Conclusions

The ESDI had acceptable performance features (area under the curve = 0.95, sensitivity 87% (95% confidence interval [CI], 80%-92%), specificity 88% (95% CI, 87%-89%), positive predictive value 10% (95% CI, 9%-12%), and negative predictive value of 99% (95% CI, 98%-100%) in the population of all 7563 enrolled children. A score chart, for routine clinical use, was derived from the prognostic model and could improve triage and management of children presenting with fever in dengue-endemic areas.

Expanded dengue syndrome in secondary dengue infection: A case of biopsy proven rhabdomyolysis induced acute kidney injury with intracranial and intraorbital bleeds

Dengue fever is endemic in the Indian subcontinent and can have myriad presentations. The term expanded dengue syndrome (EDS) is used for atypical manifestations in dengue fever. We present a rare case of EDS in a patient with secondary dengue infection who developed rhabdomyolysis induced acute kidney injury (RAKI) along with intracranial and intraorbital bleeds. Patient was successfully managed in our institute and was discharged in stable condition. To the best of our knowledge, this is the only reported case of simultaneous occurrence of these complications in a dengue patient. This case is being presented to make clinicians aware of the spectrum of dengue infection.

Review on transovarial transmission potentiality of dengue vectors: An international perspective with special reference to North-Eastern region of India

Despite extensive research in vaccine development, there is at present no known method of controlling dengue except by the mosquito vectors. Virologic surveillance which involves the detection of dengue virus (DENV) in human serum and followed by isolation of virus using cell culture or mosquito inoculation is used as an early warning symptom to predict the outbreak. The technique is not much effective as the virus is in the human population. However, if the virus is detected in mosquito before it can infect humans could be more effective approach. One of the great mysteries about the epidemiology of dengue is how the virus persists in the interepidemic period. So far, no such studies on dengue vectors have been conducted in the north-eastern region of India, especially in Assam and the dengue cases are increasing every year. There are no reports on the identification of active and potential role of dengue vector responsible for the transmission of dengue in this state. Such type of study will give an overall picture of potential dengue vector responsible for human DENV infection and the viral load carried by the mosquito species in different generations. Such study will be useful in helping the public health personnel.

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.

Post-dengue acute disseminated encephalomyelitis: A case report and meta-analysis

BACKGROUND

Dengue is one of the most common infectious diseases. The aim of this study was to systematically review acute disseminated encephalomyelitis (ADEM) and to represent a new case.

METHODOLOGY/PRINCIPAL FINDINGS

We searched for articles in nine databases for case reports, series or previous reviews reporting ADEM cases in human. We used Fisher's exact and Mann-Whitney U tests. Classification trees were used to find the predictors of the disease outcomes. We combined findings using fixed- and random-effects models. A 13-year-old girl was admitted to the hospital due to fever. She has a urinary retention. The neurological examinations revealed that she became lethargic and quadriplegic. She had upper limbs weakness and lower limbs complete paraplegia. Her status gradually improved after the treatment. She was nearly intact with the proximal part of her legs had a mild weakness in discharge. The prevalence of ADEM among dengue patients was 0.4% [95% confidence intervals (95% CI) 0.1-2.5%], all neurological disorders among dengue was 2.6% [95% CI 1.8-3.8%], and ADEM among neurological disorders was 6.8% [95% CI 3.4-13%]. The most frequent manifestation of ADEM was altered sensorium/consciousness (58%), seizures and urination problems (35%), vision problems (31%), slurred speech (23%), walk problems (15%) then ataxia (12%). There was a significant difference between cases having complete recovery or bad outcomes in the onset day of neurological manifestations being earlier and in temperature being higher in cases having bad outcomes (p-value < 0.05). This was confirmed by classification trees which included these two variables.

CONCLUSIONS/SIGNIFICANCE

The prevalence of ADEM among dengue and other dengue-related neurological disorders is not too rare. The high fever of ADEM cases at admission and earlier onset day of neurological manifestations are associated with the bad outcomes.