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Diagnostic Microbiology and Infectious Disease 73 (2012) 215220

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Diagnostic Microbiology and Infectious Disease


j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / d i a g m i c r o b i o

Reviews

Update: The diagnosis and management of dengue virus infection in North America
William F. Wright a,, Bobbi S. Pritt b
a
b

Division of Infectious Diseases, Department of Medicine, Institute of Human Virology, University of Maryland School of Medicine, N156, Baltimore, MD 20201, USA
Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA

a r t i c l e

i n f o

Article history:
Received 5 January 2012
Received in revised form 28 February 2012
Accepted 17 March 2012
Available online 26 April 2012
Keywords:
Dengue virus
Dengue Fever
Dengue hemorrhagic fever
Dengue shock syndrome
Dengue diagnostics

a b s t r a c t
Dengue is a mosquito-transmitted infection that poses signicant global health risks for travelers and
individuals living in the tropics and subtropics. The reported global incidence has increased dramatically in
the past century, with dengue now ranking as the most common cause of febrile illness in travelers. While
sporadic cases have been reported within the southern United States since 1980, autochthonous outbreaks
have now been described in Hawaii, St. Croix (US Virgin Islands), along the TexasMexico border, and, most
recently, in Key West, Florida. Although many infections are mild or asymptomatic, 510% of patients may
experience hemorrhagic disease, with shock and even death. Laboratory identication commonly involves
serologic and nucleic acid amplication methods. Due to rising incidence worldwide, physicians should be
familiar with the clinical manifestations, laboratory diagnosis, and management of this illness.
2012 Elsevier Inc. All rights reserved.

Dengue is an emerging mosquito-transmitted infection in North


America that is endemic in the tropics and subtropics worldwide. The
virus belongs to the Flaviviridae family, Flavivirus genus, and contains
4 serotypes that may co-circulate in the same geographic region.
Infection may result in signicant morbidity and mortality and poses
signicant public health concerns for travelers and individuals in
endemic areas. It is estimated that greater than one-third of the
world's population is at risk of acquiring infection with the virus and
that 50100 million infections occur each year (Fig. 1) (Guzman et al.,
2010; Halstead, 2007). Although the majority of infections involve
persons living in endemic areas, the GeoSentinel Surveillance Network
(GSN) reports that dengue-related infections are now the most
common cause of fever among travelers, surpassing malaria and
gastrointestinal infections as etiologic agents (Schwartz et al., 2008).
Mohammed et al. (2010b) provided a 10-year review of travelassociated dengue-related infections in the United States and reported
that the most commonly visited destinations associated with infection
were the Caribbean, Mexico and Central America, and Southeast Asia.
In addition to rises in travel-associated cases, reports of locally
acquired disease in the USA have also increased. While sporadic
imported cases have been reported within the southern United States
since 1980, autochthonous (locally acquired) outbreaks have now
been described in Hawaii, St. Croix (US Virgin Islands), along the
TexasMexico border (CDC, 2007; Efer et al., 2005; Mohammed et al.,
2010a; Mohammed et al., 2010b), and, most recently, in Key West,
Florida (CDC, 2010). The virus is predominantly transmitted to

Corresponding author. Tel.: +1-410-706-0294; fax: +1-410-706-1658.


E-mail address: wwright@ihv.umaryland.edu (W.F. Wright).
0732-8893/$ see front matter 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.diagmicrobio.2012.03.021

humans via the Aedes aegypti female mosquito; however, the Aedes
albopictus female mosquito is also a competent vector and exists
within the southeastern United States (CDC, 2007; Efer et al., 2005;
Guzman et al., 2010; Halstead, 2007; Shu and Huange, 2004).
1. Clinical manifestations
The clinical spectrum associated with dengue ranges from
asymptomatic infection to mild disease and severe, life-threatening
illness. The World Health Organization (WHO) has created denitions
for each of the dengue-related symptomatic infections (Table 1),
including probable dengue, dengue without warning signs (previously dengue fever), dengue with warning signs (previously dengue
hemorrhagic fever [DHF]), and severe dengue (also known as dengue
shock syndrome [DSS]) (Schwartz et al., 2008; World Health
Organization, 2009). Dengue without warning signs is the most
common presentation of primary infection and typically occurs after a
short incubation period of 47 days (range 314 days). The most
common manifestations are fever, headache with or without retroorbital pain, myalgia, arthralgia, and a maculopapular to petechial
rash (Guzman et al., 2010; Halstead, 2007). A prospective, 3-year
evaluation of more than 3100 patients describes the clinical proles of
suspected dengue cases admitted to 3 major hospitals in Nicaragua
(Hammond et al., 2005). Additionally, a prospective, 5-year observational study has documented clinical information among 351
serologically conrmed Vietnamese patients (Thai et al., 2010).
Taken together, fever was the most common manifestation in all
age groups (95100%). While fever and headache were more common
among adults and children, infants tended to present most frequently
with a fever and rash. The classic symptoms of dengue (e.g., fever,

216

W.F. Wright, B.S. Pritt / Diagnostic Microbiology and Infectious Disease 73 (2012) 215220

Fig. 1. Global distribution of dengue and its mosquito vectors, Aedes albopictus and Aedes aegypti. Data compiled from DengueMap (2012), UNEP (Lpez Izquierdo, 2007), and Parola
et al. (2006).

headache, retro-orbital pain with myalgia and arthralgia) were


present in more than 60% of laboratory-conrmed cases involving
both adults and children (Hammond et al., 2005). No symptom or sign
was clearly able to discriminate between patients with primary
infection or secondary (recurrent) infection (Hammond et al., 2005;
Thai et al., 2010). Less commonly, patients progress to more severe
forms of illness (WHO classications: dengue with warning signs and
severe dengue) that include thrombocytopenia, hemorrhage, plasma
extravasation, shock, and even death. These forms of severe disease
are manifested in an estimated 510% of patients and are most
commonly associated with secondary infection by a serotype other
than the one that caused the initial infection. Mortality rates
associated with more severe forms have been estimated to be from
126% but maybe as high as 47% in some areas (Guzman et al., 2010;
Ranjit et al., 2005; Wills et al., 2005; WHO, 2009). Dengue survival
may be improved if aggressive supportive therapy can be rapidly
implemented; therefore, the rapid diagnosis of dengue virus infection
is valuable for patient care and management (Guzman et al., 2010;
Ranjit et al., 2005).
2. Diagnostic testing
A number of laboratory tests may be used for dengue diagnosis,
including tests that detect viable virus, viral RNA, peripherally
circulating viral antigens, and host antibodies. Virus can be detected
in the patient's bloodstream from 4 to 5 days after illness onset (acute

or febrile phase), and, therefore, culture, antigen detection, and


molecular diagnostics such as reverse transcriptionpolymerase chain
reaction (RT-PCR) are the preferred tests during this time period.
After the acute phase, detection of circulating antibodies to dengue
virus in serum provides greater sensitivity for detection of infection
and is more widely available in the USA. Collection of acute and
convalescent sera is recommended to demonstrate the appearance of
virus-specic antibodies following infection.
Antibody detection can be accomplished using hemagglutination
inhibition (HI), complement xation, neutralization, immunoglobulin
M (IgM) capture enzyme-linked immunosorbent (MAC-ELISA), and
indirect immunoglobulin G (IgG) ELISA assays (De Paula and Fonseca,
2004; Guzman et al., 2010; Shu and Huange, 2004). While the HI test
has historically been considered the gold standard serologic method
due to a relatively easy protocol, high sensitivity, and reliability, the
method lacks reliable serotyping specicity and is not available as a
commercial test kit. In contrast, enzyme-linked immunosorbent
assays (EIA) for detection of IgM and IgG class antibodies have an
easy protocol, have commercially available kits, and are amenable to
automation, thereby making them the most commonly utilized
methods in the clinical diagnostic laboratory (De Paula and Fonseca,
2004; Guzman et al., 2010; Shu and Huange, 2004). The detection and
specicity of dengue-specic immunoglobulin depend on the acquired immune response to infection, specimen type (i.e., serum,
whole blood, and saliva), dengue virus serotype, potentially crossreacting co-circulating avivirus antibodies as a result of prior

W.F. Wright, B.S. Pritt / Diagnostic Microbiology and Infectious Disease 73 (2012) 215220
Table 1
2009 WHO-Suggested dengue case classication.
Diagnosis

Diagnostic criteria

Probable dengue

Live or travel to a dengue endemic area


Fever and at least have 2 of the following:
nausea, vomiting, rash, leukopenia, arthralgia,
myalgia, and a positive tourniquet test
Laboratory-conrmed dengue with fever and
Dengue without warning
2 or more of the following: nausea, vomiting,
signs (previously known
rash, leukopenia, arthralgia, myalgia, and a
as dengue fever)
positive tourniquet test
Same as above plus any of the following
Dengue with warning signs
warning signs: abdominal pain or tenderness,
(previously known as
persistent emesis, volume overload (edema),
dengue hemorrhagic fever)
mucosal bleeding, lethargy or restlessness,
hepatomegaly (liver edge greater than 2 cm),
and hemoconcentration (increasing
hematocrit and decreasing platelet count)
Severe dengue (previously known Dengue as above with one of the following:
as dengue shock syndrome)
shock, signicant volume overload with
respiratory distress, severe clinical bleeding,
and organ failure (e.g. heart failure, renal
failure, hepatic failure with an aspartate
aminotransferase or alanine aminotransferase
greater than 1000, or altered mental status).

Original table with information from World Health Organization (2009) guidelines.

Tourniquet test. This is a bedside test to evaluate for capillary fragility. The test is
performed by rst inating a blood pressure cuff to a value that is midway between the
systolic and diastolic blood pressure. After maintaining that pressure for 5 min the
blood pressure cuff is released. A positive test is indicated by the presence of 20 or more
petechiae per square inch on the distal forearm.

infection or vaccination (i.e., Japanese encephalitis virus, Powassan/


Deer tick virus, St. Louis encephalitis virus, tick-borne encephalitis
virus, West Nile virus, and yellow fever virus), the clinical setting (i.e.,
primary versus secondary/tertiary infection), and the quality of the
antigens utilized with the ELISA method (De Paula and Fonseca, 2004;
Shu and Huange, 2004). Dengue virus infection produces life-long
protective immunity to the infecting serotype but produces limited
and transient protection against the remaining serotypes (Shu and
Huange, 2004). Therefore, subsequent infection with a different
serotype may occur in patients living in endemic areas. The acquired
immune response to a primary dengue infection is typically
characterized by a slow and low-titer antibody rise with IgM
appearing by days 35 and IgG detectable by days 57 of illness (De
Paula and Fonseca, 2004; Guzman et al., 2010; Halstead, 2007; Innis
et al., 1989; Shu and Huange, 2004). During a secondary or tertiary
infection, IgM titers rise much slower than IgG titers and may result in
false-negative tests (De Paula and Fonseca, 2004; Guzman et al., 2010;
Halstead, 2007; Innis et al., 1989; Shu and Huange, 2004). In contrast,
IgG levels rise quickly in recurrent infection and may be detected
during the acute phase of infection. Immunoglobulin G levels may
persist for years and exhibit broad reactivity with many aviviruses.
Given these patterns, IgM and IgG ratios may be useful in
differentiating primary from secondary/tertiary infection (Innis
et al., 1989; WHO, 2009).
Rapid dengue tests are immunoassays that detect either viral
antigens (i.e., NS1 antigen) or dengue-specic immunoglobulins
using recombinant envelope proteins from all 4 serotypes usually
within 1590 min (De Paula and Fonseca, 2004; Guzman et al., 2010;
Halstead, 2007; Shu and Huange, 2004). These rapid assays are
suitable for use at point of care and include EIA and lateral ow
immunochromatrographic assays (LFIA) (Balmaseda et al., 2003;
Blacksell et al., 2006a,b; Fry et al., 2011; Hunsperger et al., 2009;
Vaughn et al., 1998). Due to the competition of IgG with IgM antigen
binding, MAC-ELISA assays have been developed using serum, whole
blood, and saliva samples obtained after 5 days of fever and
demonstrate sensitivities of 9098% with specicities of 9298%
(whole blood on lter paper produces the best sensitivity and
specicity at 98%) (Balmaseda et al., 2003; Guzman et al., 2010;

217

Hunsperger et al., 2009; Innis et al., 1989). MAC-ELISA assays are


developed on the principle that dengue-specic IgM assays are more
reactive to epitopes of the current infecting serotype, while denguespecic IgG assays are cross-reactive to shared epitopes among the 4
serotypes (Guzman et al., 2010; Innis et al., 1989). The assay initially
captures dengue-specic IgM in a patient sample using monoclonal
antibodies to human IgM (thereby removing cross-reactive denguespecic IgG) and then tests the captured IgM to a mixture of 4 dengue
antigens. False-positive results have mainly been attributed to crossreactivity with co-circulating antibodies from other aviviruses
(listed above) as well as serum from travelers returning with malaria
or leptospirosis (Balmaseda et al., 2003; Guzman et al., 2010;
Hunsperger et al., 2009).
LFIA methods provide a simple, inexpensive, and rapid
commercial method for detection of anti-dengue antibodies in
resource-limited and eld settings. The maximum time to receive a
negative result is 30 min, while positive results may be available
even sooner (Blacksell et al., 2006a; Vaughn et al., 1998). Most
assays use a test strip with anti-human IgM and IgG to the solid
phase and a monoclonal anti-dengue antibody (directed against
envelope proteins) conjugated with a colloidal gold tracer that
remains stable at a temperature range of 430 C for 24 months
(Blacksell et al., 2006a; Vaughn et al., 1998). Unfortunately, when
comparative accuracy of these assays was performed with both RTPCR and MAC-ELISA, diagnostic accuracy was poor, with sensitivities ranging from 6.4% to 65% and specicities of 69% to 100%
(Blacksell et al., 2006a). Furthermore, no evaluated assay adequately differentiated between primary and secondary infections,
and not all serotypes were adequately detected by some kits
(Blacksell et al., 2006a,b). Recently, qualitative assays that use both
a rapid (b30 min) LFIA and a microplate EIA have been developed
to detect the NS1 dengue antigen that appears within the blood as
early as 1 day after the onset of fever (Fry et al., 2011; Najioullah
et al., 2011). A prospective evaluation of these assays, as compared
to RT-PCR, produced sensitivities of 49% for LFIA and 61% for EIA,
but both methods demonstrated a specicity of 100% (Najioullah et
al., 2011). NS1 dengue antigen assays that use the capture enzymelinked immunosorbent (capture-ELISA) method demonstrated an
overall sensitivity between 64% and 83%, when compared with
serology and RT-PCR (Bessoff et al., 2008; Kumarasamy et al.,
2007). While these rapid tests offer important advantages over
traditional serology tests, it is important to note that they are not
typically available in the United States and low accuracy limits the
utility for clinical diagnosis. The accuracy of serologic testing is
summarized in Table 2.
Nucleic acid amplication offers a sensitive and relatively rapid
method for detection and identication of specic dengue virus
serotypes during the acute/viremic phase (prior to antibody production) and can provide viral quantication which may be an important
predictor of disease severity (Guzman et al., 2010; Johnson et al., 2005;
Morita et al., 1991; Shu and Huange, 2004; Vaughn et al., 2000).
Described methods include real-time and conventional RT-PCR,
including single RT-PCR, nested RT-PCR, and multiplex RT-PCR. It is
important to note that these assays are all laboratory-developed
methods that vary greatly in complexity, performance characteristics,
and time to completion. Nonnested, real-time RT-PCR methods
typically take 60 to 180 min for the reverse transcription and
amplication portion of the assay, although the entire testing process
including specimen processing, RNA extraction, and amplicon detection
may require 6 h or more. Assays that require secondary amplication
steps (e.g., nested RT-PCR) may require more time than nonnested
assays. The reported sensitivity of RT-PCR assays varies from 25% to 98%
(Guzman et al., 2010; Kumarasamy et al., 2007; Raengsakulrach et al.,
2002; Yong et al., 2007). In general, single and multiplex RT-PCR
methods are less sensitive than nested RT-PCR methods but may be
more widely available (de Oliveira Poersch et al., 2005).

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W.F. Wright, B.S. Pritt / Diagnostic Microbiology and Infectious Disease 73 (2012) 215220

Table 2
Diagnostic performance of serologic methods.
Method

Sensitivity

Specicity

MAC-ELISA
Balmaseda et al., 2003; Hunsperger et al., 2009
EIA (NS1 antigen)
Najioullah et al., 2011
Capture ELISA (NS1 antigen)
Bessoff et al., 2008; Kumarasamy et al., 2007
LFIA (envelope protein)
Blacksell et al., 2006a
LFIA (NS1 antigen)
Najioullah et al., 2011

9098%

9298%

61%

100%

6483%

97100%

6.465%

69100%

49%

100%

MAC-ELISA = Immunoglobulin M capture enzyme-linked immunosorbent assay.

EIA = Enzyme immunosorbent assay.

LFIA = Lateral ow immunochromatographic assay.

At present, no Food and Drug Administrationapproved nucleic


acid amplication assays are available in the United States, but
commercially available reagents are available for use in laboratorydeveloped tests.
Finally, viral isolation by culture may be attempted by inoculating
specialized cell lines such as the Aedes albopictus C6/36 cell line clone
with patient serum. Culture is most successful when serum is
obtained within the rst 35 days of fever. Culture is not available
in most diagnostic laboratories and is restricted to specialized
reference or research laboratories due to the need for expensive
equipment and technically trained laboratory personnel (De Paula

and Fonseca, 2004; Guzman et al., 2010; Kuno et al., 1985; Shu and
Huange, 2004).
Laboratory-based diagnosis of dengue virus infection is most often
requested on the basis of clinical manifestations in order to
differentiate other febrile illnesses. A testing algorithm that is based
on the natural course of dengue infection may be useful in guiding
clinicians to a rapid diagnosis. Based on the available information, cell
culture is insensitive, expensive, time consuming, and requires
technically trained personnel (De Paula and Fonseca, 2004; Guzman
et al., 2010; Shu and Huange, 2004). Using a combination of RT-PCR
and MAC-ELISA appears to allow for a rapid and accurate diagnosis
(World Health Organization, 2009). Thus, for areas without signicant
resource constraints such as laboratories in North America, we
propose obtaining serum samples for RT-PCR within 5 days of onset
of illness and MAC-ELISA after day 5 of illness. For resource-limited
areas, we propose using NS1 capture antigen kits within 5 days of the
onset of illness (e.g., prior to fever) and MAC-ELISA in patients after
day 5 of illness.
3. Treatment
The most recent WHO guidelines provide treatment plans for
dengue according to categories based on severity of clinical
manifestations (Table 3) (WHO, 2009). Currently, no specic therapy
or antiviral agent exists for the treatment of dengue. Most cases of
classic dengue are self-limited and can be successfully managed as an
outpatient with supportive care (e.g., acetaminophen, bed rest, and
oral rehydration) and close clinical monitoring (WHO, 2009).
Hospitalization with adequate uid resuscitation and supportive

Table 3
2009 WHO Treatment recommendations.
Group

Treatment
setting

Dengue without
admission criteria
(group A)

Outpatient

Treatment plan

Patients do not have warning signs (see Table 1) or admission criteria and can be monitored daily for disease progression.
Treatment is usually adequate oral rehydration and supportive care (e.g., acetaminophen and bed rest) until the fever resolves.
Patients should AVOID aspirin (risk of Reye's syndrome) or nonsteroidal anti-inammatory agents (risk of gastritis and
bleeding). Patients should be brought to the hospital if the patient has any warning signs and/or no clinical improvement.
Dengue with
Hospital
Patients need to be admitted for supportive care and close observation with management based on the presence of warning
admission criteria
signs.
A. Warning signs absent. Encourage oral uid intake and monitor fever, mental status, signs of bleeding, uid intake and urine
(group B)
output, complete blood count, and comprehensive metabolic panel. For patients who cannot tolerate oral uid intake, obtain a
reference hematocrit then initiate maintenance uid (0.9% saline or Ringer's lactate) based on ideal body weight (IBW) for 24
48 h: 4 mL/kg per hour for the rst 10 kg IBW plus 2 mL/kg per hour for the next 10 kg IBW plus 1 mL/kg per hour for each
subsequent kilogram of ideal body weight.
B. Warning signs present. Monitor parameters as above, obtain a reference hematocrit, then initiate maintenance uid (0.9%
saline or Ringer's lactate) based on IBW with 57 mL/kg per hour for the rst 12 h, then 35 mL/kg per hour for 24 h, and then
reduce to 23 mL/kg per hour.
Hemorrhagic complications should be treated with cross-matched blood transfusions. The hematocrit should be monitored
every 68 h for at least 48 h.
Dengue with
Hospital/Intensive Patients require emergency treatment in an intensive care facility due to the presence of respiratory distress with interstitial
admission criteria
care unit
uid accumulation, shock, severe bleeding, and/or severe organ impairment. Immediate uid resuscitation is initiated with a
bolus of crystalloid solution (0.9% saline or Ringer's lactate) at 510 ml/kg per hour. Subsequent uid administrations depend on
and require emergency
the response to the initial uid bolus.
treatment (group C)
A. Compensated shock. For patients who respond to an initial uid bolus, obtain a repeat hematocrit then initiate maintenance
uid (0.9% saline or Ringer's lactate) based on IBW for 2448 h: 57 mL/kg per hour for the rst 12 h, then 35 mL/kg per hour
for 24 h, and then reduce to 23 mL/kg per hour.
B. Refractory shock. For patients who DO NOT respond to an initial uid bolus, a second uid bolus with either a crystalloid or a
colloidal (see text) solution should be initiated at 1020 mL/kg per hour for 1 h. Further uid boluses may be provided over the
next 2448 h depending on the clinical response. Once cardiovascular status has been recovered, initiation of maintenance uid
should begin as follows: 710 mL/kg per hour for the rst 12 h, then 57 mL/kg per hour for the second 12 h, then 35 mL/kg
per hour for the next 24 h, and then reduce to 23 mL/kg per hour.
Hemorrhagic complications should be treated with cross-matched blood transfusions. The hematocrit should be monitored
every 68 h for at least 48 h or until there are no bleeding complications and the hematocrit is stable.
Original table with information from WHO (2009) guidelines.
Admission criteria. Any of the following: warning signs (see Table 1), dehydration (e.g., postural hypotension and/or profuse sweating), hypotension with systolic blood pressure
less than 90 mmHg or mean arterial blood pressure less than 70 mmHg (e.g., cold extremities), spontaneous bleeding, organ impairment (e.g., renal, hepatic, cardiac, or neurologic),
signs of plasma leakage (e.g., rising hematocrit, pleural effusions, or ascites), existence of comorbid conditions (e.g., pregnancy, diabetes mellitus, hypertension, peptic ulcer disease,
or cirrhosis), extremes of age, or living circumstances that would not allow for close monitoring (e.g., lives alone).

Ideal body weight calculation. Men: 106 lb (48 kg) for the rst 60 in., then 6 lb (2.7 kg) for every inch over 5 ft. Women: 100 lb (45.3 kg) for the rst 60 in., then 5 lb (2.3 kg) for
every inch over 5 ft.

W.F. Wright, B.S. Pritt / Diagnostic Microbiology and Infectious Disease 73 (2012) 215220

medical care remains the accepted treatment plan for patients with
dengue with warning signs (DHF) and severe dengue (DSS) (Wills et
al., 2005; World Health Organization, 2009). While the choice of
resuscitation uid has been a matter of debate, a recent doubleblind, randomized comparison of 3 different solutions for 383
Vietnamese children with moderate to severe DSS found that
Ringer's lactate (crystalloid) was as effective as either dextran or
starch containing colloidal solutions for the restoration of cardiovascular status (Wills et al., 2005). For those with refractory shock,
colloidal solutions with starch may be the safest and most effective
option for cardiovascular recovery (Wills et al., 2005). A 5-year
retrospective examination of the records for 210 pediatric patients
with DHF/DSS admitted to a children's hospital in India has
evaluated the relationship to survival and early management (Ranjit
et al., 2005). The authors reported a lower mortality difference in
patients in whom an early aggressive uid management protocol
was initiated as compared to the standard 1997 WHO guidelines.
While a recent evaluation of 3 emergency resuscitation uids also
noted a low mortality rate (less than 1%), that trial did not examine
mortality as a primary outcome (Wills et al., 2005). Finally, although
steroids are thought to stabilize capillary permeability during shock,
a trial of 63 children in Thailand randomized to high-dose
methylprednisolone (30 mg/kg) failed to demonstrate a benet in
early DSS (Tassniyom et al., 1993).
Patients with moderate to severe thrombocytopenia (platelet
count of less than 100,000 cells per cubic millimeter) are usually
hospitalized as this nding precedes plasma leakage and may be
associated with potential hemorrhagic complications (Halstead,
2007; Lye et al., 2009; WHO, 2009). Despite this potential, evidence
for the predictive value of thrombocytopenia alone for severe
bleeding is lacking (Lye et al., 2009). Additionally, trials involving
the use of prophylactic platelet transfusions and fresh frozen plasma
in an attempt to increase platelet counts have not demonstrated a
benet to improved recovery of counts or a reduction in clinical
bleeding episodes (Lye et al., 2009; Sellahewa et al., 2008). Steroids
have been effective in increasing platelet counts with immune-related
thrombocytopenia, but a trial of 200 patients in Sri Lanka with dengue
and severe thrombocytopenia (platelet count of less than 50,000 cells
per cubic millimeter) randomized to receive low-dose dexamethasone was ineffective in achieving an increase in platelet counts
(Kularatne et al., 2009). Although 2 randomized trials have shown
that the administration of anti-D immune globulin (Rho D IgG) is
effective in signicantly increasing platelet counts for children with
DHF, a reduction in hemorrhagic outcomes was not evaluated (de
Castro et al., 2007). The current evidence suggests that further trials
are needed to determine the usefulness of these treatments for
dengue infections.
Currently, there is no antiviral agent licensed for the treatment of
dengue infections, but growing interest in the potential for an
antiviral agent has led investigators to evaluate certain agents against
pathogenic aviviruses (Crance et al., 2003). Ribavirin, interferon, and
chloroquine have shown promise with some in vitro antiviral activity;
therefore, a recent clinical trial involving 307 Vietnamese adults with
secondary dengue infections was randomized to a 3-day course of
chloroquine (Tricou et al., 2010). However, among participants, the
administration of chloroquine was associated with more adverse
effects (most commonly vomiting) and failed to reduce the duration
of viremia or NS1 antigenemia.
4. Vaccination
As no virus-specic treatment exists, a safe and effective vaccine
directed against all 4 dengue serotypes (e.g., tetravalent vaccine) offers
the best option for personal protection and widespread control.
Although currently no licensed vaccine is available for this infection,
efforts to develop and evaluate a tetravalent vaccine have been recently

219

reported in the literature (Capeding et al., 2011; Morrison et al., 2010).


Traditional live attenuated virus vaccines (serial passage through dog
kidney tissue) have been hampered by difculties in achieving the
proper level of attenuation as well as by being associated with
unacceptably high reactogenic effects in participants; therefore, the
development of live attenuated chimeric vaccines with the use of
recombinant technology has been the most current method (Capeding
et al., 2011; Morrison et al., 2010). In general, live attenuated chimeric
vaccines utilize an attenuated licensed yellow fever vaccine (YF 17D)
that contains the premembrane and envelope protein genes from the 4
corresponding dengue serotypes. Morrison et al. (2010) recently
reported the ndings from an evaluation of a phase 1 trial with a
novel tetravalent vaccine in 66 adult Thailand participants (age 1845).
Among those who completed inoculations with the study vaccine (n =
23) at 0, 4, and 1215 months, 100% had seroconversion to all 4
serotypes. Additionally, 92% of participants who initially received a
saline inoculation followed by 2 inoculations with the study vaccine at 4
and 1215 months (n = 23) had seroconversion to 4 serotypes.
Researchers reported this vaccine to be well tolerated with no serious
vaccine-related events and few systemic reactions (most commonly
involved headache, fever, myalgia, malaise, and asthenia). Capeding et
al. (2011) also recently reported the results of a phase 1 trial conducted
with 126 participants in the Philippines. The baseline seropositivity rate
to at least one serotype within this population was estimated at 53
68%. Eligible children and adults (age range from 2 to 45 years) who
were randomized to receive the tetravalent study vaccine at 0, 3.5, and
12 months had 85% seroconversion to 4 serotypes and 94% to at least 3
serotypes (n = 80). Participants who initially received a licensed
typhoid vaccine (Typhim VI, Sano Pasteur SA, Lyon, France) followed
by 2 inoculations with the study vaccine at 3.5 and 12 months (n = 39)
had 85% seroconversion for 4 serotypes and 90% seroconversion to at
least 3 serotypes. Similarly, investigators reported a satisfactory safety
prole with no serious adverse vaccine-related events and few
systemic side effects (most commonly fever, headache, myalgia,
malaise, asthenia, and injection site pain). Taken together, these studies
have undoubtedly introduced further large-scale trials to help optimize
the immunization schedule of a much-needed dengue vaccine.
5. Conclusion
Dengue is responsible for signicant morbidity and mortality in
travelers and individuals living in tropical and subtropical regions,
including the southern United States. Due to the increased number of
travel-associated and autochthonous cases detected in recent years,
physicians in the USA need to be familiar with the clinical manifestations
of dengue associated disease, the laboratory methods available for
diagnosis, and current management recommendations of this infection.
Although no licensed antiviral treatment currently exists, further largescale trials are underway for a much-needed dengue vaccine.
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