DENGUE

UNS - 2014

VIRUS DENGUE
Dengue fever virus RNA type virus Family of Flaviviridae dan genus Flavivirus Transmission of virus arbovirus (arthropods borne virus) Genome of virus 11,000 nucleotide base coding for different types of proteins; C, prM and E, together comprise the viral particle. Four strains of the virus DENV-1/ D-1, DENV-2/ D-2, DENV-3/D-3, DENV-4/ D-4.
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 The dengue virus has a roughly spherical shape. Inside the virus is the nucleocapsid, which is made of the viral genome and C proteins. The nucleocapsid is surrounded by a membrane called the viral envelope, a lipid bilayer that is taken from the host. Embedded in the viral envelope are E and M proteins that span through the lipid bilayer. These proteins form a protective outer layer that controls the entry of the virus into human cells 2011 Nature Education
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 The dengue virus genome is a single strand of RNA The viral genome encodes ten genes. The genome is translated as a single, long polypeptide and then cut into ten proteins Three are structural proteins: the capsid (C), envelope (E), and membrane (M) proteins Seven are nonstructural proteins: NS1, NS2A, NS2B, NS3, NS4A, NS4B, and NS5. These nonstructural proteins play roles in viral replication and assembly.
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VIRUS DENGUE
Transmitted through Aedes aegypti. Mosquito bite during day time in early morning or evening Humans are primary host Virus transmission vertical transmission ( mother to child ) & during organ transplant/ transfusion of infected blood
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VIRUS DENGUE
Female mosquito takes a blood from a person who infected with dengue fever itself infected with the virus. About 810 days later the virus spreads to other tissues including the salivary glands subsequently present its saliva With contact with human the virus is released inside the host The virus seems to have no harmful effect on the mosquito, which remains infected for life.
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IMUNOLOGICAL RESPONSE
The acquired immune response following a dengue infection consists of the production of IgM and IgG antibodies primarily directed against the virus envelope proteins The immune response varies depending on whether the individual has a primary (first dengue or other flavivirus infection) versus a secondary (had dengue or other flavivirus infection in past) dengue infection

IMUNOLOGICAL RESPONSE
A primary dengue infection slow and low titer antibody response. IgM antibody is the first immunoglobulin isotype to appear Anti-dengue IgG is detectable at low titer at the end of the first week of illness, and slowly increases. Secondary infection, antibody titers rise extremely rapidly high levels of IgG are detectable even in the acute phase and they rise dramatically over the proceeding two weeks. The kinetics of the IgM response is more variable. IgM levels are significantly lower in secondary dengue infections and thus some anti-dengue IgM false-negative reactions are observed during secondary infections.
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LABORATORY EXAMINATION
Complete Blood Count (CBC) Metabolic panel and liver enzyme Coagulation examination Virus isolation

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COMPLETE BLOOD COUNT

Leukopenia Lymphocytosis, with atypical lymphocytes A hematocrit level increase greater than 20% is a sign of hemoconcentration and precedes shock Thrombocytopenia has been demonstrated in up to 50% of dengue fever cases Platelet counts less than 100,000 cells/L are seen in dengue hemorrhagic fever or dengue shock syndrome
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METABOLIC ENZYME & LIVER ENZYME

Hyponatremia is the most common electrolyte abnormality in patients with dengue hemorrhagic fever or dengue shock syndrome Metabolic acidosis is observed in those with shock and must be corrected rapidly Elevated blood urea nitrogen (BUN) levels are observed in those with shock Transaminase levels may be mildly elevated Low albumin levels are a sign of hemoconcentration.
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COAGULATION EXAMINATION
Prothrombin time is prolonged Activated partial thromboplastin time is prolonged Low fibrinogen and elevated fibrin degradation product levels are signs of disseminated intravascular coagulation

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SPECIFICATIONS FOR AN IDEAL DENGUE TEST

EARLY DIAGNOSIS Distinguishes between dengue and other diseases with similar clinical presentations (such as malaria, leptospirosis, typhoid, typhus and Chikungunya) Highly sensitive during the acute stage of infection Provides rapid results Inexpensive Easy to use Stable at temperatures greater than 30C for field use, if necessary
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SPECIFICATIONS FOR AN IDEAL DENGUE TEST Tests to achieve secondary endpoints Distinguishes between dengue and other flaviviruses Distinguishes between dengue serotypes Distinguishes between first and subsequent infections Correlates of protection Provides a marker of severe disease Easy to use
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SPECIFICATIONS FOR AN IDEAL DENGUE TEST

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SPECIFICATIONS FOR AN IDEAL DENGUE TEST

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Diagnostic tests

Advantages
Confirmed infection Specific Identifies serotypes

Limitations
Requires acute sample (05 days post onset) Requires expertise and appropriate facilities Takes more than 1 week Does not differentiate between primary and secondary infection Expensive Potential false-positives owing to contamination Requires acute sample (05 days post onset) Requires expertise and expensive laboratory equipment Does not differentiate between primary and secondary infection

Viral isolation and identification

RNA detection

Confirmed infection Sensitive and specific Identifies serotype and genotype Results in 2448 hours

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Diagnostic tests
Antigen detection

Advantages

Limitations

Confirmed infection Clinical specimens (for Easy to perform example, using blood in Less expensive than virus an NS1 assay) isolation or RNA detection

Not as sensitive as virus isolation or RNA detection

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Diagnostic tests
Serological tests

Advantages

Limitations
IgM levels can be low in secondary infections Confirmation requires two or more serum samples Can differentiate between primary and secondary infection*

IgM or IgG seroconversion

Confirmed infection Least expensive Easy to perform

IgM detection (single sample)

*Primary

Identifies probable dengue cases IgM levels can be low in secondary Useful for surveillance, tracking infections outbreaks and monitoring effectiveness of interventions

infection: IgM-positive and IgG-negative (if samples are taken before day 810); secondary infection: IgG should be higher than 1,280 haemagglutination inhibition in convalescent serum.
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VIRUS ISOLATION
Dengue can be diagnosed by isolation of the virus, by serological tests, or by molecular methods Seroconversion negative to positive IgM antibody to dengue or 4x IgG antibody titers in paired (acute and convalescent) serum specimens
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VIRUS ISOLATION
Pan American Health Organization (PAHO) 80% of all dengue cases have detectable IgM antibody by day five of illness, and 93-99% of cases have detectable IgM by day six to ten of illness, which may then remain detectable for over 90 days Commercial lateral flow immunochromatographic tests for NS1 detection (BIOEASY, BIORAD and PANBIO) showed high sensitivity (94%, 91% and 81%, respectively) for dengue diagnosis
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Development of ASSURE dengue IgA rapid test for the detection of anti-dengue IgA from dengue infected patients Journal of Global Infect Dis; vol 3, 2011; p.233-240

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Evaluation of Commercially Available Anti-Dengue Virus Immunoglobulin M Tests

Emerging Infectious Diseases. 2009;15(3):436-440.

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VIRUS ISOLATION
PCR
DENV can be detected in the blood (serum) the first 5 days of symptoms RTPCR has become a primary tool to detect virus early in the course of illness 80-90% sensitive, and > 95% specific A positive PCR result definite proof of current infection and it usually confirms the infecting serotype as well Patients receiving negative results before 5 days of illness asked to submit a second serum sample for serological confirmation after the 5th day of illness

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VIRUS ISOLATION
MAC ELISA
IgM antibody capture ELISA (MAC-ELISA) format is most commonly employed in diagnostic laboratories and commercial available diagnostic kits The assay capturing human IgM Ab on a microtiter plate using antihuman-IgM Ab addition of dengue virus specific antigen (DENV1-4) The antigens derived from the envelope protein of the virus One of the limitation of this testing is the cross reactivity between other circulating flaviviruses. IgM detection is not useful for dengue serotype determination due to cross-reactivity of the antibody

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DATA PASIEN
Jumlah pasien 25/11/2013 27/1/2014 : 23 Pasien Trombosit : 9 pasien NS1 positif : 6 pasien (trombosit normal) IgM positif : 3 pasien IgG positif : 1 pasien

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