ABSTRACT
BACKGROUND: The intensity of dengue virus (DV) replication and circulating non-structural protein 1 (NS1) levels may promote changes in the human immune response and favor severe forms of infection. We investigated the correlations between NS1 with CXCL-8, CXCL-10, IFN-γ, and IL-12p40 serum levels, and IFN-γ receptor α chain (CD119) expression, and CXCL10 production by peripheral blood mononuclear cells (PBMCs) stimulated with recombinant IFN-γ in DV-infected patients with different clinical forms. METHODS: Dengue virus NS1, CXCL-8, CXCL-10, IFN-γ, and IL-12p40 serum levels were measured in 152 DV-infected patients with different clinical forms and 20 non-infected individuals (NI) using enzyme-linked immunosorbent assay (ELISA). In addition, we investigated the CXCL-10 production after in vitro IFN-γ stimulation of PBMCs from 48 DV-infected individuals (with different clinical forms of dengue fever) and 20 NI individuals using ELISA, and CD119 expression on CD14+ cells with flow cytometry. RESULTS: Patients with dengue hemorrhagic fever (DHF) had significantly higher NS1, CXCL-8, and CXCL-10 serum levels than those with classic dengue fever (DF). The response of PBMCs to IFN-γ stimulation was lower in patients with DHF than in those with DF or dengue with complications (DWC), with lower CD119 expression and reduced CXCL-10 synthesis. In addition, these alterations are associated with high NS1 serum levels. CONCLUSIONS: Patients with DHF reported high NS1 levels, low CD119 expression, and low CXCL-10 synthesis in PBMCs, which may be associated with infection progression and severity.
Subject(s)
Chemokine CXCL10 , Enzyme-Linked Immunosorbent Assay , Severe Dengue , Viral Nonstructural Proteins , Humans , Chemokine CXCL10/blood , Male , Severe Dengue/blood , Severe Dengue/immunology , Female , Adult , Middle Aged , Leukocytes, Mononuclear/metabolism , Case-Control Studies , Young Adult , Interferon-gamma/blood , Adolescent , Flow CytometryABSTRACT
Dengue is a significant health problem due to the high burden of critical infections during outbreaks. In 1997, the World Health Organization (WHO) classified dengue as dengue fever (DF), dengue hemorrhagic fever (DHF), and dengue shock syndrome (DSS). It was revised in 2009 (updated in 2015), and the new guidelines recommended classifying patients as dengue without warning signs (DNS), dengue with warning signs (DWS), and severe dengue (SD). Although the utility of the revised 2009 classification for clinical studies is accepted, for immunological studies it needs to be clarified. We determined the usefulness of the 2009 classification for pediatric studies that analyze the circulating interleukin (IL)-6 and IL-8, two inflammatory cytokines. Plasma levels of IL-6 and IL-8 were evaluated in the acute and convalescent phases by flow cytometry in children with dengue classified using the 1997 and 2009 WHO guidelines. The plasma levels of IL-6 and IL-8 were elevated during the acute and decreased during convalescence, and both cytokines served as a good marker of acute dengue illness compared to convalescence. There were no differences in the plasma level of the evaluated cytokines among children with different clinical severity with any classification, except for the IL-8, which was higher in DWS than DNS. Based on the levels of IL-8, the 2009 classification identified DWS plus SD (hospital-treated children) compared to the DNS group [area under the curve (AUC): 0.7, p = 0.028]. These results support the utility of the revised 2009 (updated in 2015) classification in studies of immune markers in pediatric dengue.
Subject(s)
Dengue , Interleukin-6 , Interleukin-8 , World Health Organization , Humans , Dengue/immunology , Dengue/diagnosis , Child , Male , Female , Interleukin-6/blood , Child, Preschool , Interleukin-8/blood , Severe Dengue/diagnosis , Severe Dengue/immunology , Severe Dengue/blood , Adolescent , Severity of Illness Index , Biomarkers/blood , Dengue Virus/immunology , Practice Guidelines as Topic , Flow Cytometry , Infant , Cytokines/bloodABSTRACT
Recent studies have demonstrated that cytokine dysregulation has a critical role in the pathogenesis of dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). The aim of this study was to investigate the association between tumor necrosis factor (TNF- α), interleukin 6 (IL-6), interleukin 10 (IL-10), and interleukin 17 (IL-17) with infection status, and severity of dengue. A prospective cross-sectional study was conducted at three hospitals in Gianyar regency and Denpasar municipality, Bali, Indonesia, from June to December 2022. Sixty-four dengue infected patients were involved. Patients' serum was tested for dengue infection using NS1 antigen rapid test, dengue virus immunoglobulin M (IgM) and immunoglobulin G (IgG) test, and reverse transcription polymerase chain reaction (RT-PCR). Cytokine levels (TNF-α, IL-6, IL-10, and IL-17) were measured using enzyme-linked immunosorbent assay (ELISA). Infection status was determined by combining serological and RT-PCR results, categorizing patients into primary and secondary infections. The present study found that DF patients had lower TNF-α, IL-6, and IL-17 but higher IL-10 levels compared to DHF patients (p<0.001). Elevated TNF-α, IL-6, and IL-17 levels were higher in secondary infection, while IL-10 level was higher in primary infection (p<0.001). In conclusion, cytokines play a crucial role in the interplay between cytokine dysregulation and dengue infection dynamics.
Subject(s)
Cytokines , Dengue , Severe Dengue , Humans , Indonesia/epidemiology , Severe Dengue/blood , Severe Dengue/immunology , Severe Dengue/epidemiology , Male , Female , Cytokines/blood , Cross-Sectional Studies , Prospective Studies , Adult , Dengue/blood , Dengue/immunology , Dengue/epidemiology , Middle Aged , Interleukin-6/blood , Enzyme-Linked Immunosorbent Assay , Adolescent , Interleukin-10/blood , Tumor Necrosis Factor-alpha/blood , Young AdultABSTRACT
This study aimed to assess the clinical utility of blood lactate-to-bicarbonate (L/B) ratio, as a prognostic factor for 28-day in-hospital mortality in children with dengue shock syndrome (DSS), admitted to the pediatric intensive care unit (PICU). This single-center retrospective study was conducted at a tertiary children hospital in southern Vietnam from 2013 to mid-2022. Prognostic models for DSS mortality were developed, using a predefined set of covariates in the first 24 hours of PICU admission. Area under the curves (AUCs), multivariable logistic and Least Absolute Shrinkage and Selection Operator (LASSO) regressions, bootstrapping and calibration slope were performed. A total of 492 children with DSS and complete clinical and biomarker data were included in the analysis, and 26 (5.3%) patients died. The predictive values for DSS mortality, regarding lactate showing AUC 0.876 (95% CI, 0.807-0.944), and that of L/B ratio 0.867 (95% CI, 0.80-0.934) (P values of both biomarkersâ <â .001). The optimal cutoff point of the L/B ratio was 0.25, while that of lactate was 4.2 mmol/L. The multivariable model showed significant clinical predictors of DSS fatality including severe bleeding, cumulative amount of fluid infused and vasoactive-inotropic score (>30) in the first 24 hours of PICU admission. Combined with the identified clinical predictors, the L/B ratio yielded higher prognostic values (odds ratio [OR]â =â 8.66, 95% confidence interval [CI], 1.96-38.3; Pâ <â .01) than the lactate-based model (ORâ =â 1.35, 95% CI, 1.15-1.58; Pâ <â .001). Both the L/B and lactate models showed similarly good performances. Considering that the L/B ratio has a better prognostic value than the lactate model, it may be considered a potential prognostic biomarker in clinical use for predicting 28-day mortality in PICU-admitted children with DSS.
Subject(s)
Bicarbonates , Biomarkers , Hospital Mortality , Intensive Care Units, Pediatric , Lactic Acid , Severe Dengue , Humans , Male , Female , Retrospective Studies , Prognosis , Lactic Acid/blood , Severe Dengue/blood , Severe Dengue/mortality , Severe Dengue/diagnosis , Child , Child, Preschool , Biomarkers/blood , Bicarbonates/blood , Intensive Care Units, Pediatric/statistics & numerical data , Vietnam/epidemiology , Predictive Value of Tests , Infant , Area Under CurveABSTRACT
Background: There is a clinical imperative to devise metrics to prognosticate dengue severity. Our objective was to determine the association between longitudinal trends in atypical lymphocytes and large immature cell count with platelet count and dengue severity. Materials and methods: Retrospective analysis of longitudinally measured clinical and hematological data from (n = 79) hospitalized dengue patients was done. Results: The cohort consisted of patients with dengue fever without warning signs (DFWOWS) (n = 40, females = 14, and age = 19.9 ± 14.6 years), dengue fever with warning signs (DFWWS) (n = 36, females = 13, and age = 16.1 ± 14.1 years) and severe dengue (n = 3, females = 2, and age = 5.3 ± 4 years). Platelet count increased at a rate of 11,524 cells/mm3/day, with a slower rate of rise as the severity increased (p = 0.001***). Concurrently hematocrit and neutrophil percentage decreased, while the lymphocyte percentage and white blood cell (WBC) count increased during the hospital stay. Every 1% increase in atypical lymphocyte count (ATY) was associated with a fall in platelet count by 16,963 cells/mm3 (p = 0.001***). A similar but weaker trend was found for large immature cells (LICs). Conclusion: The data support the usefulness of longitudinal tracking of atypical lymphocyte and large immature cell count for dengue prognosis. The time trends of the hematological parameters indicate the progression of patients from the critical to the recovery phase. How to cite this article: Peraka R, Koppula A, Muppala BS, et al. Utility of Atypical Lymphocytes and Large Immature Cells in Prediction of Dengue Severity. J Assoc Physicians India 2023;71(11):19-24.
Subject(s)
Dengue , Lymphocytes , Severity of Illness Index , Humans , Male , Retrospective Studies , Female , Dengue/diagnosis , Dengue/blood , Platelet Count , Young Adult , Adolescent , Adult , Lymphocyte Count , Child , Prognosis , Severe Dengue/blood , Severe Dengue/diagnosis , Child, Preschool , Leukocyte CountABSTRACT
According to the WHO 2009 classification, dengue with warning signs is at the risk of developing severe form of dengue disease. One of the most important warning signs is plasma leakage, which can be a serious complication associated with higher morbidity and mortality. We report that the frequency of CD4+CD8+ double-positive (DP) T cells is significantly increased in patients at risk of developing plasma leakage. Transcriptomic analysis demonstrated that CD4+CD8+ DP cells were distinct from CD4+ Single Positive (SP) T cells but co-clustered with CD8+ SP cells, indicating a largely similar transcriptional profile. Twenty significant differentially expressed (DE) genes were identified between CD4+CD8+ DP and CD8+ SP cells. These genes encode OX40 and CCR4 proteins as well as other molecules associated with cell signaling on the cell surface (NT5E, MXRA8, and PTPRK). While comparing the profile of gene expression in CD4+CD8+ DP cells from patients with and without warning signs of plasma leakage, similar expression profile was observed, implying a role of CD4+CD8+ DP cells in plasma leakage through a quantitative increase rather than functional alteration. This study provided novel insight into the host immune response during the acute febrile phase of DENV infection and the role of CD4+CD8+ DP T cells in the pathogenesis of plasma leakage.
Subject(s)
Dengue/blood , Dengue/immunology , T-Lymphocyte Subsets/metabolism , Adult , CD4-Positive T-Lymphocytes/immunology , CD4-Positive T-Lymphocytes/metabolism , CD8-Positive T-Lymphocytes/immunology , CD8-Positive T-Lymphocytes/metabolism , Female , Humans , Lymphocyte Count , Male , Plasma , Severe Dengue/blood , Severe Dengue/immunology , T-Lymphocyte Subsets/immunology , Transcriptome , Young AdultABSTRACT
BACKGROUND: Dengue usually progress abnormally, especially in the critical phase. The main causes of death were shock, severe bleeding and organ failure. The aim of our study was to evaluate prognostic indicators of severe dengue according to the phases of the disease progression. METHODS: A cross-sectional study was conducted from July to December 2017 at the National Hospital for Tropical Diseases and the Hospital for Tropical Diseases of Ho Chi Minh City. 326 patients, aged 6 years and over, including 99/326 patients with severe dengue and 227/326 patients with non-severe dengue, hospitalized in the first 3 days of illness, confirmed Dengue virus by the RT-PCR assay have been registered for the study. Clinical manifestations were monitored daily. The hematocrit, white blood cells, platelet, serum albumin, ALT, AST, bilirubin, prothrombin time (PT%, PTs), fibrinogen, aPTT, INR and creatinine were evaluated at two times: febrile phase and critical phase. RESULTS: Independent factors associated with severe dengue were identified on multivariate logistic regression models. During the first 3 days of the disease, the prognostic indicators were platelet count ≤ 100 G/L (OR = 2.2; 95%CI: 1.2-3.9), or serum albumin < 35 g/L (OR = 3.3; 95%CI: 1.8-6.1). From day 4-6, the indicator were AST > 400 U/L (OR = 3.0; 95%CI: 1.1-7.9), ALT > 400 U/L (OR = 6.6; 95%CI: 1.7-24.6), albumin < 35 g/L (OR = 3.0; 95%CI: 1.5-5.9), and bilirubin total >17 µmol/L (OR = 4.6; 95%CI: 2.0-10.4). CONCLUSION: To predict the risk of patients with severe dengue, prognostic laboratory indicators should be indicated consistent with the progression of the disease. During the first 3 days of illness, prognostic indicators should be platelet count, or serum albumin. From the 4th - 6th day of illness, prognostic indicators should be AST, ALT, albumin, or bilirubin total.
Subject(s)
Dengue Virus/genetics , RNA, Viral/genetics , Serum Albumin/analysis , Severe Dengue/diagnosis , Adolescent , Adult , Aged , Aged, 80 and over , Child , Cross-Sectional Studies , Disease Progression , Female , Hospitalization , Humans , Leukocyte Count , Male , Middle Aged , Platelet Count , Prognosis , Severe Dengue/blood , Severe Dengue/mortality , Thrombin Time , Vietnam , Young AdultABSTRACT
BACKGROUND: Increased levels of inflammatory cytokines are associated with severe dengue evolution, but the source of such hypercytokinemia is elusive. We investigated the contribution of innate lymphocytes, innate lymphoid cells (ILCs), and natural killer (NK) cells in cytokine production in early dengue infection. METHODS: Peripheral blood mononuclear cells of individuals with dengue without warning signs (DWS-) and dengue with warning signs and severe dengue (SD) presentation combined (DWS+) were obtained between 2 and 7 days since fever onset and submitted to flow cytometry without specific antigen stimulation to evaluate cytokines in ILC and NK cell subpopulations. RESULTS: ILCs and NK cells were found to be important sources of cytokines during dengue. ILCs of the DWS+/SD group displayed higher production of interferon gamma (IFN-γ) and interleukin (IL) 4/IL-13 when compared to DWS- individuals. On the other hand, NK Eomes+ cells of DWS- patients displayed higher IFN-γ production levels compared with the DWS+/SD group. Interestingly, when NK cells were identified by CD56 expression, DWS+/SD displayed higher frequency of IL-17 production compared with the DWS- group. CONCLUSIONS: These results indicate that ILCs and NK cells are important sources of inflammatory cytokines during acute dengue infection and display distinct profiles associated with different clinical forms.
Subject(s)
Cytokines/metabolism , Interferon-gamma , Killer Cells, Natural/immunology , Lymphocyte Subsets/immunology , Severe Dengue , Cytokines/immunology , Humans , Immunity, Innate , Leukocytes, Mononuclear , Lymphocyte Subsets/metabolism , Lymphocytes , Severe Dengue/blood , Severe Dengue/immunologyABSTRACT
BACKGROUND: Healthcare systems in dengue-endemic countries are often overburdened due to the high number of patients hospitalized according to dengue management guidelines. We systematically evaluated clinical outcomes in a large cohort of patients hospitalized with acute dengue to support triaging of patients to ambulatory versus inpatient management in the future. METHODS/PRINCIPAL FINDINGS: From June 2017- December 2018, we conducted surveillance among children and adults with fever within the prior 7 days who were hospitalized at the largest tertiary-care (1,800 bed) hospital in the Southern Province, Sri Lanka. Patients who developed platelet count ≤100,000/µL (threshold for hospital admission in Sri Lanka) and who met at least two clinical criteria consistent with dengue were eligible for enrollment. We confirmed acute dengue by testing sera collected at enrollment for dengue NS1 antigen or IgM antibodies. We defined primary outcomes as per the 1997 and 2009 World Health Organization (WHO) classification criteria: dengue hemorrhagic fever (DHF; WHO 1997), dengue shock syndrome (DSS; WHO 1997), and severe dengue (WHO 2009). Overall, 1064 patients were confirmed as having acute dengue: 318 (17.4%) by NS1 rapid antigen testing and 746 (40.7%) by IgM antibody testing. Of these 1064 patients, 994 (93.4%) were adults ≥18 years and 704 (66.2%) were male. The majority (56, 80%) of children and more than half of adults (544, 54.7%) developed DHF during hospitalization, while 6 (8.6%) children and 22 (2.2%) adults developed DSS. Overall, 10 (14.3%) children and 113 (11.4%) adults developed severe dengue. A total of 2 (0.2%) patients died during hospitalization. CONCLUSIONS: One-half of patients hospitalized with acute dengue progressed to develop DHF and a very small number developed DSS or severe dengue. Developing an algorithm for triaging patients to ambulatory versus inpatient management should be the future goal to optimize utilization of healthcare resources in dengue-endemic countries.
Subject(s)
Severe Dengue/epidemiology , Severe Dengue/therapy , Adolescent , Adult , Antibodies, Viral/blood , Case Management , Child , Cohort Studies , Cost of Illness , Dengue Virus/genetics , Dengue Virus/immunology , Dengue Virus/isolation & purification , Female , Hospitalization , Humans , Male , Outpatients/statistics & numerical data , Platelet Count , Severe Dengue/blood , Severe Dengue/virology , Sri Lanka/epidemiology , Tertiary Healthcare/statistics & numerical data , Treatment Outcome , Young AdultABSTRACT
Background. Dengue virus (DENV) infection is the most common arboviral disease that affects tropical and subtropical regions. Based on the clinical hallmarks, the different severities of patients range from mild dengue fever (MDF) to severe dengue diseases (SDDs) and include dengue hemorrhagic fever or dengue shock syndrome. These are commonly associated with cytokine release syndrome (CRS). The types and levels of cytokines/chemokines, which are suppressed or enhanced, are varied, indicating CRS's pathogenic and host defensive effects. Principal Finding. In this study, we created an integrated and precise multiplex panel of cytokine/chemokine assays based on our literature analysis to monitor dengue CRS. A 24-plex panel of cytokines/chemokines was evaluated to measure the plasma levels of targeting factors in dengue patients with an MDF and SDD diagnosis without or with comorbidities. As identified in sixteen kinds of cytokines/chemokines, ten were significantly (P < 0.05) (10/16) increased, one was significantly (P < 0.01) (1/16) decreased, and five were potentially (5/16) altered in all dengue patients (n = 30) in the acute phase of disease onset. Compared to MDF, the levels of IL-8 (CXCL-8) and IL-18 in SDD were markedly (P < 0.05) increased, accompanied by positively increased IL-6 and TNF-α and decreased IFN-γ and RANTES. With comorbidities, SDD significantly (P < 0.01) portrayed elevated IL-18 accompanied by increased IL-6 and decreased IFN-α2 and IL-12. In addition, decreased platelets were significantly (P < 0.05) associated with increased IL-18. Significance. These results demonstrate an efficient panel of dengue cytokine/chemokine assays used to explore the possible level of CRS during the acute phase of disease onset; also, we are the first to report the increase of IL-18 in severe dengue with comorbidity compared to severe dengue without comorbidity and mild dengue.
Subject(s)
Interleukin-18/blood , Severe Dengue/diagnosis , Adult , Aged , Aged, 80 and over , Biomarkers/blood , Dengue Virus/immunology , Disease Progression , Female , Humans , Interleukin-18/immunology , Male , Middle Aged , Severe Dengue/blood , Severe Dengue/immunology , Severe Dengue/virology , Young AdultABSTRACT
BACKGROUND: Predictive markers represent a solution for the proactive management of severe dengue. Despite the low mortality rate resulting from severe cases, dengue requires constant examination and round-the-clock nursing care due to the unpredictable progression of complications, posing a burden on clinical triage and material resources. Accordingly, identifying markers that allow for predicting disease prognosis from the initial diagnosis is needed. Given the improved pathogenesis understanding, myriad candidates have been proposed to be associated with severe dengue progression. Thus, we aim to review the relationship between the available biomarkers and severe dengue. METHODOLOGY: We performed a systematic review and meta-analysis to compare the differences in host data collected within 72 hours of fever onset amongst the different disease severity levels. We searched nine bibliographic databases without restrictive criteria of language and publication date. We assessed risk of bias and graded robustness of evidence using NHLBI quality assessments and GRADE, respectively. This study protocol is registered in PROSPERO (CRD42018104495). PRINCIPAL FINDINGS: Of 4000 records found, 40 studies for qualitative synthesis, 19 for meta-analysis. We identified 108 host and viral markers collected within 72 hours of fever onset from 6160 laboratory-confirmed dengue cases, including hematopoietic parameters, biochemical substances, clinical symptoms, immune mediators, viral particles, and host genes. Overall, inconsistent case classifications explained substantial heterogeneity, and meta-analyses lacked statistical power. Still, moderate-certainty evidence indicated significantly lower platelet counts (SMD -0.65, 95% CI -0.97 to -0.32) and higher AST levels (SMD 0.87, 95% CI 0.36 to 1.38) in severe cases when compared to non-severe dengue during this time window. CONCLUSION: The findings suggest that alterations of platelet count and AST level-in the first 72 hours of fever onset-are independent markers predicting the development of severe dengue.
Subject(s)
Biomarkers/blood , Severe Dengue/blood , Severe Dengue/mortality , Adolescent , Adult , Aged , Aged, 80 and over , Aspartate Aminotransferases/blood , Child , Child, Preschool , Female , Humans , Infant , Male , Middle Aged , Platelet Count , Prognosis , Severe Dengue/diagnosis , Young AdultABSTRACT
Dengue shock syndrome (DSS) is a potentially critical and life-threatening concern, especially in children of tropical countries. The serum cortisol levels in severe DSS or later stages of DSS are limited references. We prospectively studied an association between of serum cortisol as well as interleukin levels and the severity of DSS in pediatric patients. A prospective cross-sectional study of 35 consecutive DSS cases (3 months to 16 years old) admitted to our institution from July 1, 2019, to June 30, 2020 was conducted. Serum cortisol, IL-6, and IL-10 were measured at T0 (shock recognition) and T12 (12 hours after T0); their values were presented as median and interquartile ranges (25%-75%). Severe DSS included patients with impalpable pulses or systolic blood pressure < 70 mmHg, recurrent shock, and prolonged shock. In contrast, non-severe DSS presented circulatory failure without any features of severe DSS. A total of 8 (22.8%) severe DSS patients expressed the cortisol (T0) significantly lower compared to the non-severe DSS group (7.3 µg/dl versus 14.3 µg/dl, p=0.008). In severe DSS, there was a minimal change in cortisol levels between T0 and T12 (7.3 µg/dl and 4.7 µg/dl p>0.05), whereas the decrease is significant in their counterparts (14.3 µg/dl to 5.6 µg/dl, p<0.005). Additionally, there were moderate correlations between IL-6 (T0), IL-10 (T0), IL-10 (T12) and total fluid requirement (Spearman's rho = 0.47, 0.4, and 0.36, respectively; p<0.05). Our study demonstrated that adrenal dysfunction was present in patients with severe and non-severe DSS, as noted by cortisol level at T12. In addition, IL-6 and IL-10 levels are correlated with the total fluid requirement, which is a marker of DSS severity. Further studies could reveal how adrenal dysfunction in pediatric patients with DSS can affect outcomes and the potential roles of interleukin levels in fluid management strategy.
Subject(s)
Hydrocortisone/blood , Severe Dengue , Shock , Child , Cross-Sectional Studies , Humans , Interleukin-10/blood , Interleukin-6/blood , Prospective Studies , Severe Dengue/blood , Severe Dengue/diagnosis , Shock/virologyABSTRACT
Transcriptomics, proteomics and pathogen-host interactomics data are being explored for the in silico-informed selection of drugs, prior to their functional evaluation. The effectiveness of this kind of strategy has been put to the test in the current COVID-19 pandemic, and it has been paying off, leading to a few drugs being rapidly repurposed as treatment against SARS-CoV-2 infection. Several neglected tropical diseases, for which treatment remains unavailable, would benefit from informed in silico investigations of drugs, as performed in this work for Dengue fever disease. We analyzed transcriptomic data in the key tissues of liver, spleen and blood profiles and verified that despite transcriptomic differences due to tissue specialization, the common mechanisms of action, "Adrenergic receptor antagonist", "ATPase inhibitor", "NF-kB pathway inhibitor" and "Serotonin receptor antagonist", were identified as druggable (e.g., oxprenolol, digoxin, auranofin and palonosetron, respectively) to oppose the effects of severe Dengue infection in these tissues. These are good candidates for future functional evaluation and clinical trials.
Subject(s)
Antiviral Agents/therapeutic use , Dengue/drug therapy , Transcriptome , Adenosine Triphosphatases/antagonists & inhibitors , Adrenergic Antagonists/pharmacology , Adrenergic Antagonists/therapeutic use , Antiviral Agents/pharmacology , Brain/metabolism , Computer Simulation , Dengue/blood , Dengue/genetics , Dengue/metabolism , Drug Discovery , Drug Evaluation, Preclinical , Drug Repositioning , Humans , Liver/metabolism , Metabolic Networks and Pathways/drug effects , NF-kappa B/metabolism , Serotonin Antagonists/pharmacology , Serotonin Antagonists/therapeutic use , Severe Dengue/blood , Severe Dengue/drug therapy , Severe Dengue/genetics , Severe Dengue/metabolism , Spleen/metabolismABSTRACT
We conducted a prospective, observational study to assess the serum chymase level, a mast cell derived protease, as a predictor of dengue severity. NS1-positive non-severe dengue patients of age ≥14 years with duration of fever ≤4 days were included in the study. At the time of admission, the serum sample was taken for chymase estimation. Patients were followed up to four days after they became afebrile to find out the final diagnosis. Total of 338 non-severe dengue patients were recruited (mean age: 29.15 years; male: 66%). On follow-up, 26 patients (7.8%) developed severe dengue. Only chymase level (adjusted odds ratio [aOR]: 1.787; 95% confidence interval [CI]: 1.309-2.440) and platelet count at admission (aOR: 0.981; 95% CI: 0.968-0.993) were able to predict the severity after adjustment for all variables. But, for prediction of severe dengue, the area under receiver's operating curve of chymase was 0.835 (95% CI: 0.765-0.905), which was significantly higher than that of the platelet count at admission (0.760, 95% CI: 0.650-0.870) (p < .001). Patients who developed severe dengue in due course of illness had significantly higher serum chymase level at admission as compared with the rest of the patients. Similar findings were noted across all age-groups. At an optimum cut-off value of 1.35 ng/ml, chymase had a positive likelihood ratio (LR) of 3.5 and a negative LR of 0.15, for predicting severe dengue. This study demonstrated the potential ability of serum chymase levels at admission, as a biomarker for prediction of severe dengue in due course of illness.
Subject(s)
Chymases/blood , Severe Dengue/diagnosis , Severe Dengue/epidemiology , Severity of Illness Index , Adolescent , Adult , Biomarkers/blood , Chymases/genetics , Dengue Virus , Female , Fever , Hospitalization , Humans , Male , Odds Ratio , Prospective Studies , Severe Dengue/blood , Tertiary Care Centers/statistics & numerical data , Young AdultABSTRACT
The complement system may be crucial during dengue virus infection and progression to severe dengue. This study investigates the role of MBL2 genetic variants and levels of MBL in serum and complement proteins in Vietnamese dengue patients. MBL2 genotypes (- 550L/H, MBL2 codon 54), MBL2 diplotypes (XA/XO, YA/XO) and MBL2 haplotypes (LXPB, HXPA, XO) were associated with dengue in the study population. The levels of complement factors C2, C5, and C5a were higher in dengue and dengue with warning signs (DWS) patients compared to those in healthy controls, while factor D levels were decreased in dengue and DWS patients compared to the levels determined in healthy controls. C2 and C5a levels were associated with the levels of AST and ALT and with WBC counts. C9 levels were negatively correlated with ALT levels and WBC counts, and factor D levels were associated with AST and ALT levels and with platelet counts. In conclusions, MBL2 polymorphisms are associated with dengue in the Vietnamese study population. The levels of the complement proteins C2, C4b, C5, C5a, C9, factor D and factor I are modulated in dengue patients during the clinical course of dengue.
Subject(s)
Biomarkers/analysis , Dengue Virus/isolation & purification , Immunologic Factors/blood , Mannose-Binding Lectin/blood , Mannose-Binding Lectin/genetics , Polymorphism, Genetic , Severe Dengue/epidemiology , Adolescent , Adult , Aged , Aged, 80 and over , Complement C2/analysis , Complement C5/analysis , Complement C5a/analysis , Disease Progression , Female , Follow-Up Studies , Gene Expression Regulation , Genotype , Haplotypes , Humans , Male , Middle Aged , Prognosis , Severe Dengue/blood , Severe Dengue/genetics , Severe Dengue/virology , Severity of Illness Index , Vietnam/epidemiology , Young AdultABSTRACT
Severe dengue can be lethal caused by manifestations such as severe bleeding, fluid accumulation and organ impairment. This study aimed to investigate the role of dengue non-structural 1 (NS1) protein and host factors contributing to severe dengue. Electrical cell-substrate impedance sensing system was used to investigate the changes in barrier function of microvascular endothelial cells treated NS1 protein and serum samples from patients with different disease severity. Cytokines and metabolites profiles were assessed using a multiplex cytokine assay and liquid chromatography mass spectrometry respectively. The findings showed that NS1 was able to induce the loss of barrier function in microvascular endothelium in a dose dependent manner, however, the level of NS1 in serum samples did not correlate with the extent of vascular leakage induced. Further assessment of host factors revealed that cytokines such as CCL2, CCL5, CCL20 and CXCL1, as well as adhesion molecule ICAM-1, that are involved in leukocytes infiltration were expressed higher in dengue patients in comparison to healthy individuals. In addition, metabolomics study revealed the presence of deregulated metabolites involved in the phospholipid metabolism pathway in patients with severe manifestations. In conclusion, disease severity in dengue virus infection did not correlate directly with NS1 level, but instead with host factors that are involved in the regulation of junctional integrity and phospholipid metabolism. However, as the studied population was relatively small in this study, these exploratory findings should be confirmed by expanding the sample size using an independent cohort to further establish the significance of this study.
Subject(s)
Cytokines/blood , Dengue Virus/immunology , Host-Pathogen Interactions/immunology , Severe Dengue/blood , Viral Nonstructural Proteins/blood , Cell Line , Cytokines/immunology , Cytokines/metabolism , Dengue Virus/metabolism , Endothelial Cells/immunology , Endothelial Cells/metabolism , Endothelium, Vascular/cytology , Endothelium, Vascular/immunology , Endothelium, Vascular/pathology , Humans , Phospholipids/metabolism , Primary Cell Culture , Severe Dengue/immunology , Severe Dengue/metabolism , Severe Dengue/pathology , Viral Nonstructural Proteins/immunologyABSTRACT
Dengue induces a spectrum of severity in humans from the milder dengue fever to severe disease, or dengue hemorrhagic fever (DHF). Chymase is a candidate biomarker that may aid dengue prognosis. This prospective study aimed to identify whether warning signs of severe dengue, including hypovolemia and fluid accumulation, were associated with elevated chymase. Serum chymase levels were quantified prospectively and longitudinally in hospitalized pediatric dengue patients in Sri Lanka. Warning signs were determined based on daily clinical assessments, laboratory tests and ultrasound findings. Chymase was significantly elevated during the acute phase of disease in DHF or Severe dengue, defined by either the 1997 or 2009 WHO diagnosis guidelines, and persisted longer in the most severe patients. Chymase levels were higher in patients with narrow pulse pressure and clinical warning signs such as severe leakage, fluid accumulation, pleural effusion, gall-bladder wall thickening and rapid haematocrit rise concurrent with thrombocytopenia. No association between chymase and liver enlargement was observed. This study confirms that serum chymase levels are associated with DHF/Severe dengue disease in hospitalized pediatric patients. Chymase levels correlate with warning signs of vascular dysfunction highlighting the possible functional role of chymase in vascular leakage during dengue.
Subject(s)
Chymases/blood , Dengue Virus/pathogenicity , Hypovolemia/diagnosis , Pleural Effusion/diagnosis , RNA, Viral/blood , Severe Dengue/diagnosis , Thrombocytopenia/diagnosis , Biomarkers/blood , Child , Child, Preschool , Dengue Virus/genetics , Dengue Virus/isolation & purification , Female , Hospitalization , Humans , Hypovolemia/blood , Hypovolemia/pathology , Hypovolemia/virology , Longitudinal Studies , Male , Pleural Effusion/blood , Pleural Effusion/pathology , Pleural Effusion/virology , Prognosis , Prospective Studies , Severe Dengue/blood , Severe Dengue/pathology , Severe Dengue/virology , Severity of Illness Index , Sri Lanka , Thrombocytopenia/blood , Thrombocytopenia/pathology , Thrombocytopenia/virology , Viral LoadABSTRACT
Only a minority of dengue infections lead to plasma leakage (critical phase [CP]). Early identification of the risk for CP is helpful for triage of patients. This study aimed to identify early clinical predictors of CP that will aid in patient triage during early illness. A retrospective, case-record-based analysis was performed on all microbiologically confirmed (NS1-antigen- or dengue-IgM-antibody-positive), dengue patients (n = 697), admitted to our unit from 01.01.2017 to 30.06.2017. Bivariate analysis was performed to identify clinical and laboratory parameters that predicted CP. Stepwise multivariate logistic regression with backward elimination (p < 0.05) was used to identify independent risk factors for CP. CP developed in 226 (32.4%) patients. Mortality was 1.0%. Predictors for CP (p < 0.05) within the first three days included age category 41-50 years (OR = 1.96), females (OR = 2.09), diabetes (OR = 1.30), persistent vomiting (OR = 2.18), platelet count < 120,000/mm-3 (OR = 1.91) and AST > 60 IU/L (OR = 3.72). On multivariate analysis, other variables except diabetes remained significant. Elevated transaminase levels remained the strongest independent predictor of CP (OR 2.83). The absence of all five risk factors excluded CP (negative predictive value: 97.2%). Age 41-50 years, female gender, persistent vomiting, thrombocytopenia, and elevated transaminases were early predictors of CP in dengue fever. The absence of these can be used to identify patients who may not require hospital admission. Elevated transaminase was the strongest predictor of CP during early illness.
Subject(s)
Dengue Virus/isolation & purification , Severe Dengue/virology , Adolescent , Adult , Aged , Dengue Virus/classification , Dengue Virus/genetics , Female , Humans , Male , Middle Aged , Platelet Count , Retrospective Studies , Severe Dengue/blood , Severe Dengue/diagnosis , Young AdultABSTRACT
Dengue virus infects several million people each year. Although usually a self-limiting disease, some patients can develop life-threatening severe complications, characterized by plasma leakage, hemorrhaging, and shock. The signs and symptoms of severe disease usually arise late in the disease course when patients are recovering and fever has subsided, making it difficult to predict. Efforts are underway to identify risk factors and biomarkers that can accurately predict disease severity in the acute febrile phase of the disease, facilitating early intervention and treatment strategies for those at greatest risk. In this review we discuss recent advancements in identifying risk factors and biomarkers for the prognosis of severe dengue.
Subject(s)
Dengue Virus/physiology , Severe Dengue/blood , Severe Dengue/virology , Animals , Biomarkers/blood , Dengue Virus/genetics , Humans , Prognosis , Risk Factors , Severe Dengue/diagnosis , Severe Dengue/epidemiology , Severity of Illness IndexABSTRACT
BACKGROUND: Dengue infection can cause a wide spectrum of clinical outcomes. The severe clinical manifestations occur sufficiently late in the disease course, during day 4-6 of illness, to allow a window of opportunity for risk stratification. Markers of inflammation may be useful biomarkers. We investigated the value of C-reactive protein (CRP) measured early on illness days 1-3 to predict dengue disease outcome and the difference in CRP levels between dengue and other febrile illnesses (OFI). METHOD: We performed a nested case-control study using the clinical data and samples collected from the IDAMS-consortium multi-country study. This was a prospective multi-center observational study that enrolled almost 8000 participants presenting with a dengue-like illness to outpatient facilities in 8 countries across Asia and Latin America. Predefined severity definitions of severe and intermediate dengue were used as the primary outcomes. A total of 281 cases with severe/intermediate dengue were compared to 836 uncomplicated dengue patients as controls (ratio 1:3), and also 394 patients with OFI. RESULTS: In patients with confirmed dengue, median (interquartile range) of CRP level within the first 3 days was 30.2 mg/L (12.4-61.2 mg/L) (uncomplicated dengue, 28.6 (10.5-58.9); severe or intermediate dengue, 34.0 (17.4-71.8)). Higher CRP levels in the first 3 days of illness were associated with a higher risk of severe or intermediate outcome (OR 1.17, 95% CI 1.07-1.29), especially in children. Higher CRP levels, exceeding 30 mg/L, also associated with hospitalization (OR 1.37, 95% CI 1.14-1.64) and longer fever clearance time (HR 0.84, 95% CI 0.76-0.93), especially in adults. CRP levels in patients with dengue were higher than patients with potential viral infection but lower than patients with potential bacterial infection, resulting in a quadratic association between dengue diagnosis and CRP, with levels of approximately 30 mg/L associated with the highest risk of having dengue. CRP had a positive correlation with total white cell count and neutrophils and negative correlation with lymphocytes, but did not correlate with liver transaminases, albumin, or platelet nadir. CONCLUSIONS: In summary, CRP measured in the first 3 days of illness could be a useful biomarker for early dengue risk prediction and may assist differentiating dengue from other febrile illnesses.