Dengue

Dengue Hemorrhagic
Hemorrhagic Fever
Fever

Pathogenesis and pathophysiology

Alan
Alan R.
R. Tumbelaka
Tumbelaka,, dr.
dr. SpA(K
SpA(K))
 Dengue virus
• Family Flaviviridae
• Genus Flavivirus
• Enveloped , single strand RNA viruses
• Genomic RNA 11 kb and encodes
– 3 structural proteins : C (core), M (membrane) and
E (envelope)
– Non structural proteins (NS) : NS1, NS2a, NS2b,
NS3, NS4a, NS4b, and NS5
– NS1 present at high concentration in the sera
during the early clinical phase
 Dengue virus
• Serotypes: Den1, Den2, Den3 and Den4
• Transmitted by Stegomyia aegypti
• Wide range of symptoms:
– From unapparent to severe form
– Also cause hepatitis or encephalitis
• Detected by:
– Virus isolation on mosquitos
– Viral RNA detection (RTPCR)
– Serological tests
– Enzyme immunoassay for NS1 antigen in human
serum
 Pathogenesis of DHF/DSS

• The pathogenesis of DHF and DSS is still

controversial
• Two theories, which are not mutual exclusive – were
frequently cited to explain the pathogenetic changes
– Secondary infection or immune enhancement hypothesis
– viral virulence theory
• Both theory is supported by epidemiologic and
laboratory evidence, and are most probably valid

1. Scott B. Halstead. Pathophysiology and pathogenesis of Dengue Hemorrhagic Fever.

Monograph on Dengue / Dengue Hemorrhagic Fever. P. Thongcharoen. Ed. WHO,
SEARO, New Delhi, 1993. p80-103.
2. Duane J. Gubler. Dengue and Dengue Hemorrhagic Fever. Clinical Microbiology
Reviews, 1998:480-96
 Secondary heterologous infection theory

• Patients experiencing a 2nd infection with heterologous

dengue virus (DenV) serotype Ö have significant
higher risk for DHF/DSS
• Prior infection, through a process Ö antibody-
dependent enhancement (ADE), enhance the
infection and replication of DenV of the mononuclear
cells / macrophage
• This cells, produce and secrete vasoactive mediators
Ö increase vascular permeability Ö hypovolemia
and shock

1. Scott B. Halstead. Pathophysiology and pathogenesis of Dengue Hemorrhagic Fever.

Monograph on Dengue / Dengue Hemorrhagic Fever. P. Thongcharoen. Ed. WHO,
SEARO, New Delhi, 1993. p80-103.
2. Duane J. Gubler. Dengue and Dengue Hemorrhagic Fever. Clinical Microbiology
Reviews, 1998:480-96
Viral risk factors for DHF pathogenesis
Risk factors reported for DHF (1)
Risk factors reported for DHF (2)
 Factors that influence the risk for DHF

Factors Low risk High risk

Viral factors
Viral serotype Dengue-2 virus
Viral genotype Asian genotypes

Host factors
Immunity Prior dengue infection
Age Adult
Nutrition Malnourished
Genetics Black
 Risk factors Ö DHF

• Virus
– Serotype and virulence of the infecting virus
• Demography
– Age, sex
• Case fatality and hospitalization rate highest in infants and
elderly
• More severe among females
– Genetic background of the host
• Immune status
– Malnutrition appears to be uncommon in DHF
– DHF more common among in patients with chronic illnesses
(eq. asthma and diabetic)

Malavige GN, Fernando S, Fernando DJ, Seneviratne.

Dengue viral infections. Postgrad Med J 2004;80:588-601
Increased probability of DHF
2.5 billion people live in high risk of infection
Hypothesis on pathogenesis of DHF (1)
Homologous antibodies form non-infectious
complexes
Hypothesis on pathogenesis (2)
Heterologous antibodies form infectious
complexes
Hypothesis on pathogenesis (3)
Heterologous complexes enter more
monocytes, where virus replicates
Hypothesis on pathogenesis (4)
 Antibody Dependent Enhancement (ADE)

Dengue Virus Infection

Primary

Neutralization Non-neutralization Secondary

Antibody Antibody virus heterologous

Antigen antibody
Virus uptake complex

Reseptor Fc

Monocyte Secondary heterologous infection

Dengue, Topics in International Health CD, Wellcome Trust, May 2005.
Immunopathogenesis of plasma leakage
Skema lain ..
 Cytokine responses in DenV infections

• DenV infected monocytes, B-lymphocytes and mast

cells produce different cytokines
• TNF-α, Interleukin: IL-2, IL-6, and IFN-γ highest in
the first 3 days
• IL-10, IL-5, and IL-4 tend to appear later
• Increased level of IL-13 and IL-18 Ö severe DenV
infections (DHF IV)
• Reports suggesting cytokine type Th1 Ö protecting
severe infections, while Th2 Ö responses occurred
in DSS

Chaturvedi UC. Elbishbishi EA, Agarwal R et al. Sequential production

of cytokines by dengue virus infected human peripheral blood leucocyte cultures.
J Med Virol 1999;59:335-40
 Cytokine responses in DenV infections

• DHF patients have higher level TNF-α, IL-6, IL-13, IL-18 and
cytotoxic factor than DF
– These cytokines Ö implicated in causing increased vascular
permeability and shock
• Level of cytotoxic factor (from CD4+ T cells) ≈ diseases severity
• IL-8 higher in severe infections, may have important role in
pathogenesis
• IFN-α and IFN-γ were produced by lymphocytes infected by
DenV, not related to grading of disease; IFN-γ is produced
early, with peak on or before day of defervescence ≈
disappearance or viraemia

1. Chaturvedi UC. Elbishbishi EA, Agarwal R et al. Cytotoxic factor autoantibodies; possible
role in the pathogenesis of DHF. FEMS Immunol Med Microbiol 2001;30:181-6
2. Jufrie M, van der Meer, Hack CE et al. Inlamatory mediators in dengue virus infections In
children; interleukin-8 and its relationship to neutrophil degranulation. Infect Immun
2000;68:702-7
 Secondary heterologous dengue infection

Virus replication Anamnestic antibody respons

Complex virus-antibody

Complemen activation
Complemen È
Anafilatoxin (C3a, C5a)
Urine Histamin Ç
Capillary permeability increase
Ht increase
30% shock Plasma leakage Natrium
decrease
Hipovolemia Intra serous
fluid
Anoxia Acidosis
Shock

Death
 Secondary heterologous dengue infection

Virus replication Previously

Previously
antibody
antibody respons
respons
Virus-antibody
Virus-antibody complex
complex

Platelet Endothelial
Endothelial disturbances
disturbances Complement
Complement activation
activation
Platelet agregation
agregation

Hageman
Hageman factor
factor activation
activation Anafilatoxin
Anafilatoxin
Platelet
Platelet destruction
destruction Coagulation
Coagulation
by
by RES
RES activation
activation
Releasing
Releasing factor
factor III
III
platelet
platelet
Kinin
Kinin system
system
Thrombocytopenia
Thrombocytopenia Capillary
Capillary
Consumptive
Consumptive coagulopathy
coagulopathy Kinin
Kinin permeability
permeability
increase
increase
FDP
FDP increasing
increasing
Platelet
Platelet function
function Decreasing
Decreasing coagulation
coagulation function
function
disturbances
disturbances

Massive bleeding SHOCK

Pathogenesis of bleeding on DHF Suvatte, 1978

 Virulence theory

• DenV :
– Vary and change genetically by selection
pressure as they replicate in human /
mosquitoes Ö some strain have greater
epidemic potential
– Phenotypic expression of genetic changes
in the virus genome Ö increased replication
and viremia, severity of disease
1. Scott B. Halstead. Pathophysiology and pathogenesis of Dengue Hemorrhagic Fever.
Monograph on Dengue / Dengue Hemorrhagic Fever. P. Thongcharoen. Ed. WHO,
SEARO, New Delhi, 1993. p80-103.
2. Duane J. Gubler. Dengue and Dengue Hemorrhagic Fever. Clinical Microbiology
Reviews, 1998:480-96
 Pathophysiology changes

• Water and electrolyte shift

• Blood pressure
• Platelets
• Coagulation factors
• Complement consumption
• Vascular permeability mediators
• Immune complexes
• Leucocytes responses
Scott B. Halstead. Pathophysiology and pathogenesis of Dengue Hemorrhagic Fever.
Monograph on Dengue / Dengue Hemorrhagic Fever. P. Thongcharoen. Ed. WHO, SEARO,
New Delhi, 1993. p80-103.
Dengue IgM and IgG responses
 Role of IgE in pathogenesis

• Total and dengue specific IgE antibody levels

are higher in DHF and DSS patients compare
to DD patients
• Total IgE levels significantly higher in those
previously exposed to dengue infections
• During severe dengue infection, some
studies suggest there are suppressed Th1
and Th2 responses

Koraka P, Murgue B, Deparis X et al. Elevated levels of total and dengue

Virus specific IgE in patients with varying diseases severity.
J Med Virol 2003;70:91-8
 Pathogenesis of hematological system

• Thrombocytopenia
– IgM type of anti-platelet antibody
• Antiplatelet antibodies + complements → lysis of
platelets
– Dengue viral specific antibodies
– Bone marrow hypercellularity
– Destruction of platelet in the liver and spleen
• Atypical lymphocyte

Lin CF, Lei HY, Liu CC. Generation of IgM anti-platelet autoantibody
In dengue patients. J Med Virol 2001;63:143-9
Immune-pathogenesis of dengue virus (DV) infections.
Lei HY, Yeh TM, Liu HS, Lin YS, Chen SH and Liu CC, J
Biomed Sci 2001;8:377-88.
Relationship Cytokine  Plasma  Relationships between DHF and
level chemical substances
Directly related
TNF‐ α Ï Endothelium destruction, ↑ cap 
permeability, early stage
IL‐ 1 Î Endothelium, stimulate PAF and 
prostaglandin
IL‐ 2 Ï Same level in DF and DHF
Indirectly  IFN‐γ Ï ↑ infected cells, T cells activation
related
IL‐ 6 Ï ↑ in convalescence, feedback TNF‐ α & 
endotoxin
IL‐ 4,5,10 Ï Appear later
IL‐ 13,18 Ï DSS
Others PAF Ï ↑ cap permeability, complement 
activation
C3a,C5a Ï ↑ cap permeability, related to disease 
severity
Histamine Ï
Endotoxin Ï DSS with prolonged shock
 Summary of pathogenesis

• Available evidence suggest both viral and host

immune factors involved in pathogenesis of severe
dengue disease
• Different clinical pathologic manifestations of the
disease ≈ different pathogenetic mechanism
• Strain of virus is important
• The rate of virus replication and infectivity varies
with the strain of virus
• Data suggest that only certain strain of DenV
associated with major epidemics and severe
diseases, most likely that these viruses infect via
ADE ..