Robert Sinto

Formal education
2008: dr. , Universitas Indonesia
2014: Sp.PD, Universitas Indonesia
2018: K-PTI, Universitas Indonesia
2021-now: PhD – DPhil ClinMed., University of Oxford, UK

Informal education
2015:
Clinical training on Transplant-Oncology-
Immunocompromised Host Infectious Diseases,
Singapore General Hospital, Singapore
2018-2021:
Clinical Epidemiology, Julius Centre UMC Utrecht,
University College of London and
Autonomous University of Barcelona

Workplace & Position

2016-now:
Department of Internal Medicine,
RS Cipto Mangunkusumo - FM Universitas Indonesia
2015-now:
Indonesian College of Internal Medicine (Officer)
2014-now:
The Indonesian Society of
Tropical Medicine and Infectious Diseases (Officer)
The Importance of Rapid Diagnosis
of Dengue Infection in COVID-19

Robert Sinto
Division of Tropical and Infectious Diseases
Department of Internal Medicine
Faculty of Medicine Universitas Indonesia
Jakarta, February 2022
Outline
• Magnitude of problem
• Dengue infection diagnosis
• Conclusion
 Dengue-COVID 19 Co-infection
INDIA:
Tsheten et al. BMC Infectious Diseases (2021) 21:729
PLOS Neglected Tropical Diseases 14(8): e0008426.
https://doi.org/10.1371/journal.pntd.0008426
 Co-infection Guideline from India

Co-infection
Guideline from
India
https://www.mohfw.gov.in/pdf/GuidelinesformanagementofcoinfectionofCOVID19
withotherseasonalepidemicpronediseases.pdf
http://dbd.bmkg.go.id/
http://dbd.bmkg.go.id/
http://dbd.bmkg.go.id/
Outline
• Magnitude of problem
• Dengue infection diagnosis
• Conclusion
 Classification of Dengue Infection
1997 2009 2011
Dengue fever Dengue without warning Dengue fever
signs
DHF grade I Dengue with warning DHF grade I
signs
DHF grade II DHF grade II
DHF grade III Severe dengue DHF grade III
( severe plasma leakage,
severe hemorrhage,
severe organ involvement)
DHF grade IV DHF grade IV
Expanded dengue
syndrome
 Classification of Dengue Infection
1997 2009 2011
Dengue fever Dengue without warning Dengue fever
signs
DHF grade I Dengue with warning DHF grade I
signs
DHF grade II DHF grade II
DHF grade III Severe dengue DHF grade III
( severe plasma leakage,
severe hemorrhage,
severe organ involvement)
DHF grade IV DHF grade IV
Expanded dengue
syndrome
Manifestations of Dengue Infection: 2011

WHO SEARO. Comprehensive guidelines for prevention and control of dengue and DHF. 2011
Diagnosis of Dengue Fever
Probable diagnosis
 Acute febrile illness with > 2 of the following:
• headache • retro-orbital pain
• myalgia • arthralgia/bone pain
• rash • haemorrhagic manifestations
• leucopenia (wbc ≤5000 cells/mm3)
• thrombocytopenia (platelet count <150 000 cells/mm3)
• rising haematocrit (5 – 10%);
 and at least one of following:
• supportive serology on single serum sample: titre ≥1280
with HAI test, IgG titre with ELISA, or IgM antibody test
• occurrence at the same location and time as confirmed cases
of dengue fever.

WHO SEARO. Comprehensive guidelines for prevention and control of dengue and DHF. 2011
 Diagnosis of Dengue Fever (cont’..)
Confirmed diagnosis
Probable case with at least one of the following:
 Isolation of dengue virus from serum, CSF or autopsy
samples
 ↑> 4X serum IgG or in IgM antibody specific to dengue
virus
 Detection of dengue virus or antigen in tissue, serum or
CSF by immunohistochemistry, immunofluorescence or
ELISA
 Detection of dengue virus genomic sequences by RT-PCR

WHO SEARO. Comprehensive guidelines for prevention and control of dengue and DHF. 2011
Warning Sign of Dengue Infection
WHO 2009
 Abdominal pain or
tenderness
 Persistent vomiting
 Clinical fluid accumulation
 Mucosal bleed
 Lethargy, restlessness
 Liver enlargement >2 cm
 Laboratory: increase in
HCT concurrent with rapid
decrease in platelet count
WHO. Dengue: guidelines for diagnosis, treatment, prevention and control. 2009
WHO SEARO. Comprehensive guidelines for prevention and control of dengue and DHF. 2011
WHO SEARO 2011
 No clinical improvement or
worsening of the situation as the
disease progresses
 Persistent vomiting, not drinking
 Severe abdominal pain
 Lethargy and/or restlessness,
sudden behavioural changes
 Bleeding: epistaxis, black stool,
haematemesis, excessive
menstrual bleeding,
haemoglobinuria or haematuria
 Giddiness
 Pale, cold and clammy hands and
feet
 Less/no urine output for 4–6
hours
The Course of Dengue Illness

WHO. Dengue: guidelines for diagnosis, treatment, prevention and control. 2009
Virus, Antigen and Antibody Profile

PRIMARY INF SECONDARY INF

Diagnosis of DHF
All of these:
 Acute onset of fever of two to seven days duration
 Haemorrhagic manifestations: tourniquet test, petechiae,
ecchymoses or purpura, or bleeding from mucosa,
gastrointestinal tract, injection sites, or other locations
 Platelet count ≤100 000 cells/mm3
 Objective evidence of plasma leakage:
 – ↑ haematocrit/haemoconcentration ≥20% from baseline or
decrease in convalescence,
 Evidence of plasma leakage: pleural effusion, ascites or
hypoproteinaemia/albuminaemia

WHO SEARO. Comprehensive guidelines for prevention and control of dengue and DHF. 2011
 Serial ultrasonography, in contrast to existing
markers such as hematocrit, may better identify
patients at risk for development of severe dengue.
Diagnosis of DSS
DHF with signs of shock:
 Tachycardia, cool extremities, delayed capillary refill, weak
pulse, lethargy or restlessness, which may be a sign of
reduced brain perfusion
 Pulse pressure ≤20 mmHg with increased diastolic
pressure
 Hypotension by age, defined as systolic pressure <80 to
90 mmHg for older children and adults

WHO SEARO. Comprehensive guidelines for prevention and control of dengue and DHF. 2011
PLOS Neglected Tropical Diseases 14(8): e0008426.
https://doi.org/10.1371/journal.pntd.0008426
PLOS Neglected Tropical Diseases 14(8): e0008426.
https://doi.org/10.1371/journal.pntd.0008426
International Journal of Infectious Diseases 102 (2021) 152–154
Conclusion
• Dengue and COVID-19 infections shared similar
characteristics.
• Co-infections of both are exist.
• Evaluation of clinical and laboratory
characteristics, supported by “rapid” diagnosis is
the first important step.