HOW IT DENGUE TRANSMITTED ?
DENGUE FEVER
- Very common because it is a tropical country
in which there is a manifestation of these
disease
- Discuss the causative agent of these disease
and also the clinical manifestation
pathogenesis and also the laboratory
diagnosis or the serological testing that can
be done in order to diagnose a patient
DENGUE FEVER
- It comes by a virus unlike leptospirosis it
come from a bacteria
- It is for cause a virus of family
● flaviviridae
➔ Family
Has 4 serotypes:
➔ It contains genetic make up ,even there
virulence have a greater epidemic potential.
● DEN -1
● DEN-2
● DEN-3
● DEN-4
envelope viruses
(+) Single-standed RNA virus
Accounts for ~5% of “fever in the returned
traveler” cases
➔ It is an envelope positive cells single stranded
RNA virus
➔ Accounts for approximately 5% of “fever in
the returned traveler” cases
➔ “fever in the returned traveler” cases
For example there is a tourist that comes in
our country when he/she will go home .She
has a fever.
In that case usually that fever cause by a
dengue virus
- As they go back to their home country
they already have dengue fever.
● Dengue transmitted by infected female
mosquito
● Aedes aegypti
➔ It cause by a female mosquito specifically type
of Aedes aegypti mosquito.
➔ This type of mosquito they feed on day time.
➔ They live on human habitation
➔ Prevent on habitation in these female
mosquito they lay eggs on artificial
containers with water.
➔ Any containers with water you have to
dispose it cause that is where the female
mosquito lay there eggs. It can be starts of
the transmission of dengue virus
PATHOGENESIS
1. Fusion
2. Disassembly
3. Viral Replication
4. Viral Assembly
5. Maturation and Release
➔ What happen in the human body if dengue
virus starts to infect a host
FUSION
● The viruses will fuse with a host cell or the
Langerhans cells. It enters the cell through
the viral envelope, a glycoprotein. The virus
also attaches to the viral receptors called
heparin sulfate located on the host cell.
➔ When a mosquito bite in the skin. When a
female infected mosquito bite in a human
skin.
➔ The virus will fuse with a host cell
➔ Since it will bite in the human skin the first
cells that would be infected will be the cells
present in the skin
 ➔ Keratinocytes or Langerhans cells or the
Dendritic cells present in our skin
➔ The virus will enter throug the viral envelope
a glycoprotein in which is important for
infectivity.
➔ The virus also attaches to the viral receptors
called heparin sulfate located on the host
cell.
➔ AGAIN: The virus will fuse to the host cell
NEXT STEP : ASSEMBLY
What
happens here?
● The virus will enter the cells and as it enters
the cells it is packaged into an endosome.
● Inside this endosome are acid vacuoles that
will disassemble the viral RNA.
● What happens for the host cell, it will not kill
the virus, instead the virus will use the human
cell in order to replicate.
So what happens is that
● inside the cell, once the viral RNA will be
exposed it will be replicated inside the cell.
● The virus will use the human cell in order to
clone itself and multiply itself in order to
infect again other cells
After the replication of the viral RNA
● This RNA will assemble again, they will again
make a copy of the virion through the
endoplasmic reticulum
● In the golgi apparatus, they will mature in
there and once it is mature, it will be
packaged again and will be released to the
system
● Once it is release, it will be able to infect
other cells
● That is the beginning of how Dengue virus
infect the host
➔ To further discuss that tricky part for that
part in which the virus will infect or will trick
our human body or will use the human body
in order to replicate itself
IMMUNE RESPONSE
1. The infected Langerhans cells display dengue viral
antigens on their surface, which activates the innate
immune response by alerting two types of white
blood cells, called monocytes and macrophages, to
fight the virus.
2. The dengue virus tricks the immune system to get
around its defenses and infect more cells.
3. As the infected monocytes and macrophages travel
through the lymphatic system, the dengue virus
spreads throughout the body.
4. The dengue virus infects more cells, including
those in the lymph nodes and bone marrow,
macrophages in both the spleen and liver, and
monocytes in the blood.
➔ Once the infected langerhans ingested the
virus, some of the viral antigens, because
again the cell will not be killed immediately.
They still have to use it so it must not die. But
it still functions, the immune cells will still
function and the langerhans cells will display
the dengue viral antigens on the surface.
➔ And as they present the viral antigens on
their surface, that will alert other immune
cells to tell them that there is an invasion that
comes around in the human body. There is a
foreigner, there is a foreign substance, there is
a pathogen, so kill the virus.
➔ So what happens is that the monocytes and
the macrophages will come to that site and
fight the virus
➔ But this is where the tricky part because the
dengue virus will use this time/ advantage to
infect more cells.
➔ As the infected monocytes and macrophages
travel through the lymphatic system, the
dengue virus spread through the body
because once this white blood cells,
monocytes, macrophages, they will come to
defend, some will be targeted by the virus and
become infected and then travel to other
 organs specifically the lymph nodes where
IMMUNE RESPONSE
the battle really happens, lymph nodes, bone
marrow, macrophages in both spleen and
liver and even in the monocytes of our blood.

IMMUNE RESPONSE
➔ There is still a hope because our natural
immunity takes place and our adaptive
immunity
NATURAL IMMUNITY
● Interferons have the ability to interfere with
viral replication, and they activate both the
innate and adaptive immune system defenses.
➔ Interferons has a very great role in
which they will help the immune
system to interfere with viral
replication.
➔ They will activate the innate and even
the adaptive immune system defense
● Activates the complement system
➔ Quick recap: Dengue virus is transmitted by a
➔ And you know the end product of
female mosquito specifically Aegis Egypt and
complement system, cell lysis
once disinfected mosquito bites a human skin,
ADAPTIVE IMMUNITY
the virus will infect the cells on the skin ( the
● B cells produce antibodies (IgM and IgG) that
dendritic cells, Langerhans cells and also the
are released in the blood and lymph fluid,
keratinocytes
where they specifically recognize and
➔ Once these cells will infect other cells such as
neutralize the dengue viral particles
B cells or other immune cells such as
➔ The B cells which will differentiate
monocytes and macrophages, it can
and become plasma cells they will
proliferate to the lymph nodes and also other
produce antibodies IgG and IgM in
organs such as bone marrow spleen and liver
order to combat the virus.
and that can lead to viremia.
➔ IgG and IgM- they will be released in
➔ But as our body responds to this disease or to
the blood and lymph fluid where they
this virus, our natural immunity will release
specifically recognize and neutralize
interferon in order to interfere with the viral
the dengue viral particles.
replication so that there will be no cloning
● Cytotoxic T cells, or killer T cells, recognize
that will happen or duplication.
and kill the cells that are infected with the
➔ Neutralizing antibodies in order to neutralize
dengue virus.
the Dengue antigens or Dengue viral particles
also the complement system through classical
pathway. it will help activate and it will help
the antibodies and even white blood cells to
remove the virus and also the cytotoxic T cells
or cytotoxic t lymphocytes. they are the ones
who will recognize and kill infected cells

➔ Here is a chart that shows immune response
to Dengue infection.
➔ Below here in this part, the numbers signify
the days of infection. The Orange Line
signifies the IGM and the dark pink line IGG
and the Violet is or purple that will be the
viremia or the load of the infection
➔ So from 0 to the first week of infection, there
will be an increase of course of load of the
virus in the human body.
➔ But as the days go by, within that week there
is also a production of IGM. So as you can
observe, it will pick up to the first week of the
infection but for IGM, it will gradually go
down within one to two months
➔ For IGG, high titers will rise if there is a
second encounter of the virus. So for IGM it
will rise during primary infection or the first
time that the infection will occur and then in
the secondary infection, the IGG will take rise
and the advantage of IGG is it will gradually
persist to retain High tighter. So within one to
two months, it will not easily decrease
➔ In comparison to IGM during primary
infection within one to two months, it will
gradually decrease but for IGG it will still
remain high.
➔ For IGM, it will persist or that will take rise
during primary infection or they will combat
during primary infection but for IGG it will
combat within the secondary infection
➔ For the NS1 here up the top of the lines. NS1is
actually an antigen detectable during the
acute phase of dengue virus infection or
during the first seven days of symptoms. But
if there is no symptom already, the NS1 is an
S1 antigen which is not already detectable by
serological test kits
Clinical Presentation
- From asymptomatic to life threatening
● Usually there are times in which the
dengue is asymptomatic especially for
children but it can lead from mild to
severe infection.
- Most commonly presents as a mild to
moderate, nonspecific, acute febrile illness.
- Dengue begins abruptly after a typical
incubation period of 5-7 days.
THREE PHASES OF INFECTION
1. Febrile Phase
2. Critical Phase
3. Convalescent Phase
NOTE:
- This is the one that manifest in human body.
- The other pathogenesis earlier cannot be
seen by the naked eye, but for the clinical
manifestation, this are the one that we can see
or observe
Febrile Phase
- Fever typically lasts 2-7 days
- Other signs and symptoms
● Headache
● Retro-orbital eye pain
● Muscle, joint, and bone pain
● Macular or maculopapular rash
(dominant and 50 % of cases shows
rashes)
● Nausea and vomiting, diarrhea, and
abdominal pain
● Leukopenia (decrease of wbc in cbc),
thrombocytopenia, transaminitis
(increase of liver enzymes such as
ALT and AST)
NOTE:
 - It is called febrile phase because the patient
experience fever of more than 36.5 degrees
celsius
- If someone has dengue for the first time,
he/she will develop rashes compared to the
second time.
- Rashes will erupt after 2-5 days after the
fever has started
- Here are the bleeding that may happen.
- These symptoms are most likely what happen
Critical Phase in dengue hemorrhagic fever
A. Occurs in small subset of patients: (does not - Again, these happens when the patient has a
usually happens) severe thrombocytopenia with increased risk
1. Secondary Infection (other dengue of bleeding
infection or reinfection within 1 ½ - Hematochezia
year (18 months period)) there will be red blood
- A person can be infected after cells in stool
4 times since it has 4 serotype - Melena
- Second time of infection is Black tarry stool
more critical especially if it is So if you have a fever
within 10 months after the and black tarry stool,
primary infection. do not neglect that
2. Patients with other medical because it pertains
comorbidities that there is a bleeding
- Diabetes inside your GI tract
- Heart disease specifically the upper
- They have greater risk gastrointestinal tract.
B. Occurs after defervescence and lasts for
24-48 hours (1 to 2 days)
● Thrombocytopenia→ bleeding
- There will be a
thrombocytopenia if there is a - Hematemesis
low platelet count for around - Epistaxis (nosebleed)
40,000 or worst 20,000 only
and then remember the
normal platelet count should
be 200,000-400,000. But if the
patient has undergo a critical - Menorrhagia
phase of dengue fever, the For female
platelet count decreases up to Heavy menstrual
40,000 period
- So if there is a decrease of
platelet count, there is a
greater risk of bleeding

- Vomiting of blood
 RECOVERY PHASE
➔ Patient is already in recovery
● Resolution of vascular permeability,
hemorrhagic risk
● Vascular leakage→shock→organ ● Vital signs stability
impairments ● Eruption of new rash
- Acute kidney injury ➔ Sometimes becomes itchy that lasts 1
- Liver failure to 5 days
- CNS involvement ● May have chronic fatigue
➔ Last weeks to months

LABORATORY DIAGNOSIS
● DENGUE NS1 RAPID TEST
- The Dengue NS1 Rapid Test is a qualitative,
membrane based immunoassay for the
detection of NS1 antigen in human serum.
- (PRINCIPLE) The buffer and serum mix and
- Another one is the vascular leakage in which
interact with NS1-specific monoclonal
there is there is so much inflammatory
antibodies conjugated to gold nanoparticles.
cytokines and it can lead to leakage into the
The solution migrates upward on the
intravascular space.
membrane to react with the anti-NS1
- The patient will loss intravascular volume, so
antibody on the membrane. If NS1 antigen is
if there is a loss of intravascular volume, that
present, a red line will appear at the test line.
can lead to hypotension or lower blood
➔ NS1 antigen
pressure and can lead to shock
- detectable in the blood of the patient
- Again, in this type of scenario, vascular
within 7 days of symptoms
leakage, not just the kidneys will be affected
- If the patient is experiencing fever,
but also there will be a liver failure and CNS
rashes, muscle pain, joint pain, etc. the
involvement or impairment of the organs
antigen can still be detected
such as liver, brain, kidney.
- Detected through NS1 rapid test
- So when this happens when there is a shock,
➔ Lateral flow test (qualitative)
or when there are multiple organs that has
➔ Specimen: serum
been affected, it is called dengue shock
➔ Disadvantage
syndrome
- After the 7th day of symptoms, NS1
- The term dengue hemorrhagic syndrome and
antigens are already not detectable
dengue shock fever are just older terms that
- Not recommended if after the 7th day
are being used today.
of symptoms is already gone
- Dengue hemorrhagic syndrome
- POSITIVE NS1 = CONFIRMS
(DHS)
- NEGATIVE NS1 = DOES NOT RULE
- Thrombocytopenia and severe
OUT THE INFECTION
bleeding
- Follow up test is the detection of IgM
- Dengue shock syndrome (DSS)
antibodies
- Vascular leakage leading to
shock and organ impairment
 - No viral replication that may happen, as long
RESULTS OF THE TEST THAT CAN BE PERFORMED
AND ITS SUGGESTIVE INDICATION
● DENGUE IgI AND IgM ELISA
➔ If the test is positive for NS1 antigen and
- The dengue fever ELISA test is a qualitative
enzyme immunoassay for the detection of
antibodies to dengue, in samples of human
serum or plasma
- The microwells are coated with purified
dengue virus antigen from cell cultured type
1-4 dengue. During the first incubation with
the diluted patients’ sera, any antibodies
which are reactive with the antigen will bind
to the coated wells.
➔ Incubation: 37 C
➔ Wash and incubate again
Result of test & suggestive indication
Note: no further test when NS1 antigen is positive
- It can be treated immediately
as it is treated immediately
negative for IgN and IgG antibody -> it
indicates an active dengue early infection.
Note: NS1 antigen is detectable during the 1st
week of manifestations of the symptoms.
Note: Further test can be done if NS1 antigen is
positive -> automatic that the patient is
experiencing dengue infection
Note: It can be treated immediately and no
further viral replication might happen as long
as it is treated immediately.
If both the NS1 and IgM is positive, there is a
primary infection.
Note: IgM antibody rises during primary
infection.
If both the NS1 and IgG is negative while the
IgM is positive, there is a primary initial stage
infection/early recovery phase.
If both the IgMand IgG is positive while the
NS1 is negative, there is a current/recurrent
infection.
Note: IgM antibody rises during primary
infection while IgG rises during secondary
infection.
If both the NS1 and IgM are negative while the
IgG is positive, there is a past reaction.
Note: IgG antibody persists for 1-2 months.
Note: If IgM is negative, the patient is already
recovered. But IgG is detectable in order to say
that the infection had been combated by the
body.
If all the three are positive, there is a
secondary infection in early phases.
Note: The patient may have hemorrhagic
dengue fever or dengue shock syndrome.
 If all of them are negative, there is no dengue, SUMMARY OF THE TEST FOR DENGUE:
further investigations to be done. 1. Dengue NS1 Rapid Test
2. Dengue IgG and IgM ELISA
3. IgM Antibody Capture Enzyme- Linked
Immunosorbent Assay (MAC-ELISA)
IgM Antibody Capture Enzyme- Linked
4. Hemagglutination Inhibition test
Immunosorbent Assay (MAC-ELISA)
● The dengue MAC-ELISA is used for the
qualitative detection of dengue virus IgM
antibodies.

PRINCIPLE: The MAC-ELISA is based on capturing

human IgM antibodies on a microtiter plate using
anti- human-IgM antibody followed by the addition of
dengue virus antigens. The antigens used for this
assay are derived from the envelope proteins of the
four dengue virus serotypes (DENV-1-4).

Specimen: Serum or Cerebrospinal fluid (CSF)

*If the specimen is CSF, maybe we are detecting here
is if the patient has or the dengue has already has an
infected the brain of the patient

**In this case, if the positive patients have a positive

IgM result and if negative for NS1 and positive for
IgM, it means there is a dengue infection.

Hemagglutination Inhibition
● HI assay historically has been and remains the
Gold standard for serologic testing for dengue
virus-specific antibodies.
- It is quantitative
- We are detecting or determining the
antibody titer against the virus
● >4 fold rise in HI antibody titer between acute
and convalescent samples defines acute
infection.

***The positive result of this is no agglutination

- Because what happens here is that the
agglutination is inhibited in this test.
- The highest titer that shows no agglutination
it means that is the titer
- Greater than (>) 4 fold rise in HI antibody
indicates acute infection.