Immunomodulator in

Dengue Infection

I K Agus Somia

Division of Tropical and Infectious Disease

Department of Internal Medicine
Udayana University / Sanglah Hospital
Denpasar BALI
Outline

•Introduction
•Immunopathogenesis of dengue infection
•Role of immunomodulatory
•Immunomodulator for dengue infection
•summarized
Introduction
• Dengue is an acute, systemic viral infection caused by one of four
dengue serotypes in the family Flaviviridae, transmitted by Aedes
mosquitoes.
• Dengue presents with wide clinical spectrum, ranging from
subclinical infection, or may cause mild dengue fever (DF), to
severe and even fatal dengue hemorrhagic fever (DHF) or dengue
shock syndrome (DSS).
• Three phases of disease exist – febrile phase, critical phase and
recovery phase.
• Clinical assessment (history, physical examination and vital signs)
and laboratory tests (complete blood count and hematocrit) are
required to assess disease phase and severity.
• There is no licensed drug or highly effective vaccine available at
present.
• Death is usually primarily by plasma leakage, leading to shock,
organ failure and hemorrhage.
Clinical Spectrum of Dengue infection

WHO, Searo 2011

Dengue case classification and levels of severity

Dengue ± Warning Signs Severe Dengue

With warning 1. Severe Plasma

sign Leakage
Without 2. Severe Haermorrhage
3. Severe Organ
Impairment

CRITERIA FOR SEVERE

CRITERIA FOR DENGUE ± WARNING SIGNS DENGUE
Probable Dengue Warning Signs * Severe plasma leakage
Live in /travel to dengue endemic area. • Abdominal pain or tenderness Leading to:
Fever and 2 of the following criteria : • Persistent Vomitting • Shock (DSS)
• Clinical fluid Accumulation • Fluid Accumulation with
• Nausea, vomitting
• Mucosal Bleed respiratory disstress
• Rash
• Lethargy, restlessness
• Aches and Pain
• Liver enlargement > 2cm Severe Bleeding :
• Torniquet test positive
• Laboratory : Increase in HCT As evaluated by clinician
• Leukopenia
• Any warning sign concurent with rapid decrease in
platelet count Severe organ impairment :
• Liver AST or ALT >=1000
Laboratory Confirmed Dengue * (requiring strict observation and • CNS impaired
(Important when no sign of Plasma medical intervetion) consciousness
Leakage • Heart and other organs
WHO,2009
Immunopathogenesis
dengue
infection
 Immunopathogenesis dengue infection

St John AL, Rathore APS. Adaptive immune responses to primary and secondary dengue virus infections. Nat Rev
Immunol. 2019 Apr;19(4):218-230. doi: 10.1038/s41577-019-0123-x.
Mediator theory

Bozza et al. 2008;

Increase vascular permeability leading to
plasma leakage:
Evidences for functional changes due to short lived mediato
rs
• Rapid onset of plasma leakage with sudden elevation
of Hct.
• Short duration of leakage /shock (24-48 hrs.)
• Rapid recovery without sequelae
• No inflammatory changes in vascular, pleural or perito
neal membrane
(at autopsy)
• No severe pathological changes in major organs other
than effusion and hemorrhage and some change in th
e liver.
N. Sucithra
Immunomodulator
Immunomodulator
• Immunomodulator: all of drugs which
modify immune response
• Pharmacologic immunomodulators include
suppressive and stimulatory
• Some of these can have both properties
depending on which component of
immune response they effect

Int J Pharm Pharm Sci, 4: suppl 1: 30-36

 Sites of immunomodulation
1. Antigen Recognition
2. Stimulation of IL-1
3. Expression of IL-2 and other CD8 Cell
cytokines 4
4. Proliferation and differentiation IL-2 Cytotoxic T Cells
C
E
2 3
D D Primed
1 IL-2
IL-1 IL-2 CD4
Antigen
A B D Helper
presenting D Cell
cell
CD4
CD3 Helper 4
Glyco- Peptide
protein
Cell Cytokinesis
MHC-II Plasma Cells
E
B - Cell

Inhibitors at each step acting as immuno-suppressant agents

A. Rh (D) immune globulin
B. Corticosteroid
C. ATG, OKT3, anti-CD4
D. Cyclosporine, tacrolimus
E. Azathioprine, methotrexate, cyclophospamide, rapamycin,
corticosteroids, mycophenolic acid
Nelson RP, Ballow M. Immunomodulation and immunotherapy: Drugs, cytokines, cytokine receptors, and
antibodies. Journal of Allergy and Clinical Immunology. 2003. 111,2; S720-S732
 Targets for therapeutic modulation of the innate and adaptive
immune responses to pathogen
Vasodilation, exudation, & 1. Micro-organisms contains broad
leukocyte diapedesis pathogen-associated molecular
patterns (PAMPs) which
Immune Complexes Complement Activation
stimulate cells of the innate
Opsonization & immune system by actions on
phagocytosis patern response receptors
Pathogens 2
(PRRs), such as Toll-like
receptors (TLRs
PAMP 3 ROS 2. Immunoglobulins
1 3. Dietary antioxidants,
PRM micronutrients and
Ag Processing phytopharmaceuticals modify
the phagocytes production of
4
APC reactive oxygen species (ROS)
Cytotoxicity
Tissue Injury 4. Most immunomodulatory
Antibodies agents are able to modulate
Ag inflammatory cytokine
Presentation Cytokines & production and inhibit
to CTR 5 Inflamatory Mediators
inflammatory enzyme
T Cells production with beneficial
(Th Tc effects on bystander tissue
Treg) injury and inflammation.
B Cells / 5. Specific modulation of cytokine
Plasma Cells production, such as that caused
b TLR agonist and interferon,
result in a change in the type of
Cytokines Cytokines
T cell activated by APCs
Parnham MJ. 2011.. Croation Journal of infection. 31: 15 – 27
Immunomodulator in dengue infection
Therapies targeting the host immune response

• Corticosteroids
• Intravenous immunoglobulins
• Mast cell inhibitors
• Vitamin E
• Papaya leaf extract

Candice YY Chan*,1,2 & Eng Eong Oo, 2015

Curr Treat Options Infect Dis (2019) 11:199–214
Therapeutics that have been evaluated as treatments of
dengue disease
Drug name Target Preclinical data Clinical data
Anti-D immune Reduction in NIL Randomized placebo-controlled
globulin thrombocytopenia by trials have shown faster recovery
preventing autoimmune in platelet counts.
destruction of platelets
Vitamin E Unclear mechanism. NIL One randomized placebo-
Can act as an antioxidant controlled trial (n = 66) showed
faster recovery in platelet counts.
Another randomized placebo-
controlled trial (n = 127) did not
show an effect in platelet counts
but showed less liver enzyme
derangement in treatment group
Mast cell Prevent mast cell Reduced vascular Clinical trial in progress
stabilizers degranulation and release leakage in mouse (NCT02673840)
of vasoactive products models of DENV
infection
Papaya leaf Antiviral and anti- Reduced viral Two randomized placebo-
extract inflammatory agent replication in vitro. controlled trials showed an
Reduced production of improvement in platelet counts
proinflammatory
cytokines in vivo

Curr Treat Options Infect Dis (2019) 11:199–214

 Corticosteroids
Sites of immunomodulation
1. Antigen Recognition
2. Stimulation of IL-1 CD8 Cell
3. Expression of IL-2 and other 4
cytokines IL-2 Cytotoxic T Cells
4. Proliferation and differentiation C
E
2 3
D D Primed
1 IL-2
IL-1 IL-2 CD4
Antigen
A B D Helper
presenting D Cell
cell
CD4
CD3 Helper 4
Glyco- Peptide
protein
Cell Cytokinesis
MHC-II Plasma Cells
E
B - Cell

Inhibitors at each step acting as immuno- Corticosteroids have inhibitory

suppressant agents
A. Rh (D) immune globulin effects on abroad range of immune
B. Corticosteroid
C. ATG, OKT3, anti-CD4 responses mediated by T and B
D. Cyclosporine, tacrolimus cells as well as native immune
E. Azathioprine, methotrexate,
cyclophospamide, rapamycin, responses of phagocytes
corticosteroids, mycophenolic acid
Corticosteroids
Anti-inflammatory actions

Macrophage
Activated
Lymphocyte

Activated
Macrophage

Collagenase Elastase Plasminogen Plasminogen

activator

Plasmin
Collagen Elastin
destruction digestion Clot
destruction

Tissue
destruction
Corticosteroid inhibitory
effect
 Corticosteroid
Anti-inflammatory and Immunosuppresive effects

Leukocyte ↓ Lymphocyte
Accumulation and
↓ Leukocyte
Monocyte
Function function

Monocytopenia Lymphocytopenia
Eosinopenia monocytopenia
Anti-inflammatory Immunosuppresive
effects effects
↓ Complement
components
↓ Complement
levels
↓ Histamine-
mediated
reaction
Corticosteroid
trials in dengue infection

• Effect of corticosteroid in early phase of dengue

infection
• Effect of corticosteroid in dengue shock
syndrome
• Effect of corticosteroid in dengue infection with
trombocytopenia

Zhang F, Kramer CV. 2014. Corticosteroids for dengue infection

Corticosteroid for dengue at an early stage
Patient or population : Patients with dengue infection at an early stage
Settings : Endemic settings ( Collumbia, India, Sri Lanka, and Vietnam)
Intervention : Corticosteroids
Outcome : Complications of Dengue
Illustrative comparative risks* (95% CI)
No of Quality of the
Assumed risk Corresponding risk Relative Effect
Outcomes (95% CI)
Participants eveidence Comments
(Studies) (GRADE)
Control Corticosteroid

Death - - - 664 ++ No deaths occured

(4 studies) low 1,2,3

Severe 7 per 100 9 per 100 RR 1.30 286 +

dengue: shock (3 to 23) (0.48 to 3.51) (2 studies) very low 4,5,6

Severe 1 per 100 1 per 100 RR 1.51 425 + Kularatne 2009 reported
dengue: (0 to 5) (0.24 to 9.43) (2 studies) very low 7,8,9,10 that no bleeding
complications occured
severe
bleeding
Severe 3 per 100 4 per 100 RR 1.51 225 +
thrombo- (1 to 19) (CI(0.31 to 7.28) (1 study) very low 12,13,14
cytopaenia11
Ascitis 4 per 100 1 per 100 RR 0.12 178 +
(0 to 9) (0.01 TO 2.13) (1 study) very low 12,15,16

ICU admission 8 per 100 8 per 100 RR 0.88 286 +

(8 to 106) (0.38 to 1.99) (2 studies) very low 4,5,6

•The basis of the assumed risk (eg the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is
based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk Ratio
Zhang F, Kramer CV. 2014. Corticosteroids for dengue infection
Corticosteroid for dengue-related shock
Patient or population : Patients with dengue- related shock
Settings : Endemic settings (Southeast ASIA)
Intervention : Corticosteroids
Outcome : Complications of Severe Dengue
Illustrative comparative risks* (95%
CI) Relative No of Quality of the
Outcomes Effect Participants eveidence Comments
Assumed risk Corresponding risk
(95% CI) (Studies) (GRADE)
Control Corticosteroid
Death 21 per 100 15 per 100 RR 0.68 284 +
(9 to 24) (0.42 to 1.11) (4 studies) very low 1,2,3,4
Need for blood 24 per 100 26 per 100 RR 1.08 89 +
transfusion (12 to 54) (0.52 to 2.24) (2 studies) very low 5,6,7,8
Pulmonary 3 per 100 3 per 100 RR 0.97 63 +
Haemorrhage (0 to 48) (0.06 to 14.82) (1 study) very low 9,10,11
Convulsions 0 per 100 0 per 100 RR 6.97 63 +
(0 to 0) (0.36 to (1 study) very low 9,10,11
126.24)
Days in The mean The mean duration of 63 +
Hospital duration of hospital stay in the (1 study) very low 09,10,11
hospital stay in intervention group
the control was 1.1 days higher
group was (1.83 lower to 4.03
6 days higher)

•The basis of the assumed risk (eg the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is
based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk Ratio
Zhang F, Kramer CV. 2014. Corticosteroids for dengue infection
Effect of corticosteroid
in dengue infection with
trombocytopenia
• No reduces the incidence of severe
thrombocytopaenia
• not statistically significant in platelet
counts and haematocrit, white blood cell
count

Zhang F, Kramer CV. 2014. Corticosteroids for dengue infection

Studies of corticosteroid in adult dengue
Study No Age Study design Dose steroid Outcme Favor comment
(yr) measure steroid

Premaratna 55 Adult Retrospective IV Death; Yes Recruited

et al intervention and metylprednisol volume of patients with
(2011) control group on 1 g single resuscitation severe shock.
dose fluids; time to
hemodynamic
stability

Tam et al 255 adult Randomized Oral ICU NO Inadequately

(2012) placebo- prednisolone: admission; powered for
controlled trial; either low bleeding;plate endpoints.
three arms dose (0.5 let nadir; Trend towards
(high-dose and mg/kg/day) or maximum hyperglycemia
low-dose high dose (2 hematocrit; as a
steroids, mg/kg/day) for hyperglycemi complication.
placebo). 3 days. a. Patients
recruited during
early stage of
illness.
Kularatne 200 adult Randomized IV Mean rise in No Patients
et al placebo- dexamethason platelet recruited when
(2009) controlled trial. e:4 mg initial counts. platelets
dose, 2 mg 8 dropped
hourly for 24 below50×109/L
hour
Studies of corticosteroid in adult dengue

Study (yr) No Age Study Dose Outcme Favor Comment

design steroid measure steroid
Shashidha 61 adult Randomized IV Mean rise in No Patients
ra et al , open label dexametha platelet recruited when
(2013) sone: counts platelets
8 mg dropped below
initially, 50×109/L.
4 mg 8 Those with
hourly for 4 bleeding and
days. shock
excluded

Villar et al 189 Adults Randomized IV Spontaneou No Patients

(2009) and , double- methylpred s bleeding, recruited
children blind, nisolone: ascites, within 120
stratifie placebo- 1.5 mg/kg hospitalizatio hours of onset
d 5–15 controlled single dose. n. of fever.
years trial.
and
>15
years
 Effects of Short-Course
Oral Corticosteroid Therapy Trial profile.
in Early Dengue Infection in
Vietnamese Patients:
A Randomized, Placebo-
Controlled Trial

Tam D T H et al. Clin Infect Dis. 2012;55:1216-1224

© The Author 2012. Published by Oxford University Press on behalf of the Infectious Diseases
Society of America. All rights reserved. For Permissions, please e-mail:
journals.permissions@oup.com.
 A, Dengue viremia kinetics for all serotypes by day of illness, in the 3 treatment arms separately and
finally with all data combined.

Tam D T H et al. Clin Infect Dis. 2012;55:1216-1224

© The Author 2012. Published by Oxford University Press on behalf of the Infectious Diseases
Society of America. All rights reserved. For Permissions, please e-mail:
journals.permissions@oup.com.
Intravenous immunoglobulins
• Intravenous immunoglobulins (IVIG) is an accepted treatment for
idiopathic thrombocytopenia purpura (ITP).
• Thrombocytopenia in ITP is attributed to autoantibodies called
plateletassociated IgG (PAIgG).
• PAIgG-coated platelets undergo accelerated clearance through Fcγ
receptors expressed on mononuclear phagocytic cells.
• The mechanism of IVIG is probably via competitive inhibition of Fcγ
receptors or ligation of inhibitory receptors
• A randomized, controlled study of 36 dengue patients
was conducted to evaluate treatment with IVIG according
to the dosage and frequency used for treatment of ITP for
total of 4 days
– The study failed to show efficacy of IVIG in promoting platelet
recovery

Candice YY Chan*,1,2 & Eng Eong Oo, 2015

Comparison of platelet counts in patients with secondary dengue virus infections receiving a
high dose of intravenous immunoglobulin (IVIG) and intravenous fluids (closed circle) and
patients receiving intravenous fluids alone (open circle)
Am. J. Trop. Med. Hyg., 77(6), 2007, pp. 1135–1138
Mast cell inhibitors

Mast cell
inhibitors

St John AL, Rathore APS. Adaptive immune responses to primary and secondary dengue virus infections.
Nat Rev Immunol. 2019 Apr;19(4):218-230. doi: 10.1038/s41577-019-0123-x.
Mast cell inhibitors
the role of mast cell (MC) activation in the pathogenesis of dengue-
vascular leakage and hemorrhage

activated MC was shown in a mouse model to release various proteases,

particularly chymase and tryptase, into the serum that results in loss of vascular
integrity
serum chymase levels correlated with dengue severity in patients enrolled in a
prospective study.

MC-stabilizing compounds, including cromolyn, montelukast and

ketotifen, reduced vascular leakage in wildtype mice model of DENV
challenge despite small (but nonsignificant) increase in mice viremia

A proof-of-concept clinical trial to test the efficacy of ketotifen to reduce

the degree of vascular leakage is currently in progress in Singapore
[Tambyah PA, St John A; Pers. Comm.].
Candice YY Chan*,1,2 & Eng Eong Oo, 2015
Pediatric Health, Medicine and Therapeutics 2019:10 5–11
A total of 285 Intervention
subjects were (Caripill) group Control group
evaluated N =145 N =140
The effect of a unique propolis compound (PropoelixTM) on
clinical outcomes in patients with dengue hemorrhagic fever

Lardo Soroy, Sulistyo Bagus, Iswandi Purnama Yongkie, Wibisono Djoko. Infection and Drug Resistance 2014:7
Summary
• There is no evidence to support the use of intravenous
immunoglobulins or corticosteroids in dengue and are
not recommended.
• Mast cells may be implicated in severe dengue via
release of chymase and tryptase into the serum, causing
vascular leakage.
– So far, macrophage-stabilizing compounds have showed
promising results in improving outcomes in mouse models.
– Its therapeutic use in humans awaits clinical trials