Dengue is a mosquito-borne viral infection caused by dengue virus (DENV) belonging to a group of Flaviviridae. Disease is widely spread in tropical and subtropical regions of Southeast Asia, Africa and the Americas. DENV infection causes a spectrum of illness including flu-like syndrome and potentially life-threatening dengue hemorrhagic fever. Confirmation of DENV infection requires serological serum tests or detection of viral genetic material in a serum sample. There no specific treatment for dengue but symptomatic therapy should be implemented in all cases. Recently there are two modern DENV vaccines available for the people living in the countries at a risk of infection. Efficiency and safety profile of both vaccines are debatable. Dengue symptoms may imitate clinical picture of other diseases that are typical for endemic DENV regions. We present a case of 22-year-old Indonesian woman treated originally due to typhoid fever who develop the symptoms of DENV infection

Aleksander Ryczkowski

Aleksander Sławiński

Anna Orzeł

Halina Piecewicz-Szczęsna

Zuzanna Toruń

Journal of Education Health and Sport

Ryczkowski, Aleksander

Sławiński, Aleksander

Toruń, Zuzanna

Orzeł, Anna

Piecewicz-Szczęsna, Halina

Akademicka Platforma Czasopism

Ryczkowski Aleksander, Sławiński Aleksander, Toruń Zuzanna, Orzeł Anna, Piecewicz-Szczęsna Halina. Dengue virus infection in acourse  of  typhoid  fever. Journal  of  Education,  Health  and  Sport.  2018;8(9):1090-1094.  eISNN  2391-8306.  DOIhttp://dx.doi.org/10.5281/zenodo.  1420277  http://ojs.ukw.edu.pl/index.php/johs/article/view/6012The journal has had 7 points in Ministry of Science and Higher Education parametric evaluation. Part b item 1223 (26/01/2017).1223 Journal of Education, Health and Sport eISSN 2391-8306 7© The Authors 2018;This article is published with open access at Licensee Open Journal Systems of Kazimierz Wielki University in Bydgoszcz, PolandOpen Access. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium,provided the original author (s) and source are credited. This is an open access article licensed under the terms of the Creative Commons Attribution Non commercial license Share alike.(http://creativecommons.org/licenses/by-nc-sa/4.0/) which permits unrestricted, non commercial use, distribution and reproduction in any medium, provided the work is properly cited.The authors declare that there is no conflict of interests regarding the publication of this paper.Received: 22.08.2018. Revised: 28.08.2018. Accepted: 15.09.2018.Dengue virus infection in a course of typhoid feverAleksander Ryczkowski (1), Aleksander Sławiński (1), Zuzanna Toruń (1), Anna Orzeł (1),Halina Piecewicz-Szczęsna (2)(1) Student’s Scientific Group at Department of Epidemiology and Clinical Research Methodology of Medical University of Lublin, Poland (2) Chair and Department of Epidemiology and Clinical Research Methodologymail: olek.slawinski@gmail.comAbstractDengue is a mosquito-borne viral infection caused by dengue virus (DENV) belonging to agroup  of  Flaviviridae.  Disease  is  widely  spread  in  tropical  and  subtropical  regions  ofSoutheast  Asia,  Africa  and  the  Americas.  DENV  infection  causes  a  spectrum  of  illnessincluding  flu-like  syndrome  and  potentially  life-threatening  dengue  hemorrhagic  fever.Confirmation of DENV infection requires serological serum tests or detection of viral geneticmaterial in a serum sample. There no specific treatment for dengue but symptomatic therapyshould be implemented in all cases. Recently there are two modern DENV vaccines availablefor the people living in the countries at a risk of infection. Efficiency and safety profile ofboth vaccines are debatable. Dengue symptoms may imitate clinical picture of other diseasesthat are typical for endemic DENV regions. We present a case of 22-year-old Indonesianwoman treated originally due to typhoid fever who develop the symptoms of DENV infection.IntroductionDengue is mosquito-borne tropical disease caused by dengue virus (DENV) belonging to afamily of Flaviviridae (the same as Yellow fever virus, Zika virus, West Nile Virus). Vectorsof the disease are mosquito mainly of the species Aedes aegypti and Aedes albopictus whichare  widely  spread  in  many  tropical  and  subtropical  regions  of  Africa,  the  Americas,  the1090Eastern Mediterranean, South-East Asia and the Western Pacific [1]. The global prevalence ofdengue raised in recent decades which is linked to development of urban population, increaseair travel and spreading habitat of Aedes mosquito [2]. It is estimated that 400 million peopleare affected by the disease yearly. Most of them are local citizens but tourists are also at a riskof  infection  [3].  Some popular  touristic  places  of  Southeast  Asia  are  in  a  group of  highprevalence especially: Philippines, Singapore and Indonesia. Dengue virus infection causes a spectrum of illness raging from usual flu-like syndrome torare  but  potentially  fatal  complication  called  dengue  hemorrhagic  fever.  Typically,  firstdengue  infection  is  characterized  by  high  fever,  headache,  muscle  and  joint  pain,lymphadenopathy and gastrointestinal disturbances that occur after incubation period of twoweeks.  Severe  dengue is  a  complication  more  prevalent  for  children  that  usually  happenduring  second or  next  infection.  It  features  with  severe  bleeding,  respiratory  distress  andmulti-organ impairment [4]. To confirm the diagnosis, serological (detection of IgG and IgManti-DENV antibodies) or genetic (detection of DENV RNA) tests are needed. There is nospecific treatment in case of dengue but symptomatic treatment including fluid replacement,analgesics and non-steroid anti-inflammatory drugs are provided. Tetravalent, live-attenuatedDENV vaccine is available for local people in endemic regions (especially in Philippines) butrecently it is not recommended for tourists traveling to countries with a high risk of dengueinfection [5]. Due to weakening of immune system capacity in course of dengue infection thedisease may be combined with other infectious diseases which are often characterized by thesimilar symptoms.Typhoid fever belongs to a group of infectious  diseases that can imitate  first  infection orrelapse  of  DENV  infection.  This  bacterial  infection  caused  by  gram-negative  bacteriaSalmonella Typhi usually spreads by ingestion of contaminated water or food. The disease ismainly  found  among  children  and  adolescents  in  Eastern  Asia,  Latin  America  and  theCaribbean.  Initial  phase  of  typhoid  fever  is  characterized  by  high  fever,  headache,lymphadenopathy, abdominal pain and gastrointestinal symptoms. In late phase serious, lifethreatening complications as intestinal hemorrhage or intestinal perforation may occur [6].Diagnosis in cases of suspected typhoid fever is based on typical clinical course, isolation ofthe pathogen by blood culture, classic serological Widal test and PCR-based identification ofSalmonella Typhi genetic material in blood sample [7]. Specific treatment of typhoid feverwith  antibiotics  is  decisive  to  curing  disease  with  minimal  complications.  Recommendedtherapy  including  drugs  form a  group  of  fluoroquinolones,  cephalosporins  or  macrolidesneeds to be combined with symptomatic treatment. Worldwide two types of typhoid vaccineare  available  and  used  –  inactivated  parenteral  vaccine  and  live-attenuated  oral  vaccine.Efficiency  of  vaccines  is  less  than  80%  (depending  on  source  of  a  data)  but  both  arerecommended for people living regions endemic for typhoid and also for tourists traveling tothese countries [8]. We present a case report of a patient diagnosed with typhoid fever that develops symptoms ofDENV infection during a treatment of original condition.Case reportA 22-year-old  Indonesian  woman  was  admitted  to  Dr  Soetomo  Hospital  in  Surabaya  inIndonesia with the symptoms of mild fever (38⁰C), abdominal pain, nausea and vomiting.Based on blood morphology test  and serological  Widal test  typhoid fever was confirmed.1091According to guidelines doctors implement therapy with first-line antibiotic – ceftriaxone (ina dose of 2g per day). During seven days of follow-up general condition of a patient improveand she was discharged home. On the second day out of hospital  patient  develop rapidlyincreasing fever up to 41⁰C, severe fatigue and headache, which localized in an occipital partof a head. In the next days patient presented rash in the form of petechiae on lower limbs,back  and  abdomen.  Blood  morphology  test  revealed  moderate  lymphopenia  (0,5  G/l),granulocytopenia (1,0 G/l) and severe thrombocytopenia with a platelet level dropping from111G/l to 14 G/l. However, there were no signs of external or internal bleeding. Due to the occurrence of the typical symptoms and DEMV infection in the medical past (atthe age of four) patient was diagnosed with dengue fever. Diagnose was based mainly on aclinical  picture  and basic  laboratory  tests.  Advanced diagnostic  tests  were not  performed.Patient underwent treatment including intravenous fluid replacement therapy and high dosageof acetaminophen. Due to significant risk of massive bleeding non-steroid anti-inflammatorydrugs were avoided. Two weeks of hospitalization and maintenance therapy have resulted inimprovement of patient’s condition and led to discharge home.Discussion According  to  World  Health  Organization,  denga,  the  dangerous  flavivirus  transmitted  bymosquitoes,  spreads with the fastest  rate from all  viral-borne entities [9]. Nowadays,  it  isestimated that around 100 countries are endemic to the virus that contributes to 40% of theworld’s population living in the endangered area [10]. What is more, travelers have potentialto  spread  the  disease,  yet  the  number  is  still  underestimated  due  to  shortage  of  centersallowing proper diagnosis in countries of Europe [11]. Current studies indicate that most ofinfections are imported from the regions of Asia [11]. The number of infections remains highdespite the common approach to various ways of prevention involving removal of mosquitohabitats and using the insecticides. Despite, the attempts of scientists, the efficient and unifiedvaccine has not been introduced yet. The first officially licensed vaccine was introduced in2015 [12]. It was a tetravalent recombinant, CYD-TDV vaccine (Dengvaxia) that underwentcomplex phase 3 clinical trial program. The trial involved 10 countries from Asia and LatinAmerica  that  were  endemic  to  dengue.  The  results  were  considered  as  unpredicted  thatqualified the vaccine as only an additional tool in prevention of the disease. According to theofficial study, during 25 months follow-up after first dose, in group ≥9 years (due to safetyreasons)  with  confirmed  dengue,  the  efficacy  was  estimated  to  “81.9% (95% confidenceinterval [CI], 67.2%–90.0%) for individuals with baseline seropositive status and 52.5% (95%CI, 5.9%–76.1%) for those who were seronegative at baseline” [12]. Such numbers indicatethat a mechanism of the vaccine broadens preexisting immunity levels rather than stimulatesnewly developing immunity. Yet, while taking into account long term follow-up (4-5 years),it appears that the rate of hospital cases in vaccinated group (age 9-16) was significantly lowerthan  in  case  of  on-vaccinated  teenagers.  Moreover,  predictions  show that  the  number  ofdengue hospitalization  may be minimized by 10%-30% over 30 years.  The prevention ofdengue is essential  as it  minimize the chance of life-threatening type of dengue - denguehaemorrhagic fever (DHF) and shock syndrome (DSS). These conditions could result in highmortality rate - considering patients with DSS it may reach 44%. Furthermore, both DHF andDSS are more likely to happen as secondary infection [13] as it may happen in case of patientpresented in the report due to coinfection of dengue and typhi. The coinfection of dengue is an1092effect of the virus on the immune system of the organisms. Most common coinfections withdengue  are  Escherichia  coli,  Salmonella,  Burkholderia  pseudomallei,  herpesvirus,Streptococcus pneumoniae, Mycobacterium tuberculosis and Mycoplasma pneumoniae [14].Nevertheless, the coinfection of dengue and typhoid is rare yet still observed not only in theregion of  Asia,  but  also in  India.   Secondly,  coinfection  with the  diseases may delay  theprocess of diagnosis due to atypical manifestation. Such misinterpretation can postpone thesufficient treatment of the patient. Presented patient was not vaccinated for dengue or typhi.However, there is a great probability that this fact would not change the course of illness andwould  not  minimize  the  risk  of  dengue  reinfection.  More  efficient  seem  to  be  simpleprevention considering usage of repellents,  window protective mesh and suitable  clothing.When it comes to typhi, the vaccine is effective although the protective period last around 3years.  Female  patient  suffered from the typical  form of  acute  dengue fever:  with  suddenbeginning, high body temperature up to 41 Celsius degree, headache, pain of the bones andjoints  and lymphadenopathy.  The general  signs  were associated  with  rash in  the  form ofpetechiae on lower limbs, back and abdomen. Due to severe thrombocytopenia with a plateletlevel dropping there was a suspicion of dengue hemorrhagic fever but any kind of bleeding,external or internal, was not diagnosed. DHF is typical for Thailand and Philippines regionand is more frequents among people reinfected with another serotype of the virus. The patientwas secured against bleeding by avoidance of non-steroid anti-inflammatory drugs. The feverstarted to decrease after 2 days and patient has started to go into remission. Because womanmanifested  typical  symptoms  and  signs  of  dengue  disease  as  well  as  she  reported  thisinfection in her medical past, the diagnosis was fast and did not require any specific tests. Thetreatment  was symptomatic  -  it  supposed to  prevent  hemorrhage,  shock and alleviate  thehemorrhagic diathesis. Presented case report is not a warning for tourists. Described patient isan  Indonesian  female  with  curious  coinfection  of  typhoid  fever  and  second-time  dengueinfection.  Typhoid fever can be easily avoided by vaccination which is recommended. Asmentioned above, the vaccine for dengue is not as effective as it should be, that is why thereare ongoing programs working on a dengue vaccine to cover all four serotypes [15]. In 2017 itwas announced that the vaccine should have been used only in people who had had a previousdengue infection  due  to  more severe course of  the  subsequent  infections  [16].  For  manydeveloping countries - like Indonesia, typhoid fever and dengue fever, endemic infections,remain as crucial public health concerns [17]. Co-infection supposed to be considered while dealing with cases of dengue or typhoid feverwith or without atypical features. In order to reduce the development and negative effects ofdisease,  along with  improvement  of  sanitation  and personal  hygiene,  emphasis  should begiven on vaccination against typhoid [18]References1.  Cogan J.,  Dengue and severe dengue,  available  at:  http://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue on Aug 13 2018.2. Tantawichien T., Dengue fever and dengue hemorrhagic fever in adults, Southeast Asian JTrop Med Public Health. 2015;46(1): 79-98.3. Dengue, available at: https://www.cdc.gov/dengue/index.html on Aug 13 2018.10934. Guzman Maria G. et al., Secondary infection as a risk factor for dengue hemorrhagic fever/dengue  shock  syndrome:  an  historical  perspective  and  role  of  antibody-dependentenhancement of infection, Archives of Virology 2013;158(7): 1445-1459.5.  Scott  Lesley  J.,  Tetravalent  Dengue Vaccine:  A Review in  the  Prevention  of  DengueDisease, Drugs 2016;76(13): 1301-1312. 6. Wain J. et al., Typhoid fever, The Lancet 2015;385(9973): 1136-1145. 7.   Wain  J.  et  al.,  The laboratory diagnosis of enteric  fever,  The Journal  of Infections  inDeveloping Countries 2008;2(6): 421-425. 8. Sandhya A. Marathe et al., Typhoid fever & vaccine development: a partially answeredquestion, Indian J Med Res. 2012; 135(2): 161–169.9.  Bhatt S. et al., The global distribution and burden of dengue, Nature 2013;496: 504-507.10. Dengue, available  at:  http://www.who.int/immunization/diseases/dengue/en/  on Aug 132018.11.  Jelinek  T.  et  al.,  Epidemiology  and  Clinical  Features  of  Imported  Dengue  Fever  inEurope:  Sentinel  Surveillance  Data  from  TropNetEurop,  Clinical  Infectious  Diseases2002;35(9): 1047–1052.12.  Wilder-Smith  A.  et  al.,  Population  Perspectives  and  World  Health  OrganizationRecommendations  for  CYD-TDV  Dengue  Vaccine,  The  Journal  of  Infectious  Diseases2016;214(12): 1796–1799.13.  Rigau-Perez  J.  et  al.,  Dengue  and  dengue  haemorrhagic  fever,  The  Lancet1998;352(9132): 971-977.14.  Panchoren  et  al.,  Coinfections  in  dengue  patients,  The  Pediatric  Infectious  DiseaseJournal, 1998;17(1): 81-82. 15.  Geneva:  World  Health  Organization,  Dengue  Guidelines  for  Diagnosis,  Treatment,Prevention and Control, 2009, p. 137-14616.  Soucheray  S.  Sanofi  restricts  dengue  vaccine  but  downplays  antibody  enhancement,CIDRAP, 2017.17. Jusuf H. et al., Concurrent dengue hemorrhagic fever and typhoid fever infection in adult:Case report, 1998; 29(2): p. 370-372.18. Kumar S. et al., Rare concurrent infection with scrub typhus, dengue and malaria in ayoung female, Journal of Vector Borne Disease, 2014; 51: p. 71-72.1094

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Dengue virus infection in a course of typhoid fever

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Ryczkowski Aleksander, Sławiński Aleksander, Toruń Zuzanna, Orzeł Anna, Piecewicz-Szczęsna Halina. Dengue virus infection in a course of typhoid fever. Journal of Education, Health and Sport. 2018;8(9):1090-1094. eISNN 2391-8306. DOI http://dx.doi.org/10.5281/zenodo.1420277

http://ojs.ukw.edu.pl/index.php/johs/article/view/6012

 

 

 

 

 

 

The journal has had 7 points in Ministry of Science and Higher Education parametric evaluation. Part b item 1223 (26/01/2017).

1223 Journal of Education, Health and Sport eissn 2391-8306 7

 

© The Authors 2018;

This article is published with open access at Licensee Open Journal Systems of Kazimierz Wielki University in Bydgoszcz, Poland

Open Access. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author (s) and source are credited. This is an open access article licensed under the terms of the Creative Commons Attribution Non commercial license Share alike.

(http://creativecommons.org/licenses/by-nc-sa/4.0/) which permits unrestricted, non commercial use, distribution and reproduction in any medium, provided the work is properly cited.

 

The authors declare that there is no conflict of interests regarding the publication of this paper.

 

Received: 22.08.2018. Revised: 28.08.2018. Accepted: 15.09.2018.

 

 

 

 

 

Dengue virus infection in a course of typhoid fever


 

Aleksander Ryczkowski (1), Aleksander Sławiński (1), Zuzanna Toruń (1), Anna Orzeł (1), Halina Piecewicz-Szczęsna (2)

 

(1) Student’s Scientific Group at Department of Epidemiology and Clinical Research Methodology of Medical University of Lublin, Poland 

(2) Chair and Department of Epidemiology and Clinical Research Methodology

 

mail: olek.slawinski@gmail.com

 

Abstract

Dengue is a mosquito-borne viral infection caused by dengue virus (DENV) belonging to a group of Flaviviridae. Disease is widely spread in tropical and subtropical regions of Southeast Asia, Africa and the Americas. DENV infection causes a spectrum of illness including flu-like syndrome and potentially life-threatening dengue hemorrhagic fever. Confirmation of DENV infection requires serological serum tests or detection of viral genetic material in a serum sample. There no specific treatment for dengue but symptomatic therapy should be implemented in all cases. Recently there are two modern DENV vaccines available for the people living in the countries at a risk of infection. Efficiency and safety profile of both vaccines are debatable. Dengue symptoms may imitate clinical picture of other diseases that are typical for endemic DENV regions. We present a case of 22-year-old Indonesian woman treated originally due to typhoid fever who develop the symptoms of DENV infection

NEUROSURGERY ENTHUSIASTIC WOMEN SOCIETY

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Dengue virus infection in a course of typhoid fever

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NEUROSURGERY ENTHUSIASTIC WOMEN SOCIETY