Dengue virus pathogenesis
Dengue virus (DENV) is a mosquito-transmitted (primarily from the female mosquitoes of genus Aedes) RNA virus that infects an estimated 390 million humans each year. DENV is a member of the Flavivirus genus of single-stranded positive-sense RNA viruses that cause visceral and central nervous system disease in humans. Dengue is currently the most prevalent arthropod-borne viral disease of humans that is caused by four antigenically distinct serotypes of dengue virus (DENV 1–4) that are genetically similar and share approximately 65% of their genomes. Infection with any of the DENV serotypes may result in a wide spectrum of clinical symptoms, ranging from a mild flu-like syndrome (known as dengue fever [DF]) to the most severe forms of the disease, which are characterized by coagulopathy, increased vascular permeability (increased hemoconcentration or fluid effusion in chest or abdominal cavities), fragility (dengue hemorrhagic fever [DHF]) and dengue shock syndrome [DSS]. Severe dengue is a potentially deadly complication due to plasma leaking, fluid accumulation, respiratory distress, severe bleeding and organ impairment [1]. The World Health Organization (WHO) classifies DHF in four grades (I to IV). DHF grades I and II represent relatively mild cases without shock, whereas grade III and IV cases are more severe and accompanied by shock. Recovery from infection by one serotype provides lifelong immunity against that particular serotype, and does not provide cross-immunity against other serotypes.
The primary vector of dengue is Aedes aegypti mosquito that lives in urban habitats and breeds mostly in man-made containers. Ae. aegypti is a day-time feeder and its peak biting periods are early in the morning and in the evening before dusk. Aedes albopictus is the secondary dengue vector in Asia, has spread to North America and more than 25 countries in the European Region. During the feeding of mosquitoes on humans, DENV is presumably injected into the bloodstream, with spillover in the epidermis and dermis, resulting in infection of immature Langerhans cells (epidermal dendritic cells [DC]) and keratinocytes. Infected cells then migrate from site of infection to lymph nodes, where monocytes and macrophages are recruited, which become targets of infection. Consequently the infection is amplified and virus is disseminated through the lymphatic system. As a result of this primary viremia, several cells of the mononuclear lineage, including blood-derived monocytes, myeloid DC, and splenic and liver macrophages are infected [2]. There are several immune cells associated with the pathogenesis of DENV infection and systemic spread, including dendritic cells, macrophages, and mast cells (MCs). MCs are widely recognized for their immune functions and as cellular regulators of vascular integrity in human skin [3].
Several genetic factors have been shown to be associated with the development of DHF/DSS and some have been shown to be protective. Certain HLA- class I and class II allele polymorphisms in the tumor necrosis factor alpha (TNF-α), Vitamin D receptor, CTLA-4 and transforming growth factor ß (TGF-β) have been shown to be associated with development of DHF/DSS. Several studies have shown that concentrations of multiple cytokines and other mediators, as well as soluble receptors, are significantly increased during severe dengue infections. Higher plasma levels of IL-1β, IL-2, IL-4, IL-6, IL-7, IL-8, IL-10, IL-13, IL-18, TGF-1β, TNF-α, and IFN-γ have been found in patients with severe DENV infections, in particular in patients with DSS [4].
There is no specific treatment for dengue fever. Maintenance of the patient's body fluid volume is critical to severe dengue care. In late 2015 and early 2016, the first dengue vaccine, Dengvaxia (CYD-TDV) by Sanofi Pasteur, was registered in several countries for use in individuals 9-45 years of age living in endemic areas. WHO recommends that countries should consider introduction of the dengue vaccine CYD-TDV only in geographic settings (national or subnational) where epidemiological data indicate a high burden of disease.
References:
- https://www.hindawi.com/journals/isrn/2013/571646/
- http://cmr.asm.org/content/22/4/564.full
- http://online.liebertpub.com/doi/abs/10.1089/dna.2017.3765?journalCode=dna
- https://sljid.sljol.info/articles/abstract/10.4038/sljid.v1i1.2987/