This document summarizes research on dengue hemorrhagic fever. It finds that patients with more severe forms of dengue fever have higher hematocrit levels and plasma volume depletion. Cytokines like TNF-α, IL-6, and IL-8 increase during infection and correlate with hematological changes and disease severity. Peripheral blood mononuclear cells harbor dengue virus early in infection. Certain HLA alleles and variants in OAS1 are associated with increased risk of bleeding and shock. The research helps explain disease pathogenesis and identifies host factors influencing clinical outcomes.

1. What’s New in Hematology?
Dengue Hemorrhagic Fever
Ampaiwan Chuansumrit, M.D.
Department of Pediatrics
Faculty of Medicine Ramathibodi Hospital,
Mahidol University, Bangkok, Thailand

2. Hematocrit (Hemoconcentration)
Serotypes DF DHF I DHF II DSS OFIs
Number of patients 51 43 36 19 15
Max Hct (%) 39.5 + 4.0 43.5 + 3.9 44.7 + 4.3 44.9 + 8.1 36.6 + 6.1
Min Hct (%) 34.6 + 3.8 3.6 + 4.0 35.7 + 4.7 32.8 + 3.9 31.0 + 5.9
Mean increment of Hct (%) 14.4 21.1 26.0 37.7 18.8
DF, dengue fever; DHF, dengue hemorrhagic fever; DSS, dengue shock syndrome; OFIs, other febrile illnesses

3. Pleural Effusion

4. Romsai Suwanik, Prasong Tuchinda, et al. J Med Assoc Thai 1967; 50:48-66.
Date of Disease
1 2 3 4 5 6 7 8 9 10 11 12 13 -30+
FEBRILE STAGE
TOXIC
STAGE CONVALESCENT STAGE
Normalrange
ml/kg
80
70
60
50
40
30
20
10
0
Plasma Volume in Dengue Hemorrhagic Fever

5. Elevated Soluble Thrombomodulin in the Febrile Stage
Related to Patients at Risk for Dengue Shock Syndrome
Day of illness Day of illness
SolubleThrombomodulin(ng/ml)
Butthep P, et al. Pediatr Infect Dis J 2006;25:894-7.

6. Tissue Plasminogen ActivatorPlasminogen Activator Inhibitor-1
DF
DHF I
DHF II
DSS
OFIs
Chuansumrit A, Chaiyaratana W. Thromb Res 2014;133:10-16.

7. DF
DHF I
DHF II
DSS
OFIs
Antithrombin Protein C
Protein S Free Protein S
Chuansumrit A, Chaiyaratana W. Thromb Res 2014;133:10-16.

8. Thromboelastometry (ROTEM®
)

9. From Mosquito Bite to
Dengue Virus Infection
• Dengue virus: serotype 1- 4
• Host response
– cytokines/chemokines
– monocyte/macrophage
– host genetics

10. Cytokine/Chemokine Kinetics
• Increase levels
- tumor necrosis factor-α
- interferon-γ
- interleukin (IL)-4, IL-6, IL-8, IL-10
- monocyte chemottract protein-1(MCP-1)
• Decrease levels
- IL-1β, IL-2
- vascular endothelial growth factor (VEGF)
- epidermal growth factor (EGF)
Butthep P, et al. Pediatr Infect Dis J 2012; 31:e232-8.

11. Mean Levels of IL-6,IL-8,IL-10 and IFN-γ
(A)
DF
DHF I
DHF II
DSS
OFIs
Day -2 Day -1 Day 0 Day +1 Day +2 Conval
Day of illness
0
10
20
30
40
50
60
70
80
90
100
IL-6(pg/ml)
(B)
DF
DHF I
DHF II
DSS
OFIs
0
50
100
150
200
250
300
350
IL-8(pg/ml)
Day of illness
Day -2 Day -1 Day 0 Day +1 Day +2 Conval
(C) (D)
DF
DHF I
DHF II
DSS
OFIs
Day of illness
20
40
60
80
100
120
140
160
180
IL-10(pg/ml)
0
Day -2 Day -1 Day 0 Day +1 Day +2 Conval
DF
DHF I
DHF II
DSS
OFIs
Day -2 Day -1 Day 0 Day +1 Day +2 Conval
Day of illness
0
50
100
150
200
250
300
IFN-γ(pg/ml)
Butthep P, et al. Pediatr Infect Dis J 2012; 31:e232-8.

12. Hematological Parameters
• DHF patients
Cytokines
Hematological
parameters
Day of defervescence
Day-2 Day-1 Day 0 Day+1 Day+2
MCP-1
WBC count
Absolute monocytes
IL-8 Platelet count
IL-6
Neutrophil
Absolute neutrophils
Lymphocytes
Butthep P, et al. Pediatr Infect Dis J 2012; 31:e232-8.

13. Dengue Virus Antigen in Peripheral
Blood Mononuclear Cell
• Dengue virus antigens are found in most PBMC samples of
dengue infected patients on Day -3 to Day -1, Day 0 and cont
inue until Day +1 to Day +3
Chunhakan S, et al. Pediatr Infect Dis J 2009;28:1085-8.

14. 100
80
60
40
20
0
Day -1 Day 0 Day +1 Conval
Day of defervescence
UnstimulatedTNF-αexpression(%)
* ** *
DF
DHF I
DHF II
DSS
OFIs
100
80
60
40
20
0
Day -1 Day 0 Day +1 Conval
Day of defervescenceLPS-stimulatedTNF-αexpression(%)
* ** *
Unstimulated TNF-α Expression (%)
LPS-stimulated TNF-α Expression
(%)
Chunhakan S, et al. Int J Vas Med 2015:917143.

15. Unstimulated IL-1 β Expression (%) LPS-stimulated IL-1β Expression (%)
DF
DHF I
DHF II
DSS
OFIs
10
8
6
4
2
0
Day -1 Day 0 Day +1 Conval
Day of defervescence
UnstimulatedIL-1-βexpression(%)
*
*
*
*
100
80
60
40
20
0
Day -1 Day 0 Day +1 Conval
Day of defervescence
LPS-stimulatedIL-1βexpression(%)
*
*
*
*
Chunhakan S, et al. Int J Vas Med 2015:917143.

16. Host Genetics
• Alleles of susceptibility or resistance
– HLA class I and II
– Tumor necrosis factor-α
– CD209
– OAS gene

17. Association of -308 A of TNF-α and Bleeding
Case Frequency
With bleeding 38 9/76 = 11.8%*
Without bleeding 63 5/126 = 4.0%*
*P = 0.045
Chuansumrit A, et al. Pediatr Inter Child Health 2013;33:97-101.

18. Oligoadenylate Synthetase (OAS) Gene
• OAS gene related to interferon alpha/beta
• The very first line of antiviral innate immune
response against arbovirus
• OAS 1 splicing variant: susceptible to plasma
leakage and shock
• OAS 3 missense variant: protection against shock
Simon-Loriere E, et al. J of Infectious Disease 2015; pii: Jiv321.

19. Acknowledgement
• Kanchana Tangnararatchakit, M.D.
• Anant Khositseth, M.D.
• Suthep Wanitkun, M.D.
• Nongnuch Sirachainan, M.D.
• Rojjanee Lertbunrian, M.D.
• Nattachai Anantasit, M.D.
• Marut Chantra, M.D.
• Pimpun Kitpoka, M.D.
• Wathanee Chaiyaratana, M.Sc.
• Sirichan Chunhakan, Ph.D.
• Punnee Butthep, Ph.D.
• Staff and nurses at ICU, Ward Pediatric 2
Faculty of Medicine, Ramathibodi Hospital, Mahidol University
Center for Vaccine Development, Institute of Molecular Biosciences,
Mahidol University: Sutee Yoksan, M.D., Ph.D.
Institut Pasteur, Paris, France: Anavaj Sakuntabhai, M.D., Ph.D.