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Dengue virus, Nepal.

To the Editor: Dengue virus belongs to the genus Flavivirus, family Flaviviridae. It has 4 serotypes: dengue virus type 1 (DENV-1), dengue virus type 2 (DENV-2), dengue virus type 3 (DENV-3), and dengue virus type 4 (DENV-4). Dengue virus is maintained in a cycle between humans and Aedes aegypti, domestic day-biting mosquitoes. Dengue virus induces clinical illness, which ranges from a nonspecific viral syndrome (dengue fever [DF]) to severe and fatal hemorrhagic disease (dengue hemorrhagic fever [DHF]). DF/DHF occurs primarily in tropical and subtropical areas of the world. Domestic dengue virus infection occurs in >100 countries; >2.5 billion persons live in these areas. Approximately 100 million cases of DF, 500,000 cases of DHF, and several thousand deaths occur annually worldwide (1). During the past decades, dengue virus has emerged in southern Asia; DF/DHF epidemics have occurred in Bhutan, India, Maldives, Bangladesh, and Pakistan (2-4).

From August through November 2006, the number of febrile patients increased in 4 major hospitals in the Terai region of Nepal: Nepalgunj Medical College, Bheri Zonal Hospital in Nepalgunj, Tribhuban Hospital in Dang, and Narayani subregional hospital in Birgunj. Patients with severe symptoms were referred to Sukraraj Tropical and Infectious Disease Hospital, Kathmandu, for diagnosis and treatment. The clinical features in most patients were consistent with signs of DF, but some patients showed signs (high fever, rash, ecchymosis, epistaxis, positive tourniquet test, liver dysfunction, and thrombocytopenia [platelet count <100,000/m[m.sup.3]]) consistent with the World Health Organization (WHO) definition of DHF. Ascites and plural effusion developed in 2 patients. Blood specimens were collected from all patients at the time of admission to the local hospitals. Particle agglutination (PA) assay (Pentax Ltd, Tokyo, Japan) (5) and immunoglobulin (Ig) M-capture ELISA (Dengue/JE IgM Combo ELISA kit, Panbio Ltd, Brisbane, Queensland, Australia) were performed. Dengue virus-specific IgM was detected in 11 patients who had fever, headache, and rash (Table). Each of these patients had negative results for Japanese encephalitis virus-specific IgM. Of the 11 patients, 10 had no history of travel to India or other dengue-endemic countries. DF or DHF was initially diagnosed for 7 patients, and viral encephalitis, typhoid fever, or viral fever was diagnosed for others without serologic tests. Reverse transcription-PCR and virus isolation were performed at Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan, but the dengue virus genome was not detected, and no virus was isolated, likely because sample collection was delayed and the sample was transported to Japan in a deteriorated condition.

DF/DHF have been considered to be a possible public health threat to Nepal because DF/DHF epidemics have occurred recently in India and Pakistan, which reported several thousand cases and >100 deaths (6). The first DF case in Nepal was reported in 2004 (7). Further, the first DENV-2 strain of Nepal origin was isolated from a Japanese traveler who visited Nepal and in which DF developed after the patient returned to Japan. The isolated DENV-2 (GenBank accession no. AB194882) was 98% homologous with DENV-2 isolated in India (8). The prevalence of dengue virus antibody was reported to be 10.4% in the southwestern region of Nepal (9). These reports suggest that dengue virus has been circulating in Nepal for several years. Thus, DF/DHF has likely been misdiagnosed and illness caused by dengue virus underestimated in Nepal. In contrast, Japanese encephalitis has been a public health problem in southwestern region of Nepal, and large epidemics have occurred almost every year since 1978 (10). Nepal has no dengue surveillance programs, and health professionals do not usually consider dengue as a differential diagnosis.

The emergence occurred in the lowland Terai belt region, which borders the state of Bihar, India. The Aedes mosquito is known to persist in this region. The emerging DENV-2 is likely to have been introduced into Nepal from India.


(1.) World Health Organization. Dengue and dengue haemorrhagic fever. Fact sheet no. 117; revised 2002 Apr [cited 2006 Oct 31]. Available from mediacentre/factsheets/fs117/en

(2.) World Health Organization. Dengue outbreak in Bhutan. Communicable Disease Newsletter. 2007;4(1).

(3.) Islam MA, Ahmed M, Begum N, Choudhury N, Khan A, Parquet C, et al. Molecular characterization and clinical evaluation of dengue outbreak in 2002 in Bangladesh. Jpn J Infect Dis. 2006;59:85-91.

(4.) Jamil B, Hasan R, Zafar A, Bewley K, Chamberlain J, Mioulet V, et al. Dengue virus serotype, Karachi, Pakistan. Emerg Infect Dis. 2007;13:182-3.

(5.) Pandey B, Yamamoto A, Morita K, Kurosawa Y, Rai S, Adhikari S, et al. Serodiagnosis of Japanese encephalitis among Nepalese patients by the particle agglutination assay. Epidemiol Infect. 2003; 131: 881-5.

(6.) Gupta E, Dar L, Kapoor G, Broor S. The changing epidemiology of dengue in Delhi. Virol J. 2006;3:92.

(7.) Pandey BD, Rai SK, Morita K, Kurane I. First case of dengue in Nepal. Nepal Med Coil J. 2004;6:157-9.

(8.) Takasaki T, Kotaki A, Nishimura K, Sato Y, Tokuda A, Lira C, et al. Dengue virus type 2 from an imported dengue patient in Japan. First isolation of dengue vires from Nepal. J Travel Med. 2007;14:445-8

(9.) Sherchand JB, Pandey BD, Haruki K, Jimba M. Sero-diagnosis of Japanese encephalitis and dengue virus infection from clinically suspected patients of Nepal. J Inst Med. 2001 ;23:25-31.

(10.) Epidemiology and Disease Control Division, Ministry of Health Nepal. The annual report of malaria, Kala-azar and Japanese encephalitis in Nepal, 2005. Kathmandu, Nepal: Ministry of Health; 2006.

Basu Dev Pandey,*

Kouichi Morita, ([dagger])

Santa Raj Khanal, ([double dagger])

Tomohiko Takasaki, ([section])

Isao Miyazaki, ([paragraph])

Tetsuro Ogawa, ([paragraph])

Shingo Inoue, ([dagger])

and Ichiro Kurane ([section])

* Tropical and infectious Disease Hospital,

Kathmandu, Nepal; ([dagger]) Nagasaki University,

Nagasaki, Japan; ([double dagger]) Tribhuban University,

Kathmandu, Nepal; ([section]) National Institute of

Infectious Diseases, Tokyo, Japan; and

([paragraph]) Pentax Company Limited, Tokyo, Japan

Address for correspondence: Basu Dev Pandey, Tropical and Infectious Disease Hospital, Teku Road, GPO Box 9045, Kathmandu, Nepal; email:
Table. Clinical and laboratory data for 11 patients admitted to
hospitals and diagnosed with dengue fever or dengue hemorrhagic fever,
Nepal, 2006 *

Patient Month Initial Travel
age, y/Sex admitted Location diagnosis history

20/M Sep Kathmandu DF Yes
27/F Sep Bardiya Viral fever No
3/M Sep Salayan Encephalitis No
13/M Oct Sindhuli Typhoid No
22/M Oct Birgunj DHF No
55/F Oct Dang DF No
22/F Oct Birgunj Viral fever No
13/M Nov Dang DF No
35/F Nov Birgunj DHF No
40/M Nov Birgunj DF No
42/M Nov Dang DF No

Patient Clinical signs and Selected laboratory and other
age, y/Sex symptoms test results

20/M Fever, headache, Hb 15.4 g/dL; TLC 10,500/
 nausea [mm.sup.3]; Plt 185,000/[mm.sup.3];
 blood culture for salmonellae
 negative; ALT 38 IU/L
27/F Fever, headache, TLC 5,600/[mm.sup.3]; blood culture
 vomiting for salmonellae negative
3/M Fever, vomiting, Widal negative; TLC
 convulsions 4,700/[mm.sup.3]
13/M Fever, headache Widal negative; TLC 4,500/
 [mm.sup.3]; blood culture for
 salmonellae negative; Brucella
 antigen negative; chest radiograph
22/M Fever, headache, Bil 0.8 mg/dL; ALT 80 IU/L; Plt
 vomiting, ascites 22,000/[mm.sup.3]; chest
 radiograph normal
55/F Fever, headache, Plt 51 ,000/[mm.sup.3]; TLC 7,600/
 muscular pain [mm.sup.3]; MP negative; ESR 20
 mm/h; Bil 0.7 mg/dL
22/F Fever, headache, Brucella negative; Widal negative;
 body ache TLC 5,600/[mm.sup.3]
13/M Fever, headache, Plt 95 ,000/[mm.sup.3]; TLC 4,700/
 rashes [mm.sup.3]; Hb 13.1 g%; Bil
 0.8mg/dL; ALT 26 IU/L
35/F Fever, headache, Bil 0.81 mg/dL; Plt 31 ,000/
 bruises; tourniquet: [mm.sup.3]; PT 2 min 30 s
 positive (control 14)
40/M Fever, headache, ALT 1271U/L; Plt 110,000/
 rashes [mm.sup.3]; PCV 38.8%;TLC 5,500/
 [mm.sup.3]; ultrasonography liver
 size, 16.8 cm
42/M Fever, headache, Bil 0.7 mg/dL; Widal test negative;
 rashes TLC 6,800/[mm.sup.3]; Plt

* Blood specimens were collected at time of hospital admission.
Diagnosis was confirmed by using immunoglobulin M-capture ELISA. DF,
dengue fever; Hb, hemoglobulin; TLC, total leukocyte count; Plt,
platelets; ALT, alanine aminotransferase; DHF, dengue hemorrhagic
fever Bil, bilirubin; MP, malaria parasites; ESR, erythrocyte
sedimentation rate; PT, prothrombin time; PCV, packed cell volume.
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Article Details
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Title Annotation:LETTERS
Author:Pandey, Basu Dev; Morita, Kouichi; Khanal, Santa Raj; Takasaki, Tomohiko; Miyazaki, Isao; Ogawa, Tet
Publication:Emerging Infectious Diseases
Article Type:Letter to the editor
Date:Mar 1, 2008
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