1. Peran Antigen NS1 Dengue Untuk Diagnosis Infeksi Virus Dengue Oleh: T.Elfin W. Pembimbing : Aryati 1 Tinjauan Pustaka Penyakit Infeksi 1
2. Pendahuluan 2 ANGKA KEJADIAN DAN INSIDEN DemamBerdarah Dengue (DBD) TH. 2008 DinkesTk.IJatim 2.145 orang 10 org meninggal 75,50/100.000 penduduk CFR 0,47 % 16.589 orang 165 org meninggal 44,68 /100.000 penduduk CFR 0,99 % Jatim Surabaya 2
3. Sulit diagnosis Tidakkhas Manifestasi klinis Pendahuluan … Infeksi virus dengue penyakit flu, demam tifoid, demam chikungunya, leptospirosis, malaria Peran NS1 dengue Terutamapadamasaawaldemam (3-4 hari) Beragam : asimtomatik, undifferentiated febrile illness, demam dengue, demam berdarah dengue (DBD) ,perembesan plasmasyok hipovolemik (SSD),kematian Manifestasi laboratoris Trombositopenia ringan sampai dengan berat, berbagai kombinasi kehadiran IgG dan IgM dan variasi kadar sitokin. 3 3
4. 4 DEN 3 Virus dengue DEN 2 DEN 1 DEN 4 Struktur virus dengue 4
5. Struktur Virus dengue… 5 Gambar . Sketsa Genom RNA Virus Dengue. Gambar. Sketsa Virion Virus Dengue 5
6. Struktur Virus dengue… glikoprotein 46-50 kDa terdapat di intraselular, permukaan sel (membrane-associated /mNS1 ) & secreted form (sNS1) bentuk homodimer, partially hydrophobic nature bukan bagian dari struktur virus diekspresikan pada permukaan sel yang terinfeksi 1 dari 7 protein NS yang dihasilkan selama replikasi virus protein yang disekresikan melalui cellular secretory pathway ke permukaan sel 6 antigen NS1 dengue 6
7. 7 Gambar: Siklus hidup virus dengue dalam sel. Role of T cells, cytokines and antibody in dengue fever and dengue haemorrhagic fever. Rev. Med. Virol. 2006; 16: 263–275.
8. 8 Struktur Virus dengue… tidak menunjukkan perbedaan pada infeksi primer maupun sekunder, dan beberapa kasus masih (+) pada fase konvalesen marker deteksi dini infeksi dengue primer-sekunder Antigen NS1 ditemukan dalam sirkulasi darah selama fase akut infeksi virus dengue protein non-struktural yang disekresikan di permukaan sel terinfeksi 8
9. Keuntungan pemeriksaan antigen NS1 deteksi infeksi dengue pada fase awal demam (hari ke-1 sampai ke-9 sakit), tanpa menunggu terbentuknya antibodi. Sensitivitas pemeriksaan NS1 (88,7%) lebih tinggi dibandingkan kultur virus (68,1%) dan RT-PCR (66,7%). Pemeriksaan IgG dan IgM antidengue tetap diperlukan untuk membedakan infeksi primer atau infeksi sekunder 9 9
10. Patogenesis Virus dengue masuk ke dalam tubuh manusia lewat gigitan nyamuk Aedes aegypti atau Aedes albopictus. Organ sasaran dari virus adalah organ RES meliputi sel kupffer hepar, endotel pembuluh darah, nodus limfaticus, sumsum tulang, serta paru-paru. Dalam peredaran darah, virus tersebut akan difagosit oleh sel monosit perifer. 10 10
11. 11 Gambar: Imunopatogenesis dari DHF. Immunopathological mechanisms in dengue and dengue hemorrhagic fever Current Opinion in Infectious Diseases 2006, 19:429–436
19. Pemeriksaan Antigen NS1 Metode ELISA NS1 antigen-capture ELISA Prinsip pemeriksaan: one-step sandwich ELISA dengan serum atau plasma penderita. Menggunakan Monoclonal antibody (Mab) murine sebagai capture. Jika terdapat antigen NS1 pada sampel, akan terbentuk komplek imun Mab-NS1-Mab/ peroksidase. 19 19
21. 21 Pemeriksaan NS1 denganImmuno Chromatography Test A B C D Serum 50µL Buffer 1 tetes masukkan strip tunggu 15 menit Gambar . Prosedur pemeriksaan Dengue NS1 Ag STRIP 21
25. 25 Figure: Colour-enhanced transmission electron micrograph of dengue virus. Severe dengue: the need for new case definitions. Lancet Infect Dis 2006; 6: 297–302
26. Gambar 5. Struktur Virion Virus dengue dan konfirmasi protein prM , E 26 26
27. 1 1 1 1 1 Homologous Antibodies Form Non-infectious Complexes Dengue 1 virus Neutralizing antibody to Dengue 1 virus Non-neutralizing antibody Complex formed by neutralizing antibody and virus 27 27
28. 2 2 2 2 2 2 Heterologous Antibodies Form Infectious Complexes Dengue 2 virus Non-neutralizing antibody to Dengue 1 virus Complex formed by non-neutralizing antibody and virus 28 28
29. 2 2 2 2 2 2 2 2 2 2 2 2 Heterologous Complexes Enter More Monocytes, Where Virus Replicates Dengue 2 virus 29 Non-neutralizing antibody Complex formed by non-neutralizing antibody and Dengue 2 virus 29
30. 30 Dengue Derajatkeparahan (WHO) Demam Perdarahan Permeabilitas pembuluh darah meningkat Kerusakan hemostasis I Trombositopenia Coagulopathy Plasma Leakage Hemokonsentrasi II Hipovolemik perdarahan Circulatory colapase III Syok IV meninggal Gambar . Derajat keparahan infeksi dengue 30
37. 37 Schema for the differential diagnosis of dengue-like diseases based on clinical dengue illness day Military Preventive Medicine: Mobilization and Deployment, Volume 2 37
38. 38 VIRUSES AND HUMAN DISEASE 2002. JAMES H. STRAUSS. ELLEN G. STRAUSS. Division of Biology california Institute of Technology Pasadena, California
48. 48 Pathogenesis of dengue virus infection. DENV initially infects a cell of the dendritic cell/macrophage/monocyteline (reviewed in reference 5) via receptor-mediated endocytosis and/or enhanced uptake via antibody-virus complexes attached to Fcγreceptors (reviewed in references 5 and 73). TNF-α(22, 52) and NO (24, 141) are produced primarily by infected monocytes/macrophages and activate endothelial cells, which can contribute to increased vascular permeability (reviewed in reference 17). Changes in vascular permeability in DENV infections have classically been measured by monitoring levels of albumin in the plasma (195). IFN-γis produced primarily by NK and CD8+ T cells and activates macrophages as well as CD4+ T cells (17). High levels of DENV and sNS1 circulate in the bloodstream (9, 114), and both have been shown to circulate as immune complexes as well. FcγR, Fc gamma receptor Recent Advances in Deciphering Viral and Host Determinants of Dengue Virus Replication and Pathogenesis. JOURNAL OF VIROLOGY, Dec. 2006, p. 11418–11431
49. 49 The early contact of DV with the host. DV enters through skin during the mosquito feeding, and DCs are the prime immune cells at the early times of dengue infection. Infected DCs into the dermis migrate to regional lymph nodes along with their maturation process. Innate Immune Responses to Dengue Virus. Navarro-Sa ´nchez et al. /Archives of Medical Research 36 (2005) 425–435
50. 50 Figure . Innate immune encounter upon virus injection in the capillary vessel. There are several immune-related components circulated in the capillary, which is surrounded by multiple cell layers. The enlarged circle indicates the mosquito’s probing site. Prior to the feeding process,mosquito saliva-containing factors (e.g., apyrases) and virus are released into the blood stream. A color figure is available in the online version. Alternate Hypothesis on the Pathogenesis of Dengue Hemorrhagic Fever (DHF)/ Dengue Shock Syndrome (DSS) in Dengue Virus Infection. MINIREVIEW. Accepted October 14, 2007.
52. 52 A hypothetical model of autoimmunity in dengue pathogenesis. Severe thrombocytopenia, plasma leakage, bleeding tendency, and hepatomegaly are the hallmarks of DHF/DSS. Viral pathogenesis and immunopathogenesis of DV infection are the causes of DHF/DSS in DV infection. Increased virus load by ADE and virus variation may directly cause an effect. In addition, immunopathogenesis by DV-induced inflammatory activation and autoimmunity may be involved in dengue pathogenesis. Our findings suggest that a mechanism of molecular mimicry is responsible for the induction of autoimmunity in DV infection. Autoimmune Pathogenesis in Dengue Virus Infection. VIRAL IMMUNOLOGY. Volume 19, Number 2, 2006
53. 53 Dengue viral infections. G N Malavige, S Fernando, D J Fernando, S L Seneviratne Postgrad Med J 2004;80:588–601.
54. 54 Dengue: an escalating problem. BMJ 2002;324:1563–6
55. 55 VIRUSES AND HUMAN DISEASE. JAMES H. STRAUSS. ELLEN G. STRAUSS. Division of Biology california Institute of Technology Pasadena, California
65. 65 Endothelial cells in infection. Normal endothelium produces inhibitors of blood coagulation such as thrombomodulin, heparan sulphate, and plasminogen activators. Non-thrombogenic properties are lost when endothelial cells are stimulated by microorganisms (dengue virus?) and/or mediators (ie, cytokines). Plasminogen activator inhibitor 1 (PAI-1), von Willebrand factor (vWF), and tissue factor (TF), the critical inducer of in vivo coagulation, are expressed. F1 and F2=prothrombin fragments 1 and 2; VIIa/TF=activated factor VII/tissue factor complex; Xa/Va=activated factor X/activated factor V complex; IXa/VIIIa=activated factor IX/activated VIII complex.
