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A Curious Case of Dengue Fever: A Case Report of Unorthodox Manifestations

Raja shakeel mushtaque.

1 Jinnah Post Graduate Medical Center, Karachi, Pakistan

Syed Masroor Ahmad

Rabia mushtaque.

2 National Institute of Cardiovascular Diseases, Karachi, Pakistan

Shahbano Baloch

Dengue is the major cause of arthropod-borne viral disease in the world. It presents with high fever, headache, rash, myalgia, and arthralgia and it is a self-limiting illness. Severe dengue can occur in some cases resulting in dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). We present a case of a 32-year-old male patient of high-grade fever, bilateral subconjunctival hemorrhages, swelling on hands and lips, and nasal bleeding. After investigations, he was diagnosed with dengue fever and it was observed that he developed systemic fungal infection secondary to Candida tropicalis infection. The patient's bone marrow biopsy showed hemophagocytic activity. He also developed hepatitis E infection while hepatitis A, B, or C serology profile showed no active infection. The bilateral iliopsoas hematoma was also observed on CT scan manifested by decreased power in bilateral lower limbs and pain in the right leg. The patient was treated in the hospital with antibiotics (ceftriaxone 2 g once daily for 14 days) and antifungal (fluconazole 200 mg per oral initially for one day then 100 mg daily for 13 days) medicines, and his condition improved on discharge. There is evidence of variable presentations of dengue fever after the disease burden is increased, and thus, diagnosing with such manifestations can be very challenging.

1. Background

Dengue is the foremost cause of arthropod-borne viral disease in the world and due to severe muscle aches. It is transmitted through Aedes mosquito and commonly found in tropical and subtropical parts of the world. The incidence of dengue has substantially increased over the past few decades [ 1 ]. It was estimated in a study that 3.9 billion people are at risk of infection with dengue viruses in the world and Asia is the most affected part [ 2 ]. A seasonal pattern of dengue linked to climate. In Pakistan, the highest dengue cases are reported during July-September due to more rainfall, optimum temperature, and humid environment which are ideal for breeding of Aedes mosquitoes [ 3 ]. Last year, the outbreak was first reported on 8 July 2019 in Peshawar city. A total of 47,120 confirmed cases of dengue fever, including 75 deaths, were reported during the outbreak period in the entire country [ 4 ].

Dengue fever is caused by one of the four distinct serotypes (DENV 1-4) of single-stranded RNA Flavivirus genus [ 5 ]. Infection caused by one serotype results in lifelong immunity to that serotype, but not to others. Dengue fever (DF) presents with high fever, headache, rash, myalgia, and arthralgia, and case fatality is less than 1%. Severe dengue, dengue hemorrhagic fever (DHF), and dengue shock syndrome (DSS) are accompanied by thrombocytopenia, vascular leakage, and hypotension [ 5 ]. DSS is characterized by systemic shock, which can be fatal with case fatality high as 12% to 44% [ 6 ].

There are few atypical manifestations of dengue fever growing with rising disease burden, often missed and sometimes difficult to comprehend the case collectively. In this case report, we will discuss atypical manifestations observed in dengue fever patients.

A 32-year-old male patient, married, with no previous comorbidities presented through the emergency room with complaints of fever for 8 days, bilateral subconjunctival hemorrhages, and swelling of hands and lips for 3 days and 1 episode of nasal bleed one day back. Fever was high grade, continuous, and associated with rigors/chills and generalized body ache. The patient developed bilateral conjunctival hemorrhages that were all of sudden, not associated with any trauma. The patient also had swelling on both hands and lips, which progressed over the 3 days. He also had one episode of nasal bleeding that was all of sudden and 1-2 teaspoons in quantity. He also had a tingling sensation in both lower limbs and difficulty in walking. He denied any history of bleeding from other parts of the body or any vomiting. He denied any previous hospitalization or any drug intake or any substance abuse. Her family came from a middle‐class background, he was sexually active with his wife, and he denied any chronic illness in his family.

3. Examination

A middle-aged male patient, ill-looking but oriented with time, place, and person. His vitals at the time of examination were blood pressure of 110/80 mmHg and pulse of 82/min regular, and the respiratory rate was 20/min. He was febrile (101°F), anemic, and jaundiced, while his hands and legs were mildly edematous, and lips were mildly swollen up and bilateral subconjunctival hemorrhage was noted. His abdomen was soft, slightly tender over the right hypochondrium, and mildly distended, and the liver was enlarged 3 cm below the right costal margin, firm, and nonnodular. On auscultation of the chest, there was normal vesicular breath sounds bilaterally except decreased breath sounds over the right base. The examination of the cardiovascular system was unremarkable.

On neurological examination, his GCS was 15/15, there were no signs of meningeal irritation, pupils were 3 mm bilaterally equally reactive to light and accommodation, and cranial nerves were intact. On motor examination, muscle bulk and tone were normal. Power in the lower limb was reduced, but normal in the upper limbs. Medical Research Council (MRC) grade in the right lower extremity was hip flexion 3/5 and extension 3/5, hip abduction 4/5 and adduction 4/5, and leg flexion 3/5 and extension 3/5 and dorsiflexion and plantar-flexion 5/5 strength bilaterally. MRC grade in the left lower extremity was hip flexion 4/5 and extension 4/5, hip abduction 5/5 and adduction 5/5, and leg flexion 4/5 and extension 4/5 and dorsiflexion and plantar-flexion 5/5 strength bilaterally. Additionally, there was a pain in the distribution of dermatome L2, L3, and L4 on the right lower limb. Deep tendon reflexes on the right lower cannot be performed due to pain, although they were normal and 2+ on the left side, and planters were bilaterally downgoing. The sensation was intact throughout, and the cerebellar examination was normal.

4. Differential Diagnosis

As this patient presented with high-grade fever, subconjunctival hemorrhage, nasal bleeding, and hepatosplenomegaly, a provisional diagnosis of viral hemorrhagic fever was made. The other differentials included malaria, viral hepatitis, and leptospirosis.

5. Investigation

Baseline laboratory investigations are shown in Table 1 , and hepatitis virology and autoimmune work are given in Table 2 . Serum dengue NS-1 antigen was positive while the MP-ICT was negative. Peripheral smear of CBC showed a leukoerythroblastic picture. Platelet clumps were observed, and anisocytosis, poikilocytosis, polychromasia, macrocytes, nucleated RBC, myelocytes, and metamyelocytes were seen.

Baseline laboratory investigations.

Hb: hemoglobin; MCV: mean corpuscular volume; TLC: total leukocyte count; GGT: gamma-glutamyltransferase; ALT: alanine transaminase; ALP: alkaline phosphatase; INR: international normalization ratio; APTT: activated partial thromboplastin time; LDH: lactate dehydrogenase; ESR: erythrocyte sedimentation rate.

Hepatitis virology and autoimmune workup.

IgM: immunoglobulin M; IgG: immunoglobulin G; HBsAg: hepatitis B surface antigen; ANA: antinuclear antibodies.

Urine analysis was suggestive of urinary tract infection (nitrate 1+, leukocytes: 40–50/HPF, RBC: 20–25/HPF, epithelial cells: ++/HPF, and casts: nil), but no organism grew on culture studies. The blood culture grew Candida tropicalis , which was sensitive to fluconazole and voriconazole. His bone marrow biopsy report showed preserved trilineage hematopoiesis along with the hemophagocytic activity. Leptospirosis serology was unremarkable.

Computed tomography (CT) scan of the chest and abdomen revealed bilateral pleural effusions with adjacent patchy consolidations and hepatosplenomegaly along with moderate ascites was noted. Diffuse thickening of bilateral iliopsoas muscles was also noted with areas of internal necrosis and ill-defined heterogeneous enhancement. His ultrasound Doppler of both legs was unremarkable except mild soft-tissue edema.

7. Treatment and Follow-Up

The patient was started on intravenous antibiotics (ceftriaxone 2 g once daily for 14 days) and antifungal (fluconazole 200 mg per oral initially for one day then 100 mg daily for 13 days). He was symptomatically managed with intravenous fluids (0.9% normal saline), antipyretics (paracetamol), and antiemetics (inj. gravinate[dimenhydrinate]). He improved with the treatment. He was discharged home after three weeks. At the time of discharge, his fever was subsided, bilateral hand and feet swelling subsided, and subconjunctival hemorrhage resolved, but he still complained of pain during walking and lower limb weakness. On the first clinic follow-up visit, his leg pain and weakness improved.

8. Discussion

This patient's complete blood picture showed increased total leukocyte count (TLC): 25.2 (neutrophils 40% and lymphocytes 57%), and later, the blood culture was positive for Candida tropicalis . The phenomenon of bacteremia in dengue has been identified and can occur simultaneously with various organisms like Streptococcus pneumoniae , E. coli , Salmonella species, Shigella sonnei , Klebsiella species, Enterococcus faecalis , Moraxella lacunata , Staphylococcus aureus , Haemophilus influenzae , Candida tropicalis , Mycobacterium tuberculosis , Mycoplasma , or Herpesviruses [ 7 ]. Candida tropicalis normally inhabit the skin and intestinal tract. There is evidence of intestinal mucosal injury in patients with dengue infection. Therefore, the vulnerability of intestinal mucosa due to dengue virus infection may lead to the transfer of organisms into the bloodstream [ 8 ].

The peripheral smear of complete blood count of this patient showed the leukoerythroblastic picture, and bone marrow biopsy showed preserved trilineage hematopoiesis along with the hemophagocytic activity. Hemophagocytic lymphohistiocytosis (HLH) (also known as “hemophagocytic syndrome”) is a hyperinflammatory condition characterized by sustained activation of the mononuclear phagocytic system that may result in a severe hyperinflammatory response. Epstein–Barr virus (EBV-HLH) is a recognized cause of acquired HLH [ 9 ], but it has also been reported as a complication of dengue. In a retrospective study carried out in Malaysia, adult patients with severe dengue showed HLH in twenty-one patients of 180 (12%) [ 10 ]. In another study, a total of 33 HLH patients were identified, of which 22 (67%) were associated with dengue and 1 died [ 11 ]. HLH was not found to be associated with a particular type of dengue virus. These patients had a longer duration of fever and were more likely to have anemia, hepatomegaly, and elevated liver transaminases than controls.

In this case report, there was no active infection of hepatitis A or B or C infection, but the patient had acute hepatitis E infection as shown by hepatitis virology and autoimmune workup in Table 2 . The presenting signs and symptoms were overlapping between viral hepatitis and dengue fever, and thus, it could be hard to challenging diagnosis in an endemic area. In one study, it was found that women were infected with dengue virus and hepatitis E virus simultaneously [ 12 ]. Another study was conducted in India found that a young man was infected with dengue, HEV, and Leptospira at the same time [ 13 ]. In epidemic regions, a physician should be vigilant for identifying such coinfections.

Our patient had decreased hip flexion and extension, hip abduction and adduction, and leg flexion and extension on the right leg, while on the left side, hip flexion and extension and leg flexion and extension were affected. There was also the pain in the distribution of dermatome L2, L3, and L4 on the right lower limb. On CT scan, there was diffuse thickening of the bilateral psoas muscle and iliacus muscles noted with areas of internal necrosis and ill-defined heterogeneous enhancement noted, pointing towards bilateral iliopsoas hematoma. Iliopsoas hematomas have also been associated with compressive femoral neuropathy due to the long course of the femoral nerve. Iliopsoas hematoma is usually caused by trauma in patients on anticoagulation/antiplatelet therapy or in those with hemophilia [ 14 ]. In 1939, Tallroth first ever explained the occurrence of spontaneous hemorrhage in the iliopsoas muscle followed by an injury to the femoral nerve in a hemophilia patient. Muscle hematomas are a rare complication of dengue fever. Only a few cases have been reported in the literature of spontaneous muscle hematomas in DHF reported by Ammer et al. [ 15 ], Ganeshwaran et al. [ 16 ], Ganu and Mehta [ 17 ], Koshy et al. [ 18 ], and Kumar et al. [ 19 ]. The hematoma could have resulted from thrombocytopenia and deranged international normalization ratio (INR), thus resulting in hemorrhage.

9. Learning Points

• Bacteremia or systemic fungal infections can occur in dengue fever. Thus, it should be looked at with high suspicion to avoid morbidity and mortality.
• Hemophagocytic lymphohistiocytosis (HLH) can occur in dengue fever and can cause high mortality.
• Coinfection of dengue fever can occur with hepatitis E and cause overlapping symptoms which can cause a challenging situation for a physician to diagnose.
• Dengue fever can present with bilateral iliopsoas muscle hematoma with femoral nerve palsy. This phenomenon was only reported a few times.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Dengue Prevention

Jul 16, 2014

810 likes | 2.14k Views

Dengue Prevention. What you need to know…. What is Dengue Fever?. Dengue is a tropical disease caused by a virus and transmitted to humans by the mosquito Aedes aegypti . Dengue is also known as Dengue Fever or "break bone fever".  It’s the most common arbovirus in the world.

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Presentation Transcript

Dengue prevention what you need to know….

What is Dengue Fever? Dengue is a tropical disease caused by a virus and transmitted to humans by the mosquito Aedes aegypti. Dengue is also known as Dengue Fever or "break bone fever".  It’s the most common arbovirus in the world. Close-up of an Aedes mosquito

Aedes mosquito

Symptoms of Dengue Fever Example of a Skin Rash due to Dengue Fever

Do you know… • Dengue fever and dengue haemorrhagic fever are the most common mosquito-borne viral diseases in the world. • Only the female mosquito feeds on blood. This is because they need the protein found in blood to produce eggs. Male mosquitoes feed only on plant nectar. • The mosquito is attracted by the body odours, carbon dioxide and heat emitted from animal or humans. • The female Aedes mosquito searches for suitable places to lay their eggs. • Aedes are day-biters, most active during dawn and dusk.

Life cycle of the Aedes mosquito

How do Aedes mosquitoes transmit diseases… • The transmission cycle of dengue virus by the mosquito Aedes aegypti begins with a dengue-infected person. This person will have virus circulating in the blood—a viremia that lasts for about five days. During the viremic period, an uninfected female Aedes aegypti mosquito bites the person and ingests blood that contains dengue virus; • The mosquito then bites a susceptible person and transmits the virus to him or her, as well as to every other susceptible person the mosquito bites for the rest of its lifetime.

How do Aedes mosquitoes transmit diseases…

This is what you can do to help… Prevent mosquitoes from Breeding! Remove ALL sources of stagnant water. Deny the Aedes mosquito of any chance to breed!

Potential Breeding Grounds

Artificial Containers (man-made): Flower vases and pot plates; Pails, water-storage jars, basins; Discarded receptacles; Roof gutters; Gully traps; Unused toilet bowls and cisterns; AC tray and dish rack tray; Concrete drains Natural Containers: Tree Holes; Leaf axils, fallen leaves; Ground depressions; Common Mosquito Breeding Grounds All these sites require constant inspection!

Potential Breeding Grounds Flower Pot Plates Flower Pots

Potential Breeding Grounds Gully Trap Roof gutters

Potential Breeding Grounds Tree-holes Plant axils

To prevent Dengue… • To prevent the spread of dengue fever, you must first prevent the breeding of its vector, the Aedes mosquitoes. • The Aedes mosquito is easily identifiable by its distinctive black and white stripes on their body. It prefers to breed in clean, stagnant water easily found in our homes. • You can get rid of the Aedes mosquito by frequently checking and removing stagnant water in your premises.

Easy steps to wipe-out the Aedes Mosquitoes • Change water in vases/bowls every other day; • Remove water from flower pot plates every other day, and add sand to the plates; • Turn over all storage containers; • Remove stagnant water collected on leaves, tree branches and in drains • Clean roof gutters at least once a month;

How to prevent Mosquito Bites? • No vaccine is available; • Use a mosquito repellant containing DEET; • Dress in protective clothing – long-sleeved shirts, long pants, socks and shoes; • Because Aedes mosquitoes usually bite during the day, be sure to use precautions especially during early morning hours before daybreak and in the late afternoon before dark. • Keep unscreened windows and doors closed. • Keep window and door screens repaired.

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April 24, 2024

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Expert sounds alarm as mosquito-borne diseases become a global phenomenon in a warmer, more populated world

by European Society of Clinical Microbiology and Infectious Diseases

The geographical range of vector-borne diseases, especially diseases such as malaria and dengue, that are transmitted by mosquitoes, has expanded rapidly over the last 80 years, with over half the world's population now at risk. Spurred on by global warming and urbanization, mosquito-borne disease outbreaks are set to spread across currently unaffected parts of northern Europe, Asia, North America and Australia over the next few decades.

In a new research review to be given at this year's ESCMID Global Congress (formerly ECCMID) in Barcelona, Spain (27-30 April), ICREA Professor Rachel Lowe, who leads the global health resilience group at the Barcelona Supercomputing Center in Spain, will discuss the changing global threat of vector-borne disease and the critical importance of improved surveillance and early warning systems to tackle this now almost global phenomenon.

"Global warming due to climate change means that the disease vectors that carry and spread malaria and dengue can find a home in more regions, with outbreaks occurring in areas where people are likely to be immunologically naive and public health systems unprepared," warns Prof. Lowe. "The stark reality is that longer hot seasons will enlarge the seasonal window for the spread of mosquito-borne diseases and favor increasingly frequent outbreaks that are increasingly complex to deal with."

Previously, dengue (spread by mosquitoes that bite during the day) was largely confined to tropical and subtropical regions because freezing temperatures kill the mosquitoes' larvae and eggs, but longer hot seasons have enabled dengue to become the most rapidly spreading mosquito-borne viral disease in the world.

Nine of the 10 most hospitable years for dengue transmission have occurred since 2000, allowing mosquitoes that carry dengue to invade 13 European countries, with local spread of disease seen in France, Italy, and Spain in 2023. The number of dengue cases reported to the WHO has increased eight-fold in the last two decades, from 500,000 in 2000 to over 5 million in 2019.

Prof. Lowe will explain how her recent research on climate extremes in the Caribbean found that drought conditions followed 4–5 months later by warmer-than-usual temperatures and excessive rainfall increases the chances of dengue outbreaks.

"Droughts and floods linked to climate change can lead to greater transmission of the virus, with stored water providing additional mosquito breeding sites. Lessons from previous outbreaks underscore the importance of assessing future vector-borne disease risks and preparing contingencies for future outbreaks," she emphasizes.

Projections suggest that if global warming can be limited to the ambitious goal of 1°C, the population at risk of malaria and dengue is expected to increase by an additional 2.4 billion people by 2100, relative to 1970-1999. However, if the current trajectory of high carbon emissions and population growth continues, double the number of additional people—4.7 billion—will be affected by dengue and malaria by the end of the century.

Infectious disease outbreaks in the aftermath of El Niño and extreme climatic events like severe floods, prolonged droughts, tropical cyclones , and dangerous heat waves are on the rise. As Prof. Lowe explains, "El Niño events that occur every 2-7 years cause hotter and wetter weather, providing ideal conditions for water-borne and mosquito-borne disease outbreaks, allowing disease-carrying insects like the Aedes aegypti and Aedes albopictus mosquitoes, which spread the viruses that cause Zika and dengue, to proliferate."

The Zika pandemic that emerged in Brazil in 2015 reflects the El Niño connection—months of warmer-than-average temperatures helped fuel the spread of the virus that infected 1.5 million people. The current El Niño is now one of the strongest on record, catapulting it into rare "super El Niño" territory.

Prof. Lowe warns, "With climate change seeming so difficult to address, we can expect to see more cases and possibly deaths from diseases such as dengue and malaria across mainland Europe. We must anticipate outbreaks and move to intervene early to prevent diseases from happening in the first place. Efforts need to focus on enhancing surveillance with early warning and response systems similar to those seen in other parts of the world, to more effectively target finite resources to the most at-risk areas to control and prevent disease outbreaks and save lives."

By combining disease-carrying insect surveillance with climate forecasts, researchers are developing ways to predict when and where epidemics might occur and direct interventions to the most at-risk areas in advance. One such project, being led by Prof. Lowe, is using a powerful supercomputer to understand how the climate and disease transmission are linked to predict mosquito-borne disease outbreaks in 12 countries.

"By analyzing weather patterns, finding mosquito breeding sites with drones, and gathering information from local communities and health officials, we are hoping to give communities time to prepare and protect themselves," explains Prof. Lowe. "But ultimately, the most effective way to reduce the risk of these diseases spreading to new areas will be to dramatically curb emissions."

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Mosquito-borne diseases spreading in Europe due to climate crisis, says expert

Illnesses such as dengue and malaria to reach unaffected parts of northern Europe, America, Asia and Australia, conference to hear

Mosquito-borne diseases are spreading across the globe, and particularly in Europe , due to climate breakdown, an expert has said.

The insects spread illnesses such as malaria and dengue fever, the prevalences of which have hugely increased over the past 80 years as global heating has given them the warmer, more humid conditions they thrive in.

Prof Rachel Lowe who leads the global health resilience group at the Barcelona Supercomputing Center in Spain, has warned that mosquito-borne disease outbreaks are set to spread across currently unaffected parts of northern Europe, Asia, North America and Australia over the next few decades.

She is due to give a presentation at the global congress of the European Society of Clinical Microbiology and Infectious Diseases in Barcelona to warn that the world must be prepared for a sharp uptick in these diseases.

“Global warming due to climate change means that the disease vectors that carry and spread malaria and dengue [fever] can find a home in more regions, with outbreaks occurring in areas where people are likely to be immunologically naive and public health systems unprepared,” Lowe said.

“The stark reality is that longer hot seasons will enlarge the seasonal window for the spread of mosquito-borne diseases and favour increasingly frequent outbreaks that are increasingly complex to deal with.”

Dengue used to be primarily found in tropical and subtropical regions, as freezing overnight temperatures kill the insect’s larvae and eggs. Longer hot seasons and less frequent frosts have meant it has become the fastest-spreading mosquito-borne viral disease in the world, and it is taking hold in Europe.

The Asian tiger mosquito ( Aedes albopictus) , carries dengue fever and has become established in 13 European countries as of 2023: Italy, France, Spain, Malta, Monaco, San Marino, Gibraltar, Liechtenstein, Switzerland, Germany, Austria, Greece and Portugal.

The insect is thriving; nine out of the 10 most hospitable years for transmission of the disease have occurred since 2000, and the number of dengue cases reported to the WHO has increased eightfold in the past two decades, from 500,000 in 2000 to more than 5m in 2019.

Lowe said climate breakdown would turbocharge this spread as droughts followed floods: “Droughts and floods linked to climate change can lead to greater transmission of the virus, with stored water providing additional mosquito breeding sites.

“Lessons from previous outbreaks underscore the importance of assessing future vector-borne disease risks and preparing contingencies for future outbreaks.”

She said that if the current trajectory of high carbon emissions and population growth continued, the number of people living in areas with mosquito-borne diseases would double to 4.7 billion by the end of the century.

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Lowe added: “With climate change seeming so difficult to address, we can expect to see more cases and possibly deaths from diseases such as dengue and malaria across mainland Europe. We must anticipate outbreaks and move to intervene early to prevent diseases from happening in the first place.

“Efforts need to focus on enhancing surveillance with early warning and response systems similar to those seen in other parts of the world, to more effectively target finite resources to the most at-risk areas to control and prevent disease outbreaks and save lives.”

Climate breakdown is also amplifying the threat from antimicrobial resistance, a separate presentation at the conference will warn.

Prof Sabiha Essack, the head of the antimicrobial resistance unit at the University of KwaZulu-Natal in South Africa, said climate breakdown was a “threat multiplier” for antimicrobial resistance: “Climate change compromises the ecological and environmental integrity of living systems and enables pathogens to increasingly cause disease. The impact on water systems, food-producing animals and crops threatens global food supply.

“Human activities associated with population growth and transport, together with climate change, increase antibiotic resistance and the spread of waterborne and vector-borne diseases of humans, animals and plants.”

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• Dengue fever

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Mosquito-borne diseases spreading in Europe due to climate change, says expert

Prevalence of illnesses such as malaria and dengue fever has hugely increased over the past 80 years.

Mosquitoes spread illnesses such as malaria and dengue fever. Photograph: iStock

Mosquito-borne diseases are spreading across the globe, and particularly in Europe, due to climate breakdown , an expert has said.

The insects spread illnesses such as malaria and dengue fever, the prevalences of which have hugely increased over the past 80 years as global heating has given them the warmer, more humid conditions they thrive in.

Prof Rachel Lowe who leads the global health resilience group at the Barcelona Supercomputing Center in Spain, has warned mosquito-borne disease outbreaks are set to spread across currently unaffected parts of northern Europe, Asia, North America and Australia over the next few decades.

She is due to give a presentation at the global congress of the European Society of Clinical Microbiology and Infectious Diseases in Barcelona to warn the world must be prepared for a sharp rise in these diseases.

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“Global warming due to climate change means that the disease vectors that carry and spread malaria and dengue [fever] can find a home in more regions, with outbreaks occurring in areas where people are likely to be immunologically naive and public health systems unprepared,” Prof Lowe said.

“The stark reality is that longer hot seasons will enlarge the seasonal window for the spread of mosquito-borne diseases and favour increasingly frequent outbreaks that are increasingly complex to deal with.”

Dengue used to be primarily found in tropical and subtropical regions, as freezing overnight temperatures kill the insect’s larvae and eggs. Longer hot seasons and less frequent frosts have meant it has become the fastest-spreading mosquito-borne viral disease in the world, and it is taking hold in Europe.

The Asian tiger mosquito (Aedes albopictus), carries dengue fever and has become established in 13 European countries as of 2023: Italy, France, Spain, Malta, Monaco, San Marino, Gibraltar, Liechtenstein, Switzerland, Germany, Austria, Greece and Portugal.

The insect is thriving; nine out of the 10 most hospitable years for transmission of the disease have occurred since 2000, and the number of dengue cases reported to the WHO has increased eightfold in the past two decades, from 500,000 in 2000 to more than 5m in 2019.

Prof Lowe said climate breakdown would turbocharge this spread as droughts followed floods: “Droughts and floods linked to climate change can lead to greater transmission of the virus, with stored water providing additional mosquito breeding sites.

“Lessons from previous outbreaks underscore the importance of assessing future vector-borne disease risks and preparing contingencies for future outbreaks.”

She said that if the current trajectory of high carbon emissions and population growth continued, the number of people living in areas with mosquito-borne diseases would double to 4.7 billion by the end of the century.

Lowe added: “With climate change seeming so difficult to address, we can expect to see more cases and possibly deaths from diseases such as dengue and malaria across mainland Europe. We must anticipate outbreaks and move to intervene early to prevent diseases from happening in the first place.

“Efforts need to focus on enhancing surveillance with early warning and response systems similar to those seen in other parts of the world, to more effectively target finite resources to the most at-risk areas to control and prevent disease outbreaks and save lives.”

Climate breakdown is also amplifying the threat from antimicrobial resistance, a separate presentation at the conference will warn.

Prof Sabiha Essack, the head of the antimicrobial resistance unit at the University of KwaZulu-Natal in South Africa, said climate breakdown was a “threat multiplier” for antimicrobial resistance.

“Climate change compromises the ecological and environmental integrity of living systems and enables pathogens to increasingly cause disease. The impact on water systems, food-producing animals and crops threatens global food supply.

“Human activities associated with population growth and transport, together with climate change, increase antibiotic resistance and the spread of waterborne and vector-borne diseases of humans, animals and plants.” – Guardian

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