Journal of Medical Virology 63:143±149 (2001)

Generation of IgM Anti-Platelet Autoantibody

in Dengue Patients
Chiou-Feng Lin,1 Huan-Yao Lei,1 Ching-Chuan Liu,2 Hsiao-Sheng Liu,1 Trai-Ming Yeh,3
Shan-Tair Wang,4 Tzu-I Yang,1 Fuh-Chiang Sheu,1 Chih-Feng Kuo,1 and Yee-Shin Lin1*
1
Department of Microbiology and Immunology, National Cheng Kung University Medical College, Tainan, Taiwan
2
Department of Pediatrics, National Cheng Kung University Hospital, Tainan, Taiwan
3
Department of Medical Technology, National Cheng Kung University Medical College, Tainan, Taiwan
4
Department of Public Health, National Cheng Kung University Medical College, Tainan, Taiwan, Republic of China

Dengue virus infection causes a wide range of
diseases from dengue fever to life-threatening
dengue hemorrhagic fever and dengue shock
syndrome (DHF/DSS). The mechanisms involved
in DHF/DSS pathogenesis remain unclear. Pa-
tient sera collected from an outbreak in southern
Taiwan from November 1998 to January 1999
were studied. The presence of antibodies which
cross-reacted with platelets could be detected in
patient sera, and the isotype of these autoanti-
bodies was IgM. The anti-platelet IgM levels
were higher in DHF/DSS than in dengue fever
patient sera in disease acute phase. These auto-
antibodies were still detectable in convalescent
stage (1±3 weeks after acute phase) and even
eight to nine months after illness. The platelet
binding activity was not observed in other virus-
infected patient sera tested. Further investiga-
tion showed that dengue patient sera caused
platelet lysis in the presence of complement. The
platelet cytotoxicity induced by DHF/DSS patient
sera was higher than that by dengue fever sera.
Dengue patient sera also inhibited platelet aggre-
gation which, however, appeared to be not
related to DHF/DSS development. J. Med. Virol.
63:143±149, 2001. ß 2001 Wiley-Liss, Inc.
KEY WORDS: dengue; IgM autoantibody; platelet
lysis; platelet aggregation
INTRODUCTION
Dengue viruses belong to the genus Flavivirus of the
family Flaviviridae. They are subgrouped into four
serotypes, dengue virus 1, 2, 3, and 4. Infection with
dengue viruses is associated with a wide range of
clinical severity, from mild febrile illness as dengue
fever to life-threatening disease including dengue
hemorrhagic fever (DHF) and dengue shock syndrome
(DSS) [Halstead, 1988; Henchal and Putnak, 1990;
Gubler, 1998]. The mechanisms involved in the patho-
genesis of DHF/DSS remain unclear. One of the
hypotheses is that patients who have developed non-
neutralizing cross-reactive antibodies would cause the
antibody-dependent enhancement of infection in Fc-
receptor bearing cells [Halstead, 1970, 1979; Morens,
1994]. The immune activation including complement
activation, monocyte/macrophage and lymphocyte acti-
vation, and cytokine production may also be involved
[Bielefeldt-Ohmann, 1997; Rothman and Ennis, 1999;
Green et al., 1999]. The alternative hypothesis involves
virus variation, virulence and dynamics that may
account for severe dengue disease [Rico-Hesse et al.,
1997; Leitmeyer et al., 1999]. Both hypotheses seem to
provide the plausible explanations [Bielefeldt-Ohmann,
1997; Rigau-Perez et al., 1998], yet they cannot explain
some of the clinical manifestations of DHF/DSS.
The clinical features of DHF/DSS include plasma
leakage, bleeding tendency, and liver involvement
[Rothman and Ennis, 1999]. Thrombocytopenia, which
is common in dengue fever and is constant ®nding in
DHF/DSS, is suggested to be related to the bleeding
tendency [Henchal and Putnak, 1990; Gubler, 1998;
Rothman and Ennis, 1999; Rigau-Perez et al., 1998].
The mechanisms of dengue virus-induced effect on
thrombocytes need to be elucidated. Anti-envelope
protein monoclonal antibodies have been shown to
enhance binding of dengue virus 2 to human platelets
via non-Fc receptors [Wang et al., 1995]. Studies of
mouse antibodies generated to nonstructural protein 1
(NS1) cross-reacted with human thrombocytes, and
produced hemorrhage in mice [Falconar, 1997]. In this
study, the presence of antibodies in patient sera which
may bind to platelets was examined. Dengue patient
Grant sponsor: National Science Council, Taiwan, Republic of
China; Grant number: NSC89-2318-B006-009-M51.
*Correspondence to: Dr. Yee-Shin Lin, Department of Micro-
biology and Immunology, National Cheng Kung University
Medical College, Tainan, Taiwan, R.O.C. E-mail: yslin1@-
mail.ncku.edu.tw
Accepted 17 July 2000

# 2001 WILEY-LISS, INC.

144 Lin et al.

sera were collected from an endemic outbreak in
southern Taiwan. Patient sera from the acute and con-
valescent phases were tested for reactivity with plate-
lets. The sera of DHF/DSS patients had higher binding
activity to platelets than those of dengue fever patients,
and these antibodies declined with times. Interestingly,
the isotype of anti-platelet autoantibodies was IgM but
not IgG. The effects of dengue patient sera on platelet
lysis and aggregation were also assessed.
MATERIALS AND METHODS
Clinical samples
Blood specimens were collected from dengue patients
showing clinical symptoms of fever, rash and bone pain
during an outbreak in southern Taiwan from November
1998 to January 1999. Dengue virus 3 infection was
con®rmed and reported by the Center for Disease
Control, Department of Health, Taiwan. Among those
patients in this outbreak, ®ve dengue fever patients
whose sera from acute (3±7 days after fever onset),
convalescent (1±3 weeks after acute phase), and later
(8±9 months) stages had been collected were included
in this study. Sera (acute, convalescent and later stages
of disease) from four patients diagnosed as DHF/DSS
were collected, studied and compared with dengue
fever patient sera (except for one who died on day 25 of
illness so the serum at later stage could no longer be
obtained). Day 0 of illness represents day of fever onset.
A dengue virus 2-infected patient serum collected in the
acute phase on August 1996 was also tested. Table I is
an outline of individuals included in this study. Sera
from ®ve patients of each group diagnosed as Japanese
encephalitis virus, hepatitis C virus, and enterovirus 71
infections, respectively, were used as the controls. The
Japanese encephalitis patient sera (days 14±30 of
illness, the presence of anti-Japanese encephalitis
virus IgM and IgG had been con®rmed) were obtained
from the Center for Disease Control, Department of
Health, Taiwan. Both the hepatitis C virus (chronic,
hepatitis C virus RNA positive, anti-hepatitis C virus
positive) and enterovirus 71 (from the acute phase)
patient sera were from National Cheng Kung Uni-
versity Hospital. Normal control sera from six healthy
individuals were used as the background for anti-
platelet activity.
Detection of anti-platelet antibodies
by ¯ow cytometry
Human peripheral blood was mixed with 0.11 M
sodium citrate (9:1) and centrifuged at 100  g for
10 min at room temperature. The upper layer as
platelet-rich plasma was removed to a 15-ml tube,
mixed with 0.34% EDTA in phosphate-buffered saline
(PBS), and centrifuged at 1000  g for 10 min. The
pellets were washed 3 times with 0.34% EDTA in PBS
and ®xed in 10 ml of 1% formaldehyde in PBS at room
temperature for 10 min. The ®xed platelet suspension
was centrifuged at 1000  g for 10 min at room tempera-
ture. The pellets were washed in PBS twice and resu-
spended in 2 ml of PBS. The platelet count was
determined using a hemacytometer.
For the assay, 2.5  106 platelets were incubated with
various dilutions of patient or control serum for 60 min
on ice, then washed twice with PBS. The secondary
antibodies, i.e., 20 ml of FITC-conjugated anti-human
IgG or FITC-conjugated anti-human IgM monoclonal
antibody (Pharmingen, San Diego, CA), were added
and the mixture was incubated for 40 min on ice. After
washing twice with PBS, the platelets were resus-
pended in PBS and analyzed by ¯ow cytometry
(FACScan, Becton Dickinson, Mountain View, CA)
with excitation set at 488 nm.
Platelet lysis assay
Patient and normal control sera were preheated at
56 C for 30 min to inactivate complement, serially
diluted, and then incubated with Low-Tox-M rabbit
complement (1:25 dilution; Cedarlane Laboratories
Ltd., Hornby, Ontario, Canada) at 37 C for 60 min
before addition to the platelet-rich plasma. The plate-

TABLE I. Clinical Features of Study Subjects

Platelet count (103/mL)

Age
Patienta Sex (years) Diagnosis Acuteb Convalescentc

1 F 7 Dengue fever Dengue virus 3 (IgM ‡ ) 127 225

2 M 7 Dengue fever Dengue virus 3 (IgM ‡ , RT-PCR ‡ ) 66 393
3 M 17 Dengue fever Dengue virus 3 (IgM ‡ ) 112 326
4 M 12 Dengue fever Dengue virus 3 (IgM ‡ ) 71 206
5 M 10 Dengue fever Dengue virus 3 (IgM ‡ ) 67 246
6 M 13 DSS Dengue virus 3 (IgM ‡ ) 39 NAd
7 M 13 DHF with DSS Dengue virus 3 (IgM ‡ , RT-PCR ‡ ) 46 262
8 M 15 DHF Dengue virus 3 (IgM ‡ ) 42 286
9 F 57 DHF with DSS Dengue virus 3 (IgM ‡ ) 90 128
10 M 15 Dengue fever Dengue virus 2 (IgM ‡ , RT-PCR ‡ ) NA NA
a
Patients 3 and 8 are brothers, and so are patients 4 and 7.
b
Patient's blood was collected 3±7 days after fever onset.
c
Patient's blood was collected 1±3 weeks after acute phase.
d
NA, not available.
Anti-Platelet IgM from Dengue Patients 145

let-rich plasma was prepared as described above and Anti-platelet IgM levels are higher in DHF/DSS
105 platelets in PBS were added into each well of than in dengue fever patient sera
96-well ELISA plate. After incubation for 4 h, the level
The anti-platelet IgM levels were higher in DHF with
of lactate dehydrogenase activity in the culture super-
or without DSS than in dengue fever patient sera in
natant was determined using a Cytotoxicity Detection
both acute and convalescent phases (Fig. 1). The anti-
Kit (Boehringer Mannheim GmbH, Germany). The
platelet IgM levels were demonstrated quantitatively
absorbance of the sample was measured at 490 nm.
further by both the percentages of platelets reactive
Platelet aggregation assay with patient sera (Fig. 2A) and the mean ¯uorescence
intensity among positive platelets (Fig. 2B). Results
The platelet-rich plasma was prepared as described showed that the anti-platelet activity of DHF with or
above. After 10 min centrifugation at 100  g, the lower without DSS (DHF/DSS) patient sera was higher than
layer was subsequently centrifuged at 1000  g for that of dengue fever patient sera in the acute phase.
10 min and the supernatant was collected as the There was a decrease in platelet binding activity
platelet-poor plasma. The platelet-rich plasma was when the sera collected in the convalescent phase were
diluted to 107 platelets in 450 ml of platelet-poor plasma, compared with those in the acute phase. Patient sera
and 1:25 dilution of patient or control serum (which had
been preheated at 56 C for 30 min) was added and
incubated at 37 C for 30 min. Platelet aggregation was
measured in an automated aggregometer (PACKS-4,
Platelet Aggregation Chromogenic Kinetic System,
Helena Laboratories, Beaumont, TX). Platelets were
induced to aggregate by addition of adenosine 5 0 -dipho-
sphate (ADP; 20 mM ®nal concentration) with stirring
at 37 C.

Statistical analysis
Between-group comparisons were made by using
Wilcoxon rank sum statistics. Within-group compar-
isons (i.e., comparisons between the three stages) were
made by using Wilcoxon signed rank statistics. The
difference was considered signi®cant if P < 0:05.

RESULTS
Dengue patients produce anti-platelet
autoantibodies which belong to IgM
but not IgG isotype
Thrombocytopenia and clotting defects are clinical
features of dengue virus infection. In an attempt to
investigate the role played by dengue patient sera, the
binding activity of patient sera with normal human
platelets was examined by ¯ow cytometry. Results
showed that dengue patients produced antibodies which
cross-reacted with platelets (Fig. 1). Sera from normal
controls were examined for anti-platelet IgM and IgG
levels. All of the six normal sera showed similar
patterns, one of them was thereby used as the negative
control and shown as the dotted lines in Fig. 1. The
FITC-conjugated anti-human IgM and anti-human IgG
were used as the secondary antibodies in ¯ow cyto-
metric analysis. Both antibodies had been con®rmed for
their reactivities with human peripheral blood lympho-
cytes to assure that these two antibodies could bind to
IgM- and IgG-expressing cells, respectively. As com-
pared to the normal control (dotted lines), there was an
increase in the platelet binding activity when dengue Fig. 1. Dengue patients produce IgM anti-platelet autoantibodies.
patient sera were tested. Interestingly, the isotype of Human platelets were incubated with 1:25 dilution of patient or
normal control sera, followed by FITC-conjugated anti-human IgM or
these anti-platelet autoantibodies was IgM but not IgG. IgG and analyzed by ¯ow cytometry. The normal controls are shown as
Figure 1 illustrates a set of representative data. the dotted lines and the patient sera are shown as the solid lines.
146 Lin et al.

TABLE II. Anti-platelet IgM Levels in Different Disease

Stagesa

% of platelets Mean
reactive with IgM ¯uorescence
autoantibodies intensity

Dengue virus 3 infection

Normal (n ˆ 6) 6:5  1:3 77:7  9:7
Dengue fever
Acute (n ˆ 5) 28:0  2:4 140:0  15:5
Convalescent (n ˆ 5) 24:1  2:7 101:0  4:0
Later (n ˆ 5) 15:7  4:9 78:6  6:1
DHF/DSS
Acute (n ˆ 4) 34:6  4:1 276:0  19:8
Convalescent (n ˆ 4) 26:3  3:8 159:0  60:9
Later (n ˆ 3) 11:5  2:7 95:3  13:3
Dengue virus 2 infection
Normal 5:2  1:6 46:2  7:2
Dengue fever (Acute) 26:0  4:2 132:5  18:5
a
Acute phase ranges from days 3 to 7, convalescent phase refers to 1±3
weeks after acute phase, and later stage ranges from 8 to 9 months
after disease onset. Values are expressed as mean SD; for dengue
virus 3 infection, mean indicates average of data from different
patients; for dengue virus 2 infection, mean indicates average of data
from one patient in duplicate experiments.
*P < 0.05 vs. Normal;
**P < 0.01 vs. Normal;
***P < 0.001 vs. Normal.

Serum IgM and IgG from other virus-infected

Fig. 2. Anti-platelet IgM levels are higher in DHF/DSS than in
dengue fever patient sera. Human platelets were incubated with 1:25
dilution of patient or normal control sera, followed by FITC-
conjugated anti-human IgM and analyzed by ¯ow cytometry. Both
the percentages of platelets which reacted with patient sera (A) and
the mean ¯uorescence intensity (B) in different disease stages are
shown. The differences between groups are shown. * P < 0:05,
** P < 0:01.
collected 8±9 months later showed a further decrease
in anti-platelet activity. In Fig. 2, the statistically
signi®cant differences between groups are marked.
The averages of anti-platelet IgM levels in each
group are shown in Table II and the statistical diffe-
rences as compared to the normal control group
are indicated. In addition to the patients reported
herein, the dengue patients whose sera were collected
in either acute or convalescent phases had also been
determined and the anti-platelet IgM levels fell into the
ranges shown in Fig. 2 and Table II of corresponding
groups (data not shown). A dengue virus 2-infected
dengue fever patient acute serum collected previously
was also tested and had a level of anti-platelet IgM
similar to those of dengue virus 3-infected patients
(Table II).
patients tested do not show
anti-platelet activity
Whether anti-platelet autoantibody production also
occurred in other virus infection was then asked.
Studies using patient sera from Japanese encephalitis
virus, hepatitis C virus, and enterovirus 71 infections
showed levels similar to that of the normal control
when the anti-platelet IgM reactivity was demon-
strated by both the percentages of platelets reactive
with patient sera (Fig. 3A) and the mean ¯uorescence
intensity (Fig. 3B). The IgG anti-platelet antibodies
could not be observed in these patient sera, either
(Fig. 3).
Dengue patient sera induce platelet lysis
The consequence of dengue patient serum binding to
platelets was then assessed. The platelet cytotoxicity
induced by test sera was measured using lactate dehy-
drogenase activity assay. Sera from disease acute phase
were used and results showed that dengue patient sera
induced platelet lysis as compared to the normal
control. In the presence of complement, the cytotoxicity
level was much higher than that without complement.
The DHF/DSS sera caused a higher level of platelet lysis
than the dengue fever patient sera. A dose-dependent
effect was shown (Fig. 4).
Dengue patient sera inhibit ADP-induced
platelet aggregation
The platelet functional assay was also carried out and
results showed that the patient serum caused an inhi-
bition on platelet aggregation induced by ADP (Fig. 5).
Anti-Platelet IgM from Dengue Patients 147

Fig. 4. Platelet lysis induced by dengue patient sera. Patient or

normal sera were serially diluted and incubated with or without
complement (1:25) before addition to human platelets. After 4 h, the
culture supernatant was harvested and the lactate dehydrogenase
activity was determined by Cytotoxicity Detection Kit. Experiments
were carried out in duplicate, and six serum samples from normal
control, ®ve serum samples from dengue fever and four serum samples
from DHF/DSS patients were tested. Data are expressed as the mean
 SD.

dengue fever patient sera particularly during acute

phase. Those DHF/DSS patients were graded from II to
IV. The anti-platelet IgM levels were not correlated
positively with the grade of disease among the DHF/
DSS patients. However, this may not be conclusive due
to the small sample size categorized into each grade.
Data of patients presented in this study are those that
the complete set of sera (i.e., acute, convalescent and
later stages) were collected except for one who died on

Fig. 3. Anti-platelet autoantibody production is not observed in

other virus infections. Human platelets were incubated with 1:25
dilution of various patient or normal control sera, followed by FITC-
conjugated anti-human IgM or IgG and analyzed by ¯ow cytometry.
Both the percentages of platelets which reacted with patient sera (A)
and the mean ¯uorescence intensity (B) are shown. * P < 0:05.

However, the inhibitory effect on platelet aggregation

by DHF/DSS was not higher than that by dengue fever
patient sera. In addition, the inhibitory activity was not
reversed in convalescent stage and was actually
slightly higher than that in the acute phase.

DISCUSSION
In this study, the presence of antibodies directed
against platelets was demonstrated in dengue patient
sera. The kinetics of anti-platelet autoantibodies
showed a gradual decrease along acute, convalescent,
and later stages. The antibody isotype which showed
cross-reactivity with platelets appeared to be IgM,
while patient serum IgG did not react with platelets. Fig. 5. Effect of dengue patient sera on ADP-induced platelet aggre-
Patient sera tested in this study were collected from gation. Human platelets were incubated with 1:25 dilution of patient
or normal control sera, and the percentages of platelet aggregation in
an outbreak of dengue virus 3 infection. The anti- the presence of ADP were monitored by the aggregometer. The normal
platelet IgM levels were higher in DHF/DSS than in control group was normalized to 100% of platelet aggregation.
148
day 25 so the later stage serum was absent. For the
other patients in the outbreak whose sera were
collected but not in complete set, results also indicated
that the IgM anti-platelet levels fell into the range of
each corresponding group (data not shown). Based on
the antibody titers from haemagglutination inhibition
assay to de®ne the primary and secondary infections,
the majority of the patients in this outbreak have the
primary infection and only a few are considered as the
secondary infection. Since the isotype of anti-platelet
antibodies present in patient sera is IgM, the IgM
production is not associated with primary or secondary
infections. The onset of DHF/DSS is associated fre-
quently with the secondary dengue virus infection, the
production of high level of anti-platelet IgM as shown in
this study may provide an explanation to that in some
cases the primary infection causes DHF/DSS. Besides
anti-platelet IgM, other parameters of immune res-
ponse should also contribute to the development of
DHF/DSS. In this study, only ®ve patients with dengue
fever and four with DHF/DSS from dengue virus 3
infection and one with dengue fever from dengue virus
2 infection were investigated. Further studies are
required using a large panel of patients infected with
the four serotypes in order to gain a more clear picture
for the role of anti-platelet IgM in dengue pathogenesis.
It is intriguing that only patient serum IgM but not
IgG could bind to platelets. In other words, only IgM are
induced to react with the epitopes of dengue virus
antigens which are shared with platelets. A recent
report demonstrated that the isotype of NS1-P1 (amino
acids 1-15)-speci®c antibodies was mainly IgM in all
dengue patient sera that tested positive [Huang et al.,
1999]. The anti-NS1 antibodies present in patient sera
at least partially accounted for the cross-reactivity with
platelets (unpublished data). Previous studies using
murine anti-NS1 antibodies also showed their cross-
reaction with human platelets [Falconar, 1997]. There-
fore, it is speculated that the dengue virus antigens, for
example, NS1 amino acids 1-15 which possess B-cell
epitope may induce IgM autoantibodies cross-reactive
with platelets. The reason for IgM but not IgG isotype
to react with platelets is not due to the lack of IgG
production, high levels of anti-NS1 IgG were detected
in these patient sera. In dengue patient sera, antibodies
which could not be absorbed by puri®ed recombinant
NS1 also exist (unpublished data). Induction of IgM by
dengue virus antigens other than NS1 thus needs to be
taken into consideration. The alternative explanation is
that dengue virus infection causes polyclonal B-cell
activation which leads to IgM production. These possi-
bilities are not mutually exclusive.
The cross-reaction of patient sera with platelets was
not observed in patients with Japanese encephalitis
virus infection when both anti-viral IgM and IgG were
present in the sera. This is consistent with the ®nding
that the immunodominant NS1-P1 epitope reacted
with sera from dengue but not Japanese encephalitis
patients [Huang et al., 1999]. Patient sera from hepa-
titis C virus and enterovirus 71 infections did not react
Lin et al.
with platelets, either. Furthermore, sera from all four
dengue virus types react with dengue virus 2 NS1-P1
[Huang et al., 1999]. In this report, patient sera from
dengue virus 3 infection were studied. The dengue
virus 2 patient serum had also been tested showing that
it contained platelet-reactive IgM (Table II).
The effects of the cross-reactive antibodies included
both induction of platelet lysis and inhibition of platelet
aggregation. Induction of platelet lysis may, at least in
part, explain thrombocytopenia in the acute phase. The
platelet lysis was mainly via complement activation.
The platelet-binding antibodies belong to the IgM class
which may ef®ciently activate complement cascade. On
the other hand, although inhibition of platelet aggrega-
tion was observed, it did not correlate well with disease
severity and disease stage. The suppression of platelet
aggregation during acute phase of DHF/DSS patients
has previously been demonstrated [Srichaikul et al.,
1989]. Results in this study showed that the inhibitory
effect on platelet aggregation by DHF/DSS patient sera
was not higher than that by dengue fever patient sera.
Also, the inhibitory activity was even higher when sera
from the convalescent phase were compared with those
from the acute phase.
Thrombocytopenia is common in dengue fever, and is
a constant ®nding in DHF and DSS [Gubler, 1998;
Rothman and Ennis, 1999]. One of the possible causes
of thrombocytopenia is that dengue virus impairs
hematopoietic progenitor cell growth resulting in a
decrease in thrombopoiesis [Murgue et al., 1997]. The
present study provides another possibility that the
presence of cross-reactive antibodies may account for
thrombocytopenia which is observed in patients during
the acute phase. The platelet counts reached normal
range in both dengue fever and DHF/DSS patients in
convalescent phase (Table I). However, the anti-plate-
let IgM autoantibodies were still present at signi®cant
levels during this time period. It is speculated that in
the acute phase those platelets expressing speci®c
surface molecules are recognized by the autoantibodies
and subsequently lysed. The newly replaced platelets
from hematopoietic progenitors in the convalescent
phase do not or slightly express these surface mole-
cules, the platelet levels therefore maintain normal.
The pattern derived from ¯ow cytometric analysis sup-
ports this notion, by demonstrating that only some
subpopulation of platelets could react with patient IgM
when platelets from healthy volunteers were used.
Nevertheless, this hypothesis needs to be tested by
showing the differential expression of speci®c surface
molecules at different activation stages of platelets.
Importantly, platelet surface molecules recognized by
autoantibodies present in patient sera need to be identi-
®ed. The epitopes shared by platelet surface molecules
and dengue virus antigens could then be mapped and
avoided in designing the safe candidate vaccines.
So far, only several live-attenuated candidate dengue
vaccines have been undergoing clinical trials [Dharakul
et al., 1994; Vaughn et al., 1996; Bhamarapravati
and Yoksan, 1997; Chambers et al., 1997]. Recent
Anti-Platelet IgM from Dengue Patients
approaches for the development of new generation of
dengue vaccines involve the use of recombinant pro-
teins, synthetic peptides, and subunit vaccines [Venu-
gopal and Gould, 1994; Srivastava et al., 1995; Velzing
et al., 1999], as well as DNA vaccine [Kochel et al.,
1997]. An ideal dengue vaccine should elicit protective
immunity and avoid potential pathogenic effects. The
mechanisms of dengue pathogenesis are still not clear
that remain an area of great challenge. Many viral
infections have been associated with thrombocytopenia
[van Gorp et al., 1999]. The occurrence of thrombocy-
topenia may be caused by a direct or indirect interac-
tion of the virus with platelets. This is the ®rst report,
to our knowledge, to describe the cross-reactivity of
patient serum IgM with platelets. The epitopes which
are shared between dengue virus proteins (e.g., NS1)
and speci®c platelet surface molecules remain further
elucidation.
ACKNOWLEDGMENTS
We thank Dr. J. H. Huang from the Center for
Disease Control, Department of Health, Taiwan for
providing the Japanese encephalitis patient sera; Dr.
D. C. Chang from Department of Medicine and Dr. K. C.
Yang from Department of Medical Technology, National
Cheng Kung University Medical College for providing
the hepatitis C patient sera. The enterovirus 71 patient
sera were collected by Dr. C. C. Liu, Department of
Pediatrics.
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