pathogenesis liver involvement

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Transactions of the Royal Society of Tropical Medicine and Hygiene (2006) 100, 608614

a v a i l a b le a t w w w . s c i en c e d i r e c t .c o m

j o u r n a l h o m e p a g e : w w w . e l s e v i e r h e a l t h . c o m / j o u r n a l s / t r s t

REVIEW

Pathogenesis of liver involvement during dengue

viral infections

S.L. Seneviratne a,, G.N. Malavige b, H.J. de Silva c

a Department of Clinical Immunology, Level 7, John Radcliffe Hospital, Oxford OX3 9DU, UKb Department of Microbiology, Faculty of Medicine, University of Jayawardenapura, Sri Lankac Department of Medicine, Faculty of Medicine, University of Kelaniya, Sri Lanka

Received 9 August 2005; received in revised form 21 October 2005; accepted 21 October 2005

Available online 17 February 2006

KEYWORDS

Dengue;Liver;Transaminases;Immune mechanisms;Clinical observations

Summary The dengue virus can infect many cell types and cause diverse clinical and patho-

logical effects. We describe clinical and experimental observations that suggest that liver

involvement occurs during dengue infections, and we outline the possible role played by host

immune responses in this process.

2005 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights

reserved.

1. Introduction

Dengue is epidemic or endemic in virtually every tropi-cal country. It is the most important viral haemorrhagicfever in the world. Infection may be clinically asymptomaticor give rise to undifferentiated fever, dengue fever (DF),dengue haemorrhagic fever (DHF) or dengue shock syndrome(DSS).

The dengue virus, an RNA virus, belongs to the Flaviviri-dae family, and consists of four serotypes (DEN14). Thevirus can infect many cell types and cause diverse clinicaland pathological effects. Its main effects are on the vascular,muscular and haematological systems. However, both clini-cal and experimental observations suggest that there is liverinvolvement during dengue infection. This liver dysfunctioncould be a direct viral effect on liver cells or be an adverse

Corresponding author. Tel.: +44 1865 225993;fax: +44 1865 225990.

E-mail address: [email protected] (S.L. Seneviratne).

consequence of dysregulated host immune responses againstthe virus.

In this mini-review we outline the clinical and experimen-tal observations of liver involvement during dengue infec-tions, and discuss the possible role played by host immuneresponses in this process.

2. Clinical observations

Clinical evidence of liver involvement in dengue infections

includes the presence of hepatomegaly and increased serumliver enzymes. Hepatomegaly is frequent and is commonerin patients with DHF than in those with DF. Several studiesdocument raised serum transaminase levels in dengue infec-tion. Transaminase levels are also higher in DHF/DSS than inDF and tend to return to normal 1421 d after infection.

Kuo et al. (1992) evaluated 270 dengue patients andfound abnormal aspartate transaminase (AST) and alanineaminotransaminase (ALT) levels in 93.3 and 82.2%, respec-tively. Most had mild to moderate increases, while levels

0035-9203/$ see front matter 2005 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.trstmh.2005.10.007


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Liver involvement in dengue infections 609

more than 10 times the normal upper limit were seen in11.2 and 7.4% of patients. Nimmannitya (1987), investigat-ing 145 dengue patients, found ALT levels to be normal,slightly elevated or significantly elevated in 74, 18 and 8%of patients, respectively. No mention of AST levels werefound in this report. Wahid et al. (2000) studied 50 sero-logically confirmed cases of dengue (25 cases each of DFand DHF), and found serum AST and ALT levels to be signif-

icantly higher in patients with DHF. In addition, Mohan etal. (2000), who evaluated children with dengue (37 cases ofDF, 16 with DHF and 8 with DSS), found abnormal transami-nases in 96%, with higher levels in DHF/DSS. Of 1585 denguepatients (65% with primary dengue, 91% with DF) studiedby Souza et al. (2004), during a dengue epidemic in Riode Janeiro, Brazil, alterations in AST and ALT were seen in63.4 and 45% of patients, with 3.8% having transaminase lev-els >10 times the upper limit of normal. Fulminant hepaticfailure complicating severe DHF/DSS has also been docu-mented, and is associated with a poor prognosis (Alvarezand Ramirez-Ronda, 1985; Lawn et al., 2003; Lum et al.,1993; Munasinghe and Rajasuriya, 1967; Nguyen et al., 1997;Subramanian et al., 2005). Nimmannitya et al. (1987) have

reported 18 DHF cases with jaundice and encephalopathy,of whom 10 died.

Varying abnormalities in liver enzymes appear to bepresent in most patients with symptomatic dengue infec-tions, but they tend to recover soon (Pancharoen et al.,2002). There does not appear to be chronic liver dam-age as with the hepatitis B and C viruses. In a subgroupof predominantly DHF/DSS patients, severe liver dysfunc-tion occurs and is a marker of poor prognosis. During somedengue epidemics, greater degrees of liver damage are seen(Ehrenkranz et al., 1971). Although this may be a conse-quence of different dengue serotypes having varying tissuetrophism, this has not been widely studied.

Some investigators suggest that liver damage may bepotentiated by the intake of drugs (such as acetaminophenand anti-emetics) during the early phase of the illness, butothers do not see this (Suvatte et al., 1990). The courseappears not to be influenced by concomitant hepatitis virusinfection (Chung et al., 1992). Although hepatitis B virus(HBV) is hyperendemic in parts of South America and in theFar East, no evidence exists that HBV infection acts as aco-factor for hepatic damage in dengue infections.

In dengue infections, elevations in serum AST appear tobe greater than ALT levels. This differs from the pattern inviral hepatitis, in which ALT levels are usually higher than orequal to AST levels (Gholson et al., 1990), but it is similarto that seen with alcoholic hepatitis. The exact significance

of this pattern seen in dengue is uncertain. It has been sug-gested that it may be due to excess release of AST fromdamaged myocytes during dengue infections (Chung et al.,1992), but this has not been formally tested. Simultane-ous measurement of muscle isoforms of lactate dehydro-genase and creatinine kinase may help further clarify thisobservation. The elevated AST levels tend to return to nor-mal more rapidly than ALT levels. This is possibly becauseAST (12.522 h) has a shorter half-life than ALT (3243 h)(Hawker, 1991).

Histological changes reported in the liver in dengueinclude: microvesicular steatosis, hepatocellular necrosis,Kupffer cell hyperplasia and destruction, Councilman bodies

and cellular infiltrates at the portal tract (Bhamarapravati,1989; Burke, 1968). Most reports are based on small num-bers of samples obtained from fatal cases. The presence ofthrombocytopenia and coagulative dysfunction makes it dif-ficult to obtain samples from others. As such, one is unsure ofthe degree of changes present in those with milder disease.Steatosis occurs frequently in hepatitis of viral origin andno special significance can be attributed to this process in

dengue infections. Hepatocellular necrosis in dengue gener-ally affects the midzonal area and sometimes the centrolob-ular area. Reasons for this pattern may be that hepatocytesin this zone are more sensitive to anoxia or the products ofan immune response (e.g. cytokines and chemokines) or thatthe dengue virus preferentially infects cells in this zone. Infact, dengue viral RNA and protein have been detected inmidzonal hepatocytes, mostly around necrotic foci. Council-man (acidophilic) bodies correspond to hepatocytes showingthe characteristic morphology of apoptosis. Inflammatorymononuclear cell infiltrates (of varying intensity) are seenin most specimens studied so far.

The dengue virus has been isolated from the liver of fatalcases (Burke, 1968; Rosen et al., 1989; Sumarmo et al.,

1983). Some find it the main organ from which virus could beisolated (Bhamarapravati, 1997; Huerre et al., 2001; Rosenet al., 1989). For instance, using mosquito inoculation tech-niques, DEN-2 or DEN-3 viruses were recovered from thelivers of 5 of 17 fatal cases, but rarely from other tissues(Rosen et al., 1989).

Using dengue-specific RT-PCR on liver samples from fatalcases, dengue RNA was detected in 11 of 15 (Rosen et al.,1999). Dengue RT-PCR has been done on paraffin-embeddedsamples from autopsies of 10 children with a clinical diag-nosis of DHF/DSS 17 years after their death. In 44, 80and 43% of cases, DEN-2 RNA was detected in the liver,spleen and lymph nodes (Sariol et al., 1999). Dengue viral

RNA has also been detected in midzonal hepatocytes ofarchived paraffin-embedded autopsy tissues using an in-situPCR method (Kangwanpong et al., 1995).

Immunohistochemistry and in-situ hybridization havebeen used to localize dengue antigens in naturally infectedhuman tissues (Jessie et al., 2004), with immunoperoxidasemethods suggested to be reliable and specific in diagnosingdengue or yellow fever infection from human archive sam-ples (Hall et al., 1991).

Clinical manifestations in severe dengue disease andyellow fever are similar. Viruses causing them are closelyrelated (both are flaviruses, transmitted by the same groupof vectors). Overall liver pathology in dengue appears tobe similar to that observed during the early stages of yel-

low fever (Bhamarapravati, 1997). However, in yellow fever,liver cell necrosis tends to be more severe and extensive. Inaddition, immunofluorescence patterns in infected HepG2cells differ. While dengue viral antigens are found as largeperinuclear inclusions and small cytoplasmic foci, yellowfever antigens are homogeneously distributed throughoutthe cytoplasm (Marianneau et al., 1998). DEN-2 infectionof HepG2 cells leads to the release of only a small amountof infectious particles and a slight increase in the numberof viral antigen-containing cells over time. By contrast, yel-low fever viruses replicated to high titres and infected allexposed cells (Marianneau et al., 1998). Furthermore, whiledengue virus-infected cells died rapidly by apoptosis, the


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610 S.L. Seneviratne et al.

highly productive yellow fever virus-infected cells did notshow early cytopathic changes (Marianneau et al., 1998).It is possible that early apoptosis of infected hepatocytesfollowed by their rapid clearance by surrounding phago-cytic cells may help to limit the spread of the dengue virus.By contrast, the delayed appearance of apoptotic liver celldeath in yellow fever may occur too late. At this stage mostcells may have already been infected, causing severe liver

destruction.The dengue virus is able to replicate in both hepatocytes

and Kupffer cells (Huerre et al., 2001). Although dengueviruses can enter human Kupffer cells efficiently, replica-tive infection of these cells appears not to be very effi-cient (Marianneau et al., 1999). This may be because mostviral particles enter such cells by phagocytosis, a processknown to lead to viral degradation. In the smaller num-ber of Kupffer cells in which virus replication can occur,the virus probably enters by receptor-mediated endocytosisand fusion. Two phases of Kupffer cell activation have beendescribed. The first phase occurs shortly after infection withnitric oxide and IFN- production, with a second a few hourslater, involving IL-6 and TNF- synthesis (Marianneau et al.,

1999).Infection of hepatic cell lines HepG2 and THLE-3 with

ChemiVaxTM -DEN14 and their parent viruses, wild-typeDEN14 and YF17D, showed significant differences in growthkinetics (Brandler et al., 2005). The YF17D virus producedhigher titres and caused extensive cytopathic effects earlierthan ChemiVaxTM -DEN14 or wild-type DEN14 viruses. Thelack of growth of chimeric viruses in human hepatic cellssuggests that these viruses may be less hepatotrophic thanYF17D virus vaccine in humans.

3. Experimental observations

To infect cells, dengue viruses need first to attach to hostcell surfaces. This attachment process is considered a majordeterminant of the viral host range and tissue tropism.The dengue viral envelope protein has been implicated asthe viral attachment protein (Chen et al., 1996). Followingpenetration, internalization occurs by either endocytosis ordirect fusion. Evidence exists for both receptor-mediatedand non-receptor-mediated entry pathways.

There is considerable interest in determining the natureof cellular proteins used by different viruses to enter cells.Identification of such proteins may allow us to rationallydesign small peptide-based molecules that are able to pre-vent or modify such interactions. In the case of the dengue

viruses, some of these molecules include: DC-specific ICAM-3 grabbing non-integrin (DC-SIGN) used by the virus togain entry into monocyte-derived dendritic cells (Navarro-Sanchez et al., 2003); the Fc receptor used in cases of sec-ondary infection to gain entry into monocytes (Daughaday etal., 1981); and monocytemacrophage complement recep-tors (CR3) mediating IgM-dependent enhancement of fla-vivirus replication (Cardosa et al., 1983).

Several viruses are able to bind heparan sulphate (HS),a ubiquitous glycosaminoglycan found on the surface ofcells. HS may act directly as a virus receptor or serve asa low-affinity virus-binding site, allowing the virus to accu-mulate before transfer to its high-affinity receptor (Chen

et al., 1997; Germi et al., 2002). HS is reported to beinvolved in entry of all four dengue serotypes into HepG2cells (Thepparit et al., 2004). However, the degree of inter-nalization varied between serotypes.

At present, exact mechanisms of interaction (includingthe nature of molecules that facilitate entry) between thedengue virus and liver cells are poorly defined. Glucoseregulated protein 78 (GRP78) was reported to be used by

DEN-2 to gain entry into HepG2 cells (a human hepatoblas-toma cell line) (Jindadamrongwech et al., 2004). Thepparitand Smith (2004) suggested that the DEN-1 virus (but notthe other dengue serotypes) used the 37/67 high-affinitylaminin receptor to enter liver cells. This is a non-integrincell surface molecule expressed on normal human liver cells,with upregulated levels on liver carcinoma cells. Lamininreceptor binding appeared to occur both directly or via HS-dependent interactions. Interestingly, a similar mechanismhas been previously proposed for entry of prion proteins(Gauczynski et al., 2001) and Sindbis viruses (Wang et al.,1992) into cells. Hilgard and Stockert (2000), studying DEN-1 binding protein expression using the Huh7 liver cell line,found the virus able to bind two membrane proteins (approx-

imately 33 and 37 kDa in size). It is possible that the 37-kDaprotein described in this report is similar to the moleculedescribed by Thepparit and Smith (2004).

The permissiveness of a cell to infection by a virus is con-sidered to be due to two factors: the ability of the virus toenter the cell, and the factors within the cell that enablethe virus to replicate successfully. Cellular permissivenessto dengue virus infection appears to be modulated by viralserotype, strain and cell type. HepG2 cells show a markedinfluence of cell physiology, with cells in the G2 phase ofthe cell cycle having a higher susceptibility to infection anda higher rate of virus production per cell (Phoolcharoen andSmith, 2004). The link between the cell cycle and the per-

missiveness of liver cells to infection with the dengue virusmay point the way to understanding the greater suscepti-bility of children towards the more severe forms of dengueinfection (Phoolcharoen and Smith, 2004).

Under experimental conditions, HepG2 cell bindingof DEN-1 and DEN-2 was found to be non-saturable(Suksanpaisan and Smith, 2003), in keeping with results usingHuh7 cells (Hilgard and Stockert, 2000). It is suggested thereis a degree of cooperation in dengue virus binding onto livercells. The binding of one virus to a liver cell serves to facili-tate binding of further virus particles, thus making it easierfor successive particles to bind. It does this is by inducingconformational changes in cell surface binding molecules.

Dengue viruses have varying effects on liver cell lines in

vitro. DEN-2 were able to attach equally well to five liver celllines, but rates of replication and levels of virion productionwere higher in the differentiated cell lines (Hul7, PLC, M3Band Chang) than in a de-differentiated cell line (HA22T) (Linet al., 2000b). It is possible that specific cell differentiationfactors may play important roles in viral replication withinhepatocytes. Studies aimed at identifying such factors mayallow us to understand this process better. Heparin is ableto inhibit DEN-2 virus invasion of the different liver cell lines(Lin et al., 2002). Dengue viruses have differential suscep-tibility to heparin inhibition. This property may be used forscreening and selecting mutant viruses for use in differentanimal models.


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RANTES (regulated upon activation, normal T cellexpressed and secreted), a CC chemokine has chemotac-tic activity for T cells, monocytes, natural killer cells andeosinophils. Levels are higher in patients infected withthe dengue virus. Correlation between DEN-2 infection andupregulated RANTES gene expression in liver cells has beenshown in vitro (Lin et al., 2000a). It has been hypothe-sized that dengue infection of liver cells upregulates RANTES

mRNA expression by oxidant-dependent and -independentpathways.

Following dengue infection, cellular apoptosis in the liverhas been seen both in vivo and in vitro (Couvelard et al.,1999; Marianneau et al., 1996, 1997). The Councilman bod-ies are believed to be the remains of cells undergoingapoptosis (Huerre et al., 2001). Dengue virus infection ofprimary cultures of human Kupffer cells and a hepatomacell line induces apoptosis, as evidenced by DNA laddering(Marianneau et al., 1997, 1999). Activation of the transcrip-tion factor NF-B has been implicated in the induction ofapoptosis (Marianneau et al., 1997). NF-B decoys were ableto inhibit HepG2 apoptosis, further pointing to the importantrole played by the NF-B pathway in this process. Modulat-

ing this activity may have future therapeutic potential inpatients with severe dengue-induced liver dysfunction.

Several mechanisms may be involved in dengue-inducedliver cell apoptosis. These include direct cytopathic effectsof the virus, mitochondrial dysfunction due to low flowhypoxia and the influence of cellular and humoral immunefactors in the liver (as is observed in other types of viral hep-atitis). The apoptotic process appears to be independent ofp53 (Thongtan et al., 2004). Increased levels of endoplasmicreticulum stress have been speculated to induce apoptosisin dengue, as has been previously proposed with Japaneseencephalitis, another member of the Flavivirus genus (Suet al., 2002). Recently, dengue virus-induced TRAIL (tumour

necrosis factor-related apoptosis-inducing ligand) expres-sion has been suggested to be partly responsible for causingapoptosis (Matsuda et al., 2005). DEN-2 infection was shownto cause TRAIL promotor activation, whereas a proteosomeinhibitor and TRAIL antibody were able to inhibit DEN-2-induced apoptosis.

An animal model for dengue was established by trans-planting a human HepG2 cell line into severe combinedimmunodeficient (SCID) mice, followed by intraperitonealinfection with DEN-2 virus 8 weeks later (An et al., 1999).During the early post-infection stages, high viral titres werefound in the liver and serum but not the brain. Paes et al.(2005) have used BALB/c mice to study liver injury follow-ing inoculation with a DEN-2 virus isolated from a human

patient. Although the mice did not present with clinicalsigns and survived the infection, hepatic injury was seenin all individuals. Dengue viral antigens were found in theliver. Elevated transaminase levels correlating with a peakof viraemia were noted.

4. Immunopathogenic mechanisms

An excellent review on current knowledge of dengue patho-genesis has been recently published (Stephenson, 2005).Therefore, in this article, we will only describe salient fea-tures of the immune response during dengue infections and

attempt to outline its relationship to liver involvement indengue.

Both innate and adaptive host immune responses playimportant roles in determining the natural history of viralinfections. Innate immune responses are induced rapidlyand act as first-line defences until specific adaptive immuneresponses come into play. Differences in antibody, T-cell andcytokine responses are seen among patients with uncompli-

cated DF or DHF/DSS.The immune enhancement and viral virulence hypothe-

ses have been put forward to explain the causation of severedengue disease. Antibody-dependent enhancement (ADE)attempts to explain the observation that individuals expe-riencing a secondary infection with a heterologous dengueviral serotype have a significantly higher risk of developingDHF/DSS. During secondary dengue infections, preexistingnon-neutralizing antibodies may form complexes with thevirus and enhance its uptake and replication in macrophages(Halstead and ORourke, 1977). The viral virulence hypoth-esis is based on the observation that some dengue viruseshave greater epidemic potential than others. These viru-lent strains replicate faster and to higher concentrations and

hence cause higher levels of viraemia.Effective CD4+ and CD8+ T-cell responses have been sug-

gested to play an important role in clearance of acutedengue viraemia. Following primary dengue, both serotype-specific and serotype-cross-reactive memory T cells areformed. On secondary exposure to a different viral serotype,most serotype-cross-reactive CD4+ and CD8+ T cells are ableto augment infection by producing various cytokines (Kuraneet al., 1990).

During dengue infection, monocytes, B cells, T cells andmast cells produce large amounts of cytokines. Serum con-centrations of TNF-, IL-2, IL-6 and IFN- are highest in thefirst three days of illness while IL-10, IL-5 and IL-4 tend

to appear later (Chaturvedi et al., 1999). It has been sug-gested that predominant Th2 responses (IL-4, IL-5) occur inDHF/DSS, whereas Th1 (IFN-) responses seem to protectagainst severe infections.

Using MHC class I tetrameric complexes loaded with apeptide from the NS3 protein, expansion of CD8+ T cells withrelatively low affinity for the currently infecting virus andhigher affinity for serotypes presumed to have been encoun-tered in the past were found (Mongkolsapaya et al., 2003).This was thought to result from the detrimental effects oforiginal antigenic sin. It was argued that these inappro-priate T cells contribute to immunopathology while doinglittle to clear the virus. Another explanation suggested forthese findings was that high antigenic load associated with

a second dengue infection (due to immune enhancement),may preferentially drive high-affinity T cells into apoptosis,which would in turn increase the frequency of lower-affinitycells (Mongkolsapaya et al., 2003).

T-cell responses in dengue infections need to be wellregulated, to avoid specific downsides. For instance, in theprocess of viral elimination, damage to vital target organsmay occur. As in the case of the other hepatitis viruses,dengue virus-specific CD4+ and CD8+ T cells may cause livercell damage by direct cytolytic and/or cytokine-mediatedeffects. Cytokines produced during the immune responsemay also have ill effects, such as promoting the excessivedeposition of extracellular matrix.


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Bhamarapravati et al. (1967) examined the liver pathol-ogy of 100 fatal paediatric DHF cases (aged 5 months to 14years) and reported that cellular infiltration was noted in 64cases. Lymphocytoid cells, megakaryocytes and rarely neu-trophils were observed in the sinusoids. Cellular infiltrationaround the portal tract comprised lymphocytes, plasmacy-toid cells and some histiocytes. In a recent study by Huerreet al. (2001), in five fatal paediatric cases (aged 10 months

to 6 years), little or no inflammatory infiltrate was found infour cases and a moderate periportal infiltrate in one.

Chen et al. (2004) infected immunocompetent C57BL/6mice with high titres of DEN-2 strain 16681 and studied lym-phocyte activation and hepatic cellular infiltration. T cells inthe infected mice were found to be activated and function-ally active, as evidenced by the production of IFN-. Mostof the activated cells were CD8+ T cells. Liver enzyme ele-vation and hepatic T-cell infiltration were found to coincidewith the kinetics of T-cell activation. Hepatic cellular infil-trates consisted predominantly of T cells. While most CD4+T cells clustered around the portal vein, most CD8+ T cellswere scattered in the hepatic acinus. Flow cytometric anal-ysis of liver infiltrating T cells showed that nearly two-thirds

were CD8+ T cells.Gagnon et al. (1999) have postulated that CD4+ cytotoxic

T cells (CTLs) may mediate liver damage in dengue through amechanism involving bystander lysis. CD4+ T-cell-mediatedcytotoxicity is thought to occur via two main pathways:release of perforin and granzymes from the activated CTLor the interaction of Fas ligand on T cells with Fas on thetarget cell. The Fas/Fas-L pathway could contribute to thedestruction of cells presenting viral antigens as well as non-antigen-presenting bystander cells that express Fas. Dengueviral capsid-protein-specific CD4+ T-cell clones were able tomediate bystander lysis of HepG2 and Jurkat cells. It hasbeen suggested that dengue virus-specific CTL may be acti-

vated by dengue virus-infected Kupffer cells, and in turnlyse hepatocytes via a bystander mechanism. However, suchbystander lysis has still not been demonstrated in vivo.

At present, the part played by the host immune responsein liver damage is unclear. Differences in the intensity ofmononuclear cell infiltrates in the liver have been reportedin human and animal studies. Although it has been suggestedthat cellular infiltrates are lower following arboviral infec-tions than following hepatitis B or C infection, reports inhuman and animal models of dengue suggest significant infil-trates may occur. It is known that activated viral-specific Tcells are able to bind specific receptors on virus-infectedcells and induce their apoptosis. It is possible that someT cells that enter the liver may cause damage and either

undergo apoptosis or leave the liver. They may also producea range of cytokines/chemokines, and cause damage to tar-get organs (such as the liver) at a distance from the site ofimmune activation.

5. Conclusion

In summary, clinical and experimental observations suggestthat liver involvement occurs during dengue infections. Clin-ical evidence includes hepatomegaly and increased serumliver enzymes, with liver involvement being more pro-nounced in the more severe forms of infection. Dengue viral

antigens have been found within hepatocytes, and the virusappears to be able to replicate in both hepatocytes andKupffer cells, and dysregulated host immune responses mayplay an important causative role in liver damage. Modulatingthese immune responses may have a therapeutic potential.There are limitations in the investigation of liver involve-ment in dengue infection. Immunopathological lesions in theliver are difficult to study in patients with thrombocytope-

nia and coagulative dysfunction; present knowledge is basedmainly on post-mortem specimens and animal models.

Conflicts of interest statement

The authors have no conflicts of interest concerning the workreported in this paper.

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