Additional Points

Letters to the editor regarding the article Dengue Fever Diagnosis, Risk Stratification, and Treatment by Paul Witte, Stefan Venturini, Helene Meyer, Andreas Zeller, and Michael Christ in issue 23/2024

According to more recent publications, the case fatality rate is mostly below the per mille range—which is, notably below the 1–5% mentioned in the article. Data from the Robert Koch-Institute (RKI) show a case fatality rate of 0.03% (2/6/247) for Germany over the past 10 years (2).

The Standing Vaccination Committee (STIKO) does not currently advocate a general recommendation to vaccinate dengue-naive individuals with the new vaccine—especially as questions remain regarding virus serotypes 3 and 4 and recalculations for rarely occurring severe dengue fever have shown no effect. But the license authorization in Germany is—in accordance with the European Medicines Agency (EMA) and Paul Ehrlich-Institute (PEI)—independent of any prior infection with the dengue virus as the pre-approval studies showed protection against infections and hospital admissions. After an individual risk-benefit analysis, vaccination may therefore be considered in specific situations—for example, for long-term travelers or persons who grew up in regions where dengue is endemic or have lived there for a long time and are traveling again into such regions (3).

For the clinical differential diagnosis, careful distinction is required between limb pain and arthralgia. The classic triad for dengue entails fever, headache/limb pain, and exanthema. Genuine arthralgias tend to be the exception and are mostly put into perspective by the patient when asked. By contrast, infection with the chikungunya virus—also caused by an arbovirus and accompanied by fever—has as its leading symptom symmetrical distal arthralgia and, depending on the phase, requires different analgesic treatments. The lack of distinction between the terms limb pain and arthralgia—often perpetuated in studies—is based on a historical misunderstanding. Several chikungunya epidemics in the 19th century were incorrectly referred to as dengue fever. Only modern virology allowed the specific clarification of pathognomonic arthralgia in a chikungunya epidemic in India in 1964 and enabled the distinction from the typical dengue symptoms (4).

DOI: 10.3238/arztebl.m2025.0024

Dr. med. Günther Slesak, DTM&H, MScIH

Dr. med. Johannes Schäfer, DTM&H, MScID
Tropenklink Paul-Lechler-Krankenhaus, Fachbereich Tropenmedizin

Tübingen, Germany

Conflict of interest statement

The authors declare that no conflict of interest exists.

References

1. Witte P, Venturini S, Meyer H, Zeller A, Christ M: Dengue fever—diagnosis, risk stratification, and treatment. Dtsch Arztebl Int 2024; 121: 773–8

2. RKI: Denguefieber. Infektionsepidemiologische Jahrbücher für 2013–2022. www.rki.de/DE/Aktuelles/Publikationen/Infektionsepidemiologisches-Jahrbuch/infektionsepidemiologisches-jahrbuch-node.html (last accessed on 12 February 2025).

3. STAR der DTG. FAQ zu Qdenga. Stand 16.02.24. www.dtg.org/ (last accessed on 5 February 2025).

4. Halstead SB: Reappearance of Chikungunya, formerly called Dengue, in the Americas. Emerg Infect Dis 2015; 21: 557–61