title: Cross-Reactivity of Rapid Salmonella Typhi IgM Immunoassay in Dengue Fever Without Co-Existing Infection.
abstract: BACKGROUND
  Dengue fever is endemic in developing nations worldwide with as many as 500,000 annual cases of dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). A prompt and accurate diagnosis early in the disease course is essential for prompt identification and treatment of severe complications of the dengue virus infection (DVI). We identified cross-reactivity of a rapid IgM test for typhoid fever in patients with febrile illnesses that were determined to be due to dengue virus.
  
  
  METHODS
  All patients with documented DVI during a recent epidemic in Pakistan also underwent diagnostic testing for Salmonella enterica serovar Typhi. The diagnosis of DVI was made based on clinical findings and the positive results for dengue non-structural protein 1 antigen (NS1Ag) and/or dengue IgM antibody (anti-D IgM) during the acute phase of febrile illness. Patients with positive test results for Salmonella typhi (S. Typhi) IgM also had their blood cultures done.
  
  
  RESULTS
  In the group of 322 patients with clinical and serological evidence of DVI, 107 also tested positive for S. Typhi IgM. Blood cultures were negative for S. Typhi bacteria in all patients. Principal disease features included fever, headache, myalgia, retro-orbital pain, and a rash accompanied by thrombocytopenia and leukopenia. Comparisons of clinical and routine laboratory findings between the S. Typhi-positive and negative groups showed no significant differences. Patients testing positive for both NS1Ag and anti-D IgM were significantly more likely to test positive for S. Typhi IgM, even in the absence of typhoid fever. No routine antibiotics were used and all patients survived.
  
  
  CONCLUSIONS
  One-third of a large group of patients with primary DVI also demonstrated false positive results for typhoid fever. Cross-reactivity of a rapid immunoassay for typhoid fever has not been previously reported in DVI or any other flavivirus infections. Until these findings can be further evaluated, clinicians should be cautious in interpreting S. Typhi rapid immunoassays and have a high index of suspicion of DVI in dengue fever endemic areas.
authors.affiliation: Department of Medicine, Capital Development Authority Hospital, Islamabad, Pakistan.
authors.forename: Adnan Bashir
authors.initials: AB
authors.lastname: Bhatti
authors.affiliation: Department of Medicine, Capital Development Authority Hospital, Islamabad, Pakistan.
authors.forename: Farhan
authors.initials: F
authors.lastname: Ali
authors.affiliation: Department of Medicine, Capital Development Authority Hospital, Islamabad, Pakistan.
authors.forename: Siddique Akbar
authors.initials: SA
authors.lastname: Satti
keywords: dengue cross-reactivity; dengue false positive; dengue fever; dengue hemorrhagic fever; febrile fever; misdiagnosis