**5. Dengue lethality**

*Dengue Fever in a One Health Perspective*

compared with other serotypes [41].

nation, natural selection, and genetic bottlenecks [42].

**Guillain Barre syndrome epidemic**

detection [35].

nya's diagnosis [44].

dengue since they raised IgM values early.

the sera are selected for IgG using ELISA. Dengue infection cannot be excluded in samples that are negative for the NS1 antigen and must be confirmed by IgM/IgG

The fifth variant DENV-5 has been isolated in October 2013. This serotype follows the sylvatic cycle unlike the other four serotypes which follow the human cycle. The likely cause of emergence of the new serotype could be genetic recombi-

**4. Diagnosis of dengue and other arbovirosis in the context of the** 

During the months of June–July of 2019, 35 cases were registered and diagnosed as the Guillain-Barre Syndrome, at the Almanzor Aguinaga Asenjo National Hospital of Chiclayo in Peru, of which 22 had electrophysiology results compatible with the said syndrome, two had a normal result, and 11 were not evaluated with the mentioned diagnostic test. Three cases had IgG for flavivirus, three cases had IgG for flavivirus and IgG for chikungunya concomitantly, four cases had IgG for chikungunya, and one case had IgM for chikungunya. In other words, there were 11 cases of patients with a history of flavivirus or chikungunya infections in the context of the presentation of Guillain-Barre syndrome [43]. These patients were evaluated with the recomLine Tropical Fever IgG and IgM tests, immunoblot of German origin that has a sensitivity for IgG of 100% for primary infection by Zika, 100% for secondary infection for dengue or Zika, and 98.6% for primary infection by dengue; also the IgM has a sensitivity of 72.7% for dengue or Zika, and both tests have a specificity of 96–100%. On the other hand, the mentioned test describes a sensitivity and specificity of 100% for both IgM and IgG for chikungu-

In the literature, there is the case of a dengue patient who developed Guillain-Barre syndrome, who presented the NS1 antigen on the second day of symptoms with subsequent IgM and IgG positive on the sixth day of evolution [45]. There is also another case described with similar laboratory findings, but that developed the syndrome approximately 2 weeks after the onset of dengue symptoms [46]. Therefore, this syndrome could develop early or late in relation to the onset of symptoms due to infection. In our cases, we did not have positive IgM and we did not have the opportunity to evaluate the NS1 antigen, but it is noteworthy that all cases detected with flavivirus antibodies only had positive IgG in their results. The previous cases described in the existing literature may represent primary cases of

In our cases, the majority of patients did not show joint pain during the diagnosis

of Guillain-Barre syndrome, which could suggest that these are non-acute cases, but as described in the case cited, this syndrome may occur during convalescence of the dengue; on the other hand, in an endemic area such as Lambayeque-Peru, the presence of cases with secondary infection that usually have low IgM values and not even increase it (**Figure 5**) should not attract attention [47]. In addition, Ramabhatta et al. [48] conducted a study on a sample of 568 cases diagnosed of dengue and showed that IgG-positive patients were more prone to complications

Cases of DENV-2 had a higher proportion of severe dengue than among those of DENV-1 and DENV-4 [39]. Nevertheless, the secondary infection was not a predictor of severe clinical manifestation in adults, who were primarily infected with serotype DENV-3 [40]; on the other hand, the dengue in children have suggested that infection with secondary DENV-2 is more likely to result in severe disease

**42**
