When I sliced my toe on a rusty grate during last year’s Lunar New Year fireworks in Vietnam, I never thought it was the beginning of a long saga that would end with a dengue fever diagnosis. At the time, I ignored my bleeding toe. I opted instead to breathe through the burning and the pain to watch fireworks instead. After the light show ended, I stumbled down to my friend’s apartment to examine the injury. The grate had pierced my toenail and then cut diagonally across the side of my toe, necessitating a tetanus shot and much limping, but thankfully no stitches.
My Vietnamese friends were aghast. The local beliefs surrounding Tet, Vietnam’s Lunar New Year, include the fact that what happens around midnight on Tet eve predicts and dictates the tone and spirit of your coming year. This is why, as I noted in my long roundup from last Lunar New Year, the person who crosses the threshold into a person’s house at midnight must be compatible with the new year’s astrological sign.
My Vietnamese friends urged me to take care during this Year of the Snake and they predicted that it would be fraught with health issues. After all, it started badly, with an inauspicious blow to my general health (and my toe). Business-wise it could be a success, they insisted, but in terms of personal wellness they were worried.
I laughed it off. When I climbed Agung and Rinjani in Indonesia in 2009, I lost several toenails and much of the skin off the back of my heel. Plus, I’m also fairly clumsy. I’ve been known to walk into walls when not looking, to trip over sidewalks, to have an alarming amount of near-misses over the course of my life.
But my friends were unrelenting. This injury was different. This was a harbinger of a trend for the coming lunar year. I would, they asserted, anxiously await the day that the Year of the Snake was over.
They were right.
** NOTE: for those seeking info about dengue and chikungunya, please click here to head toward the bottom of this post. I frequently update this post with dengue tallies in Southeast Asia and elsewhere, as well as news about the virus. **
How do you know if you have dengue fever? I didn’t.
There is a reason that I only do the state of the union -style posts once a year, or rarely delve into more personal issues: I don’t want this site to be a place where I whine or rant. I want it to be a place where people can learn through food.
So it is for this reason that when I started losing clumps of my hair in late February 2013. I never wrote about it, nor shared updates on my Facebook page. And a month later when I stopped being able to bend my hands or knees in the morning without considerable pain, or look at bright light, I didn’t mention that either. I kept up my usual schedule in Vietnam, exploring the Mekong and surrounding regions and walking around town for hours a day.
In May 2013, after flying to England to visit my family, I could barely walk down the street without feeling exhausted. Alarmingly, when my leg or arm was itchy and I scratched it, I’d develop lines of bruises, colouring the spot where nails had met skin.
As the summer went on and my existing obligations and plans were ticked off the list — conferences, meetups, interviews and more — I found myself getting sicker and more tired. My immune system was just not cooperating with anything I did; every cold or virus seemed to latch onto me stubbornly, and most of my days were obfuscated by a cloud of exhaustion.
Doctors were fairly unhelpful. One suggested that I was just stressed. As a former corporate lawyer I was pretty intimate with high stress situations, and I certainly was not stressed. Well, except about the fact that my health was deteriorating. Which, I think, was pretty reasonable on the spectrum of Events to Stress About.
In actuality, the pain and hair loss had started at a time when I was the least stressed in decades; I was in Vietnam, loving my exploration of the city and its soups. Another thought I had lupus, and to be fair many of the symptoms lined up, but blood tests gave no indication that I might have it — back to square one.
In August, I took friends up on their offer to housesit during their honeymoon, staying in San Francisco and exploring, and trying to rest. Notwithstanding some up days, my joints were, for the most part, worsening. I kept up my tradition of climbing a mountain for my birthday, but for two weeks after my day in Mount Tamalpais, I had trouble getting out of bed because of the pain.
Not knowing what was going on with my body coupled with the consequences of my decision not to share anything here or on social channels converted the chronic pain into a more anxious place; I was actually getting stressed. And I was having trouble explaining to people who wanted to meet up that I couldn’t, because based on my outward-facing social streams, no one would have thought I was having trouble bending my hands in the morning.
I confided in my close friends, all of whom were extremely generous with time and hugs, and who stretched their arms wide to pull in connections from their broader networks in the hopes of helping me figure out what was wrong. I was introduced to, and corresponded with, a woman whose many symptoms led her to cut out significant amounts of foods from her diet and completely change the way she lives her life in an attempt to keep her pain under control.
I met a gentleman at a conference who had similar health issues while trying to grow a successful startup, leading him to temporarily walk away from his company while he focused on getting better, a terribly tough decision to make.
Before doctors had ruled it out, I was connected to a woman had lupus, who shared coping strategies and foods to avoid.
And I was given the recommendation of a book that calmed my brain down considerably, Full Catastrophe Living, written for those dealing with the stress and exhaustion of chronic pain and fortuitously updated days before it was suggested to me.
By October when I was heading to India with my mum, I felt like I was hanging on by a thread. I sat in a pile of clothes, packing in tears. I was happy to be taking her to a country she wanted to see, but feeling like I might just stop functioning somewhere between Jaipur and Agra, and fall into a deep, long sleep.
As many of you know, we did have a terrific time in India, exploring the chaos and colour of Rajasthan in a few too-short weeks. But I did still get sick again and again, and much of the trip is cloudy with pain, too. By the time I flew home to Canada, the airline stewardesses took one look at me as we boarded the plane and then cleared out the back row and insisted I sleep. I was tired and confused and tired of being tired and confused.
And then, I figured it out.
Finally, an answer: mosquito-borne dengue fever, from my time in Vietnam.
I kept going back to February when it all began. Earlier in the month I was supposed to go to the Mekong, but I woke up feeling so sick and tired that I couldn’t budge. I had a splitting headache and it felt like someone was pressing on my eyeballs; nothing relieved the pain.
I thought I had a bad flu and I postponed my visit. My “flu” cleared up a few days later for the most part, though the headache took longer to go away. A few days later, when I was visiting Vung Tau with my friends, I developed a strange rash all over my stomach.
It wasn’t itchy — it was just flat red dots that appeared in constellations all over my torso and around my belly button. I remember my friends Christian, Marie-Claude and Andre all gathered around me and awkwardly peering in at my stomach one morning on the beach, confused. (We probably confused the passebys too).
We went with heat rash, and quickly forgot it existed.
A few days later it was gone.
What could have caused the rash and my flu-like symptoms and then all the tiredness, joint issues and pain?
Interestingly, that’s exactly why my friends Marie-Claude and Andre were in Vietnam — they had gotten dengue in Bangkok and were in recovery on their visa run. I Googled “dengue rash stomach” and saw exactly what was on my stomach in Vung Tau. And then I looked into what happens when you don’t take care of yourself when you have dengue. Those who have experience with it will know that the disease is not really treated per se; treatment involves hospital visits, hydration, and rest, and monitoring white blood cells and platelets, both of which are dangerously low when in the throes of its grasp.
But I learned that when you ignore it as I did, it starts wreaking all sorts of other havoc on your immune system, on your joints and on your general state of being. I went to a tropical diseases doctor when I was back in Vietnam and presented my case. They confirmed that dengue is almost certainly what had happened, which jived with a February infection and my subsequent blood test results, showing a lower-than-normal white blood cell and platelet count thereafter.
There are different types of dengue fever, called serotypes, that are active in different parts the of the world:
I was told often in Asia that recovery from one strain of dengue does offer lifelong immunity against that strain. And while ONE strain has immunity following infection, the infection actually makes the other strains more dangerous and more likely that they could develop into dengue hemorrhagic fever (DHF). See symptoms of that, below.
From ScienceMag’s “When Dengue Strikes Twice“:
Most of the more than 50 million people sickened by dengue virus each year develop dengue fever, a weeklong bout of joint and muscle pain. But many who suffer repeat infections have it worse. They come down with dengue hemorrhagic fever and suffer massive internal bleeding and liver damage. Oddly, the virus causing dengue fever comes in four strains, and immunity to one seems to make infection by a second strain more dangerous.”
The reason? Following one infection, T-cells were primed to fight a different strain than the new one attacking them. Plus, those dengue-specific CD4 T-cells rapidly self-destruct following a new infection, which leads to tissue damage.
For years, scientists thought that resulting immune system misfire / cell suicide could be a primary cause for DHF, versus the more ‘simple’ dengue fever. However, a late 2019 study cleared CD4 T-cells of any wrongdoing. “We found no evidence to support the common dogma that these T cells are responsible for turning a mild infection to a severe one,” said Yuan Tian, PhD, one of the scientists on the study. The hunt is on still for why DHF is so severe.
In 2020, Singapore reported a spike in the DenV-3 type of dengue, which their National Environment Agency notes may signal an outbreak in the near future. The DenV-1 and DenV-2 serotypes have been dominant in Singapore for the last three decades, so the country is on alert due to the rise of DenV-3 since population immunity is low and people are more susceptible to it.
What are the symptoms of dengue fever?
Dengue’s incubation period is between 4-10 days, so it’s difficult to backtrack to exactly what mosquito bit you. In my case, I have a very good idea. I was outside on a phone call and came inside so bitten up that I almost vomited. It was less than a week later that my symptoms started.
According to the CDC, the principal symptoms of dengue are high fever, feeling general malaise (like the flu), and at least two of the following:
- Severe headache
- Severe eye pain (behind eyes)
- Joint pain
- Muscle and/or bone pain
- Mild bleeding manifestation (e.g., nose or gum bleed, petechiae, or easy bruising)
- Low white cell count
What are the symptoms of dengue hemorrhagic fever (DHF)?
Dengue hemorrhagic fever (DHF, or as WHO calls it “severe dengue”) is a more deadly form of dengue first recognized in the 1950s during dengue epidemics in the Philippines and Thailand. In Asia, epidemic DHF expanded from Southeast Asian countries west to India, Sri Lanka, the Maldives, and Pakistan and east to China. (Source) Today, DHF is in most of Asia, Southeast Asia, and Latin America, and is a leading cause of hospitalization and death in those regions.
Symptoms of DHF include the above list plus:
- Persistent vomiting
- Severe abdominal pain
- Rapid, shallow breathing
- Blood in the vomit
- Bleeding gums
- Vascular leak syndrome
- Skin hemorrhages such as petechiae, purpuric lesions, and ecchymoses.
The even more worrisome dengue shock syndrome is defined as dengue hemorrhagic fever plus:
- Weak rapid pulse
- Narrow pulse pressure (less than 20 mm Hg)
- Cold, clammy skin
It involves a mostly clinical diagnosis, and is associated with high mortality. (Source)
What to do if you get diagnosed with dengue fever?
Obviously do NOT do what I did and simply not get tested for it.
No specific therapy has actually been shown to be effective in the treatment of any of the manifestations of dengue in a randomized controlled trial.
The mainstay of treatment is still careful fluid management. (Source)
So for treating a dengue infection:
- Get to a hospital and get tested.
- They will likely provide IV hydration and Tylenol.
- Do not use any aspirin or supplements that would thin the blood.
- Do not use NSAIDs either. This means no Advil/Ibuprofen.
- Lots of Nuun tablets and rehydration salts.
- Following the infection, I found going on a low-inflammation diet or auto-immune protocol diet very helpful. Please see my post about chronic pain for more.
- There is some evidence that mast cell stabilizers and targeting the immune system itself may be helpful, see this study.
- Avoid any medication that lowers platelet levels. These include Furosemide, NSAIDs (hence the above note about Advil), and some other medications. Best to ask your doctor to confirm.
What are the long-term, lingering effects of contracting dengue?
While many friends have come out just fine after a dengue infection, lingering effects are very widely documented.
- Depression and anxiety after the infection wanes (source) – likely due to systemic inflammation. See also this study about anxiety/depression and severity of dengue symptoms.
- Epigenetic changes – much like other severe infections or viruses, geneticists have begun to look at whether your gene composition could affect the severity of the infection or whether it creates sufficient inflammation to “express” genes you may already have and create a genetic cascade.
- Autoimmune marker changes to titers for C3/C4, rheumatoid factor (RF), C-reactive protein (CRP), antinuclear antibodies (ANA), and immune complex (IC). Study source.
- According to a survey published in 2020, patients with a history of dengue fever infection are at increased risk of developing leukemia compared with individuals without a history of dengue fever. The findings from this study were reported in Cancer Epidemiology, Biomarkers, & Prevention.
Where are you at risk for dengue fever?
Per the Center for Disease Control, dengue is endemic throughout the tropics, subtropics, Latin America, the Caribbean, and Southeast Asia. Presently, it occurs in more than 100 countries worldwide. Risk now includes the United States, where sporadic local cases have popped up in Florida, Hawaii, and Texas along the border with Mexico.
Although the geographic distribution of dengue is similar to that of malaria, dengue is more of a risk in urban and residential areas than is malaria. As such, the WHO estimates that over 40% of the world’s population live in areas where dengue viruses can be transmitted.
For up to date information of outbreaks in real-time, see DengueMap, but I’ve included the Asia/Oceania and Latin America maps from the CDC below.
Their full chapter on dengue is here.
According to the Pan American Health Organization, after almost two years of lower dengue transmission, there has been an increasing trend in both the number of reported dengue cases and the number of reported severe dengue cases since the end of 2018 and beginning of 2019. Brazil, Colombia, and Honduras account for 93% of the total number of reported cases in the Region of the Americas in that period. (source).
What about Chikungunya and Zika?
Dengue, Zika, and Chikunyunya are all carried by the pesky Aedes aegypti mosquito. As is yellow fever. And of all the mosquitoes out there, this one will happily breed in even the most shallow of water sources. It is unfortunately possible to obtain more than one mosquito-borne disease from the same mosquito.
Aedes aegypti is not the only species to carry the disease, but it is likely the most efficient: It happily takes up residence in human dwellings, biting many people in a row. If it feeds on a sick person, the disease incubates in its belly, then migrates to its salivary glands. It is injected at the next bite.[…]
After six dengue-free decades, Brazil had its first outbreak in 1981. The situation has deteriorated: Last year, 1.6 million people in Brazil were diagnosed with dengue, more than ever before. Chikungunya and Zika have infected hundreds of thousands more.
– Zika Uncontained, Frontline
An American reader living in Manila for many years kindly sent me her story of both dengue and a similar disease called Chikungunya. In her words:
“My experience was horrendous. Very, very similar to what you went through. The reason I am emailing you is to let you know it’s very likely you had both dengue and Chikungunya. The mosquito that carries dengue can also carry Chikungunya. If you get bit by a mosquito carrying both, you can be infected by both dengue and Chikungunya at the same time. This is what happened to me.
While both diseases have similar symptoms, the main difference is dengue can be fatal, Chikungunya isn’t. However, and this is huge — Chikungunya gives you terrible joint and muscle pains. These pains can last up to TWO years! Eventually you will recover completely though. And it can also leave you exhausted. This is all somewhat new – in fact most of us had never heard of Chikungunya before. There was an outbreak in Manila, and there has also been an increasing number of people getting both dengue and Chikungunya at the same time. Most ridiculously, there is not enough information about this.”
So, something to keep in mind if you’re exhibiting symptoms of the kind I mentioned. The rash for Chikungunya is generally on the stomach area, per what I’ve read, and joint pains ongoing. The high fever and joint and muscle pain can last for several months.
The symptoms for both diseases are quite similar, per the CDC, and it has so far been found far outside its usual locations and as far as Texas, Spain (as of August 2015), Mexico, and more, including the Caribbean where it was first detected in the Americas.
The mechanisms of infection of human cells with the virus remain very poorly understood. In September 2019, researchers have identified a protein, four-and-a-half LIM domain protein 1 (FHL1), that is required for the virus to replicate within its target cells. The study shows that FHL1 is a key factor that enables a Chikungunya infection, and allows for a target to potentially develop therapies to treat or preemptively prevent the infection/
Given that the three illnesses offer up similar symptoms, I wanted to devote a part of this post to Zika as well. The virus didn’t just appear in 2016. In fact, it’s been around for a long time. First identified in monkeys in Africa (Uganda to be exact) in the late 1940s, it spread to humans around the early 1950s. The World Health Organization documents the first case at 1952.
In recent years, with a warming planet and an increase in travel, the disease spread. In 2007, cases were reported in the South Pacific’s Yap Island with a larger outbreak on French Polynesia and in Brazil in 2013.
Zika’s symptoms are reported as quite mild — far more so than my dengue symptoms noted in this piece. Per Vox’s Zika Primer,
Zika produces very mild symptoms — rash, headaches, pain in the bones, and fever — that usually show up between three and 12 days after a mosquito bite. These symptoms usually go away within a week, and one in four people don’t even develop any symptoms after being infected with the virus. This means people don’t usually go to the doctor for Zika, and many cases go unnoticed. There’s also no vaccine or treatment for the virus, so doctors just work on controlling and alleviating its symptoms.
Prior to 2013, the disease was not in the Western media, partly because of these mild symptoms and a fairly low mortality rate (compared to, say, malaria or dengue). However, given its now-establish effects on pregnant women and microcephaly in their fetuses, the disease has become a global concern and opened up debates about women’s rights and contraception in the often-conservative countries that Zika has thus far spread.
Please see the end of this post for more articles about Zika.
An end to my year of travels … with dengue fever
So, after many months of not saying anything I’m writing this post to reiterate what not to do when you get dengue. Or, put another way, when in dengue-prone areas and having symptoms of the flu, if you then see a rash on your person GET THEE TO A DOCTOR. I wish I had gone to check it out, and could have then taken care of myself properly.
Many months later, when my toe hit my bed frame I heard it crack, a small echo that resonated despite the fact that I was on the curled edges of sleep. Clawing out of morning cobwebs I peered down, noticing quickly that my toe was bent forward at an unnatural angle, the pain radiating into my foot and up my leg.
I didn’t go to a doctor (I know, I know) because everyone and their mother — and even mine too — said that there’s nothing a doctor can do for a broken toe. I examined it, saw that it wasn’t turning grey or losing circulation, and that there was no open fracture or jutted bone. And then I ate a melon popsicle, cut it into pieces and made an awesome DIY splint, resigning myself to another few weeks of limping, of Vietnamese neighbours pointing at my toe and shaking their heads (in sympathy, not disgust) and of doing my food walks a little more slowly than I had initially anticipated.
My friends here were more positive.
“This all makes sense!” one of them exclaimed. “You started the year of the Snake so badly, with your toe and dengue. And now you are ending it by hurting the other foot. The snake is eating its head. You have come full circle.”
I listened to what they were saying, and I looked down at my toe.
I thought about this year of pain and exhaustion coupled with great press for the site and other business success, and then of new beginnings.
“You know”, I said, musing about the last twelve months, “I am born in the year of the goat. And it’s common for goats to have trouble in snake years, but we’re about to head into the year of the wooden horse, and goats do much better then.”
And my friend looked at me, and then looked down at my toe and giggled.
“Jodi, either you are a Vietnamese person under all of that Canadian-ness, or you’ve just been here too long.”
I look forward to ending the Year of the Snake too, and ushering in the Year of the Horse with open arms.
Global Update from 2020: Mosquito-Borne Illnesses Like Dengue, Chikunyunya and Zika
With a warming planet, mosquitoes have proliferated, and mosquito-borne illnesses have swept across the globe. Each years seems to be a been banner year for those illnesses, with more and more mainstream news coverage about dengue, Chikungunya and Zika.
I currently have friends in Siem Reap, Cuba, Rio de Janeiro, and Delhi who have dengue at the same time and in very disparate places. One of the hardest symptoms following dengue is the depression and anxiety that follows. Given how prevalent it is becoming, as well as the additional reporting about Chikungunya and Zika, I wanted to add a few more resources:
Mosquito transmission of disease:
- A November 1, 2019 episode of Bloomberg’s Moonshot investigates how scientists are attempting to modify the Aedes aegypti mosquito, the primary vector for infecting humans with dengue. After injecting the insects with a bacteria called Wolbachia, which blocks transmission of the disease to humans, the non-profit research team released them out into the world. “My hope,” Scott O’Neill, the founder of The World Mosquito Project, says, “would be that we could eliminate dengue at some point.”
- Interesting article from the Smithsonian Magazine, about how the isolation of a single protein could help develop a vaccine for dengue. This is a different vaccine than the Sanofi one that is in development and testing stages, since it targets a protein that, if this piece is correct, could help protect against all of the dengue strains.
- A 2019 piece in the New York Times, “The Mosquitoes are Coming for Us” goes into history as well. “The mosquito and her diseases have accompanied traders, travelers, soldiers and settlers (and their captive African slaves) around the world and have been far more lethal than any manufactured weapons or inventions.”
- A 2019 article about how mosquitoes “slaughtered our ancestors and derailed history” in the New Yorker. “Along with smallpox and influenza, mosquito-borne diseases led, by Winegard’s estimate, to the deaths of ninety-five million indigenous inhabitants of the Americas, from a pre-contact population of about a hundred million.“
- For dengue in the United States, the CDC reports that there were 1,203 cases of dengue in the USA and 56 in the US territories. Note that all US-reported cases were contracted abroad except for the state of Florida.
- A September 2019 piece from CNN about dengue and how it travels, including how climate change accelerates the spread worldwide. From the piece:
Cambodia, Laos, Malaysia, Singapore, Sri Lanka, Thailand, and Vietnam have all reported higher than normal cases of the disease and deaths [in 2019] compared to last year. And the Philippines has declared a national dengue epidemic — 1,107 people have died there since the start of the year and more than 250,000 have been infected.
Dengue is a seasonal, mosquito-borne disease commonly found in hot, wet regions of the tropics and subtropics during the rainy months. Scientists say hotter, wetter weather brought on by climate change has created ideal conditions for female mosquitoes to lay their eggs. Not only are there more mosquitoes, but the rapid urbanization occurring in many Asian nations means that susceptible populations are living in closer contact with disease-carrying insects.
The Pan-American Health organization reports that on the first 4 weeks of 2020, there were 125,514 dengue cases reported (12.86 cases per 100,000 population), including 27 deaths. Countries such as Bolivia, Honduras, Mexico, and Paraguay have reported an increase of two to three times more dengue cases in 2020 compared to the same period in 2019.
- In Brazil, dengue rates in 2019 increased 599% in eight months, and 2020 rates are even higher per the health ministry.
- The Western Pacific Region of the WHO has a dengue update often. Here is the most recent dengue situation update, including updates for Southeast Asia, the Pacific Islands, Australia and more.
- The Outbreak Observatory’s article on the rise of global dengue infections, May 2019.
- February 2020 rates of dengue fever and worldwide status report per the WHO, here.
- Massive dengue rates in Thailand in 2019 also. “According to the Thai Bureau of Epidemiology at the Department of Disease Control, there have already been more than 28 thousand cases and 53 death cases from the mosquito-borne Dengue virus. Last year, there were only 33 death cases. The Chiang Rai Times reports that medics have commented on the situation as “one of the most severe Dengue outbreaks in recent years.” The article also states that health officials have reported more than 40 thousand cases which is 1.6 times more than that of 2018.“
- Ho Chi Minh City reports big increases in cases – a 176 percent increase compared tot he same period last year — as Vietnam’s dengue total for 2019 tops 80K cases from January to July.
- The first ever known case of native dengue fever in France has been confirmed in the region of the Auvergne-Rhône-Alpes.
- World Health Organization’s Chikungunya fact sheet.
- NPR in 2015 on how Chikungunya might be scarier than we thought. (“”As it spreads across the world, we’re realizing that it’s not so benign” says Dr. Desiree LaBeaud, a professor of pediatrics who studies the Chikungunya virus at the Stanford University School of Medicine.”)
- PBS on how a warming planet has contributed to the virus’ spread.
- A history of the virus, and how it spread, from a site specializing in Chikungunya.
- 2019 study about dengue and Chikungunya in the Americas.
- A Vox News primer on Zika (video)
- Why Public Health Concerns for Global Spread of Zika Virus Means That Rio de Janeiro’s 2016 Olympic Games Must Not Proceed
- Proving that the Zika virus causes microcephaly.
- Center for Disease Control information about Zika (USA site)
- BBC on countries affected by Zika and some basic advice.
The frustrating part is, of course, that there is not much to be done other than prevention.
There is currently no widespread / accepted vaccine (though some like Dengvaxia are being rolled out for dengue with controversial results), and treatment is simply to hydrate, take painkillers, and wait.
The fatigue, the hair loss, the joint pain, and the depression and anxiety are all quite devastating but from my non-scientific poll of many friends who have gotten it, vary from person to person.
For me, with an existing immune disorder, it was really difficult. For others, they had a few months of problems but are fine now.
It has been several years and in my case I will say that my circulation has not gotten back to where I want it to be but otherwise I am back to feeling more healthy. I will be returning to Southeast Asia this year, but it definitely worries me that the cases are well on the rise. All one can do is wear mosquito repellant, cover up what you can, and be sure to get tested if you start exhibiting the symptoms of the disease.
Not the most cheerful of updates, but I wanted to make sure I kept the post current!