©
or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access COPYRIGHT 2021 EDIZIONI MINERVA MEDICA
cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically
to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,
LETTERS TO THE EDITOR
© 2020 EDIZIONI MINERVA MEDICA
Online version at http://www.minervamedica.it
Gazzetta Medica Italiana - Archivio per le Scienze Mediche 2021
May;180(5):250-1
DOI: 10.23736/S0393-3660.20.04494-0
Dengue and COVID-19: double
burden for Indonesia health system
Coronavirus disease (COVID-19) has been declared by
WHO as pandemic emergency due to rapidly increase
and spread worldwide, affecting up to 216 countries.
Since first detected till July 20, 14,500,000 cases have
been confirmed with 606,000 deaths.1 Human respiratory
system have been identified as primarily targets of Coro-
navirus, that firstly reported in Wuhan, Hubei Province,
China.2 As an archipelago and middle-income country,
Indonesia also facing COVID-19 as a public health
threat, with the number of 17,504 islands and 34 prov-
inces, it is a challenging to break the transmission of CO-
VID-19. Recent data showed the number of COVID-19
cases in Indonesia up to 88,214 cases, with 4239 deaths.1
Other than that, the number of dengue fever cases
in Indonesia shows a drastic surge in early 2020. The
Ministry of Health noticed that number of dengue cases
in Indonesia reached 68 thousand cases from January to
early June 2020. Of these, 446 people were death. WHO
in its report entitled WHO Global Strategy for Dengue
Prevention and Control 2012-2020 shows that most
countries in Southeast Asia are endemic of dengue.
WHO also explained existence of seasonal patterns of
dengue in various countries.3 In Indonesia, the increase
in cases did occur in January to February. The incidence
rate is an average of 49 dengue cases per 100,000 popu-
lation each year in all regions. Since January 1, to June
20, there were 68,753 dengue cases and 446 cases of
death were recorded. From March to the midst of a CO-
VID-19 pandemic, there was an additional 6500 cases
of dengue, so it is necessary to be aware of the pos-
sibility of coinfection of dengue and COVID-19 in one
patient. The requires special attention not only for the
patient but also health workers.
Recent studies reported that there are similarities in
clinical symptoms and laboratory results from dengue
and COVID-1.4 The common clinical symptoms are
fever, petechiae, and skin rash. Petechiae rash is a com-
mon clinical finding in dengue. The difference symp-
toms in a COVID-19 patient, are respiratory problems
such as shortness of breath, cough, and diarrhoea.4, 5
The laboratory examination between dengue and CO-
VID-19 usually has the same results with low platelet
250 Gazzetta Medica Italiana - Archivio per le Scienze Mediche May 2021
count (thrombocytopenia) and lymphopenia. Because
dengue and COVID-19 are both RNA viruses, they can
make cross reactive by the same ADE (Antibody De-
pendent Enhancement), causing false positive results
on rapid dengue tests.5, 6 Failing to consider COVID-19
because of positive dengue rapid test results has serious
implications for the patient and public health care.7 It
would be a problem in Indonesia because of the lack of
specific diagnostic tests, especially real time RT-PCR,
and would also challenging to perform early detection
of important viruses and prevent onward transmission
of COVID-19.8
Indonesia health system is provided by public and
private funding, public funding refers to decentralized
government system, with the responsibility on provin-
cial and district government. Indonesian Ministry of
Health is the central and has responsibility to manage
some tertiary and specialist hospital. During pandemic
of COVID-19, management of health system is crucial
regarding to providing service of patient. The occur-
rence of bed in hospitals must be addressed and priori-
tized for severe cases. Since number of COVID-19 cas-
es and dengue cases continuously increase, the number
of beds in hospital was limited. National government
already provoke large-scale social distancing in some of
regions with high cases of COVID-19, such as Jakarta
and Surabaya. Within this period, offices and schools
practice work from home and online learning in order
to minimize community transmission, but it does not
shows significantly decreasing number of COVID-19
cases. In line with that, Indonesia now was on rainy sea-
son that might perhaps increasing the number of mos-
quito breeding habitats. Community health centre as a
primary health service provider in a community have
responsibility to conduct surveillance on COVID-19
patient with mild-symptoms that doing self-isolation in
their home due to the prioritize of hospitals for severe
cases. This can affects regularly observation of mos-
quito breeding sites that usually were done by health
workers in community health centre.
According to the data in 2018, the number of hospi-
tals not evenly distributed with the highest distribution
in East Java (381 hospitals), and the lowest in North
Kalimantan (10 hospitals). Additionally, number of
beds in hospital was 281,081, with the number of in-
habitants around 270 million people, it can be estimated
that in every 1000 person, only 1.04 beds that were pro-
vided. Management of COVID-19 patient with severe
symptoms certainly need the occurrence of ventilators
and Intensive Care Units (ICU). Health authorities con-
firmed that 8413 ventilators were provided (3.11 ven-
tilators/100,000 inhabitants), while the number of ICU
beds was 3500 (1.29/100,000 inhabitants). If the num-
 ©
or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access COPYRIGHT 2021 EDIZIONI MINERVA MEDICA
cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically
to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,
LETTERS TO THE EDITOR
ber of severe patient with COVID-19 estimated at 5%,
severe dengue patients at <1%, and every COVID-19
patient need around three weeks till fully recovered, it
can lead to the worst situation.
From this situation, it can be concluded that break-
ing the community transmission is the best choice for
decreasing burden of health system. The more people
interact closely, the higher transmission of COVID-19
will occur.
Shifa FAUZIYAH 1, Febriana AQUARESTA 2, 3,
Teguh H. SUCIPTO 4 *, Herisa N. JUNUS 5
1Faculty of Medicine, Airlangga University, Surabaya,
Indonesia; 2Clinical Microbiology Specialist Program,
Faculty of Medicine, Airlangga University, Surabaya,
Indonesia; 3Palembang Health Laboratory Center,
Kota Palembang, Indonesia; 4Institute of Tropical
Disease, Airlangga University, Surabaya, Indonesia;
5Department of Clinical Microbiology, Abdul Aziz
Hospital Region, Singkawang, Indonesia
*Corresponding author: Teguh H. Sucipto, Institute of Tropical
Disease, Airlangga University, 60115 Surabaya, Indonesia.
E-mail: teguhharisucipto@staf.unair.ac.id
References
1.  Coronavirus disease (COVID-2019) situation reports.
World Health Organization; 2020 [Internet]. Available from:
https://www.who.int/emergencies/diseases/novel-coronavi-
rus-2019/situation-reports [cited 2021, Apr 13].
2.  Bogoch II, Watts A, Thomas-Bachli A, Huber C, Kraemer
MU, Khan K. Pneumonia of unknown aetiology in Wuhan,
China: potential for international spread via commercial air
travel. J Travel Med 2020;27:1–3.
3.  Global Strategy for dengue prevention and control, 2012–
2020. World Health Organization; 2012 [Internet]. Available
from: https://www.who.int/denguecontrol/9789241504034/
en/ [cited 2021, Apr 13].
4.  Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epi-
demiological and clinical characteristics of 99 cases of 2019
novel coronavirus pneumonia in Wuhan, China: a descriptive
study. Lancet 2020;395:507–13.
5.  Joob B, Wiwanitkit V. COVID-19 can present with a
rash and be mistaken for dengue. J Am Acad Dermatol
2020;82:e177.
6.  Yan G, Lee CK, Lam LT, Yan B, Chua YX, Lim AY, et
al. Covert COVID-19 and false-positive dengue serology in
Singapore. Lancet Infect Dis 2020;20:536.
7.  Joob B, Wiwanitkit V. COVID-19 in medical personnel:
observation from Thailand. J Hosp Infect 2020;104:453.
8.  Rodriguez-Morales AJ, Gallego V, Escalera-Antezana JP,
Méndez CA, Zambrano LI, Franco-Paredes C, et al. COV-
ID-19 in Latin America: the implications of the first confirmed
case in Brazil. Travel Med Infect Dis 2020;35:101613.
Conflicts of interest.—The authors certify that there is no conflict
of interest with any financial organization regarding the material
discussed in the manuscript.
Authors’ contributions.—Shifa Fauziyah has given substantial
contributions to manuscript preparation, Febriana Aquaresta and
Herisa N. Junus to literature review, Teguh H. Sucipto to manu-
Vol. 180 - No. 5 Gazzetta Medica Italiana - Archivio per le Scienze Mediche 251
script conception and design. All authors read and approved the
final version of the manuscript.
Acknowledgements.—The authors acknowledge the Hibah Riset
Mandat Universitas Airlangga (HRMUA) 2016.
History.—Manuscript accepted: November 5, 2020. - Manu-
script received: July 23, 2020.
(Cite this article as: Fauziyah S, Aqauresta F, Sucipto TH, Ju-
nus HN. Dengue and COVID-19: double burden for Indonesia
health system. Gazz Med Ital - Arch Sci Med 2021;180:250-1.
DOI: 10.23736/S0393-3660.20.04494-0)
© 2020 EDIZIONI MINERVA MEDICA
Online version at http://www.minervamedica.it
Gazzetta Medica Italiana - Archivio per le Scienze Mediche 2021
May;180(5):251-2
DOI: 10.23736/S0393-3660.20.04559-3
Air-fluid level in a lung bulla
Fluid-containing emphysematous bulla, first described
in 1947, is a radiological entity independent of lung ab-
scess, uncommon and underreported.1, 2 The etiopatho-
genesis is not completely understood.1, 2 Therapeutic
approach is controversial, most authors advocate ini-
tial conservative treatment depending on the severity
of symptoms and consider a more invasive approach if
clinical evolution is unfavorable.1, 2 Percutaneous inter-
vention of infected emphysematous bullae has emerged
as a safe and effective procedure insofar as it induces
clinical improvement, antibiotic guidance and reduces
treatment time.1-3
We report a case of an 82-year-old man, with a per-
sonal history of smoking and chronic obstructive pulmo-
nary disease (COPD) GOLD 4D, visited the emergency
department for worsening of dyspnea and cough produc-
tive with mucopurulent sputum. Patient was confused,
agitated, hemodynamically stable, apyretic, tachypneic,
81% pulse oximetry and pulmonary auscultation with
bilateral crackles. Analysis showed a worsening of type
1 chronic respiratory failure and increase inflammatory
markers (leukocytes 18200/uL and c-reactive protein
366 mg/L). Chest X-ray with bilateral interstitial-alve-
olar infiltrate and hypertransparent areas suggestive of
emphysematous bullae. Patient was admitted with di-
agnosis of COPD exacerbated by community acquired
pneumonia (CAP). Hemophilus influenza was isolated
in blood cultures. Chest computed tomography revealed
a bullous lesion with air-fluid level in the left lung and
exuberant centrilobular and paraseptal emphysema
(Figure 1). After a multidisciplinary discussion, percu-
taneous intervention was not performed due to the high