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KEY MESSAGE: Interspecific comparison of two Paspalum species has demonstrated that mating systems (selfing and outcrossing) contribute to variation (genetically and morphologically) within species through similar but mutually exclusive processes. Mating systems play a key role in the genetic dynamics of populations. Studies show that populations of selfing plants have less genetic diversity than outcrossing plants. Yet, many such studies have ignored morphological diversity. Here, we compared the morphological and molecular diversity patterns in populations of two phylogenetically-related sexual diploids that differ in their mating system: self-sterile Paspalum indecorum and self-fertile P. pumilum. We assessed the morphological variation using 16 morpho-phenological characters and the molecular diversity using three combinations of AFLPs. We compared the morphological and molecular diversity within and among populations in each mating system. Contrary to expectations, selfers showed higher morphological variation within populations, mainly in vegetative and phenological traits, compared to outcrossers. The high morphological variation within populations of selfers led to a low differentiation among populations. At molecular level, selfing populations showed lower levels of genotypic and genetic diversity than outcrossing populations. As expected, selfers showed higher population structure than outcrossers (PhiST = 0.301 and PhiST = 0.108, respectively). Increased homozygous combinations for the same trait/locus enhance morphological variation and reduce molecular variation within populations in selfing P. pumilum. Thus, selfing outcomes are opposite when comparing morphological and molecular variation in P. pumilum. Meanwhile, pollen flow in obligate outcrossing populations of P. indecorum increases within-population molecular variation, but tends to homogenize phenotypes within-population. Pollen flow in obligate outcrossers tends to merge geographically closer populations; but isolation by distance can lead to a weak differentiation among distant populations of P. indecorum.

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The genetic systems of Paspalum species have not been extensively studied. We analyzed the ploidy, reproductive mode, mating system, and fertility of four Paspalum species-Paspalum durifolium, Paspalum ionanthum, Paspalum regnellii, and Paspalum urvillei. An analysis of 378 individuals from 20 populations of northeastern Argentina was conducted. All populations of the four Paspalum species were pure tetraploid and had a sexual and stable reproductive mode. However, some populations of P. durifolium and P. ionanthum showed low levels of apospory. Populations of P. durifolium and P. ionanthum had low seed sets under self-pollination but were fertile under open pollination, showing that self-incompatibility likely caused self-sterility. In contrast, populations of P. regnellii or P. urvillei showed no evidence of apospory, and seed sets in both self- and open pollination conditions were high, suggesting that they are self-compatible due to the absence of pollen-pistil molecular incompatibility mechanisms. The evolutionary origin of the four Paspalum species could explain these differences. This study supplies valuable insights into the genetic systems of Paspalum species, which could have implications for their conservation and management.

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We present the complete chloroplast genome sequence of an endophytic Ostreobium sp. isolated from a 19th-century coralline red algal specimen from St. Croix, U.S. Virgin Islands. The chloroplast genome is 84,848 bp in length, contains 114 genes, and has a high level of gene synteny to other Ostreobiaceae.

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The tetraploid germplasm of Paspalum contains a large diversity that can be used to generate better forages. The objective was to evaluate a group of Paspalum notatum and Paspalum simplex apomictic hybrids for a set of agronomic traits and apomixis expressivity. Forage yield, cold tolerance, winter regrowth, and seed yield were evaluated. The expressivity of apomixis was evaluated in P. simplex hybrids by flow cytometry. Progeny testing with molecular markers was used to determine the genotypic variability in the progeny. Differences within P. notatum and P. simplex hybrids were observed for all traits, and some of them were superior in comparison with the controls. The accumulated forage yield during three years was 988 g m-2 in the P. notatum hybrids, whereas, in P. simplex, the average forage yield per harvest (40 days of regrowth) was 180 g m-2. In P. simplex, the apomixis expressivity varied between 0 and 100%, and 65% of the hybrids showed high apomixis expressivity (superior to 70%). The genotypic mean homogeneity in the progeny was 76% and 85% in P. notatum and P. simplex, respectively. The generation of hybrids with high apomixis expressivity that combine good agronomic performance and homogeneity in the offspring is possible in tetraploid P. notatum and P. simplex.

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Most apomictic plants are facultative, maintaining the ability to reproduce sexually at different frequencies depending on the taxa, ploidy, and reproductive stage. In this context, Paspalum species are good model systems for studies evaluating the varying levels of apomixis expression. We aimed to identify, in apomictic tetraploid Paspalum species, the degree of apomixis and residual sexuality in three stages of reproductive development, and if their expression varies along them in order to predict their realized impact on the genetic diversity of future generations. Three main stages in the reproductive development (i.e., ovule, seed, and progeny) were studied in tetraploids from populations of P. cromyorhizon and P. maculosum. Mature ovules were studied using cytoembryological analysis, seeds by flow cytometry, and progeny tests with molecular markers. The expression of sexuality and apomixis was compared in each stage. We observed a decline in expression of sexual reproduction through the consecutive stages, jointly with an increase of apomixis expression. Both species showed at least one tetraploid plant capable of producing progeny by sexual means. These small rates of sexually originated progeny prove the ability of apomictic plants to produce low levels of genetic variation through rare events of sexuality. This study also demonstrates the importance of analyzing different reproductive stages in order to get a whole picture of the reproductive outcomes in plant evolution.

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The objective of this review is to analyze and describe the impact that mode of reproduction in Paspalum has on germplasm conservation, genetic improvement, and commercialization of cultivars. Germplasm collection and conservation can now be rethought considering the newly available information related to how diversity is allocated in nature and how it can be transferred between the sexual and apomictic germplasm using novel breeding approaches. An inventory of species and accessions conserved around the world is analyzed in relation to the main germplasm banks. Because of the importance of apomixis in Paspalum species different breeding approaches have been used and tested. Knowledge related to the inheritance of apomixis, variable expressivity of the trait and techniques for early identification of apomicts has helped to improve the efficiency of the breeding methods. Novel breeding techniques are also being developed and are described regarding its advantages and limitations. Finally, the impact of reproductive mode on the adoption of the released cultivars is discussed.

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Dengue is widespread throughout the tropics and local spatial variation in dengue virus transmission is strongly influenced by rainfall, temperature, urbanization and distribution of the principal mosquito vector Aedes aegypti. Currently, endemic dengue virus transmission is reported in the Eastern Mediterranean, American, South-East Asian, Western Pacific and African regions, whereas sporadic local transmission has been reported in Europe and the United States as the result of virus introduction to areas where Ae. aegypti and Aedes albopictus, a secondary vector, occur. The global burden of the disease is not well known, but its epidemiological patterns are alarming for both human health and the global economy. Dengue has been identified as a disease of the future owing to trends toward increased urbanization, scarce water supplies and, possibly, environmental change. According to the WHO, dengue control is technically feasible with coordinated international technical and financial support for national programmes. This Primer provides a general overview on dengue, covering epidemiology, control, disease mechanisms, diagnosis, treatment and research priorities.

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Patients with dengue fever and comorbidities seem to be at higher risk of developing complications and/or severe dengue compared to healthier individuals. This study systematically reviews the evidence related to comorbidities and dengue. A systematic literature review was performed in five databases (EMBASE, PUBMED, Global Health, SciELO, Cochrane) and grey literature for full-text articles since its inceptions until October 10, 2015. A total of 230 articles were retrieved. Sixteen studies were analysed after applying all inclusion and exclusion criteria. Seven case control studies and nine retrospective cohort studies showed that comorbidities may contribute to severe dengue, especially 1) cardiovascular disease, 2) stroke, 3) diabetes, 4) respiratory disease and 5) renal disease, as well as old age. However, due to heterogeneity in studies, the real estimate effect of comorbidities as modifiers of dengue severity could not be established. Further research in regions with high prevalence of dengue infection would contribute to a better understanding of the relevance of comorbidities in severe dengue, especially with a standardised protocol, for outcomes, specific comorbidities, study design-best using prospective designs-and sample sizes.

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BACKGROUND: Apomixis is an alternative route of plant reproduction that produces individuals genetically identical to the mother plant through seeds. Apomixis is desirable in agriculture, because it guarantees the perpetuation of superior genotypes (i.e. heterotic hybrid seeds) by self-seeding without loss of hybrid vigour. The Paspalum genus, an archetypal model system for mining apomixis gene(s), is composed of about 370 species that have extremely diverse reproductive systems, including self-incompatibility, self-fertility, full sexual reproduction, and facultative or obligate apomixis. Barriers to interspecific hybridization are relaxed in this genus, allowing the production of new hybrids from many different parental combinations. Paspalum is also tolerant to various parental genome contributions to the endosperm, allowing analyses of how sexually reproducing crop species might escape from dosage effects in the endosperm. SCOPE: In this article, the available literature characterizing apomixis in Paspalum spp. and its use in breeding is critically reviewed. In particular, a comparison is made across species of the structure and function of the genomic region controlling apomixis in order to identify a common core region shared by all apomictic Paspalum species and where apomixis genes are likely to be localized. Candidate genes are discussed, either as possible genetic determinants (including homologs to signal transduction and RNA methylation genes) or as downstream factors (such as cell-to-cell signalling and auxin response genes) depending, respectively, on their co-segregation with apomixis or less. Strategies to validate the role of candidate genes in apomictic process are also discussed, with special emphasis on plant transformation in natural apomictic species.

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Meiotic and apomictic reproductive pathways develop simultaneously in facultative aposporous species, and compete to form a seed as a final goal. This developmental competition was evaluated in tetraploid genotypes of Paspalum malacophyllum in order to understand the low level of sexuality in facultative apomictic populations. Cyto-embryology on ovules, flow cytometry on seeds and progeny tests by DNA fingerprinting were used to measure the relative incidence of each meiotic or apomictic pathway along four different stages of the plant's life cycle, namely the beginning and end of gametogenesis, seed formation and adult offspring. A high variation in the frequencies of sexual and apomictic pathways occurred at the first two stages. A trend of radical decline in realized sexuality was then observed. Sexual and apomictic seeds were produced, but the efficiency of the sexual pathway dropped drastically, and exclusively clonal offspring remained. Both reproductive pathways are unstable at the beginning of development, and only the apomictic one remains functional. Key factors reducing sexuality are the faster growth and parthenogenetic development in the aposporous pathway, and an (epi)genetically negative background related to the extensive gene de-regulation pattern responsible for apomixis. The effects of inbreeding depression during post-fertilization development may further decrease the frequency of effective sexuality.

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In previous studies we reported the identification of several AFLP, RAPD and RFLP molecular markers linked to apospory in Paspalum notatum. The objective of this work was to sequence these markers, obtain their flanking regions by chromosome walking and perform an in silico mapping analysis in rice and maize. The methylation status of two apospory-related sequences was also assessed using methylation-sensitive RFLP experiments. Fourteen molecular markers were analyzed and several protein-coding sequences were identified. Copy number estimates and RFLP linkage analysis showed that the sequence PnMAI3 displayed 2-4 copies per genome and linkage to apospory. Extension of this marker by chromosome walking revealed an additional protein-coding sequence mapping in silico in the apospory-syntenic regions of rice and maize. Approximately 5 kb corresponding to different markers were characterized through the global sequencing procedure. A more refined analysis based on sequence information indicated synteny with segments of chromosomes 2 and 12 of rice and chromosomes 3 and 5 of maize. Two loci associated with apomixis locus were tested in methylation-sensitive RFLP experiments using genomic DNA extracted from leaves. Although both target sequences were methylated no methylation polymorphisms associated with the mode of reproduction were detected.

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OBJECTIVE: To evaluate the existing WHO dengue classification across all age groups and a wide geographical range and to develop a revised evidence-based classification that would better reflect clinical severity. METHODS: We followed suspected dengue cases daily in seven countries across South-east Asia and Latin America and then categorised them into one of three intervention groups describing disease severity according to the overall level of medical and nursing support required. Using a pre-defined analysis plan, we explored the clinical and laboratory profiles characteristic of these intervention categories and presented the most promising options for a revised classification scheme to an independent group of WHO dengue experts for consideration. Potential warning signs were also evaluated by comparing contemporaneous data of patients who progressed to severe disease with the data of those who did not. RESULTS: A total of 2259 patients were recruited during 2006-2007 and 230 (13%) of the 1734 laboratory-confirmed patients required major intervention. Applying the existing WHO system, 47/210 (22%) of patients with shock did not fulfil all the criteria for dengue haemorrhagic fever. However, no three-tier revision adequately described the different severity groups either. Inclusion of readily discernible complications (shock/severe vascular leakage and/or severe bleeding and/or severe organ dysfunction) was necessary to devise a system that identified patients requiring major intervention with sufficient sensitivity and specificity to be practically useful. Only a small number of subjects (5%) progressed to severe disease while under observation; several warning signs were identified, but much larger studies are necessary to fully characterize features associated with disease progression. CONCLUSIONS: Based on these results, a revised classification system comprised of two entities, 'Dengue' and 'Severe Dengue', was proposed and has now been incorporated into the new WHO guidelines.

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Dengue fever and dengue haemorrhagic fever are important arthropod-borne viral diseases. Each year, there are ∼50 million dengue infections and ∼500,000 individuals are hospitalized with dengue haemorrhagic fever, mainly in Southeast Asia, the Pacific and the Americas. Illness is produced by any of the four dengue virus serotypes. A global strategy aimed at increasing the capacity for surveillance and outbreak response, changing behaviours and reducing the disease burden using integrated vector management in conjunction with early and accurate diagnosis has been advocated. Antiviral drugs and vaccines that are currently under development could also make an important contribution to dengue control in the future.

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BACKGROUND: Early diagnosis of dengue can assist patient triage and management and prevent unnecessary treatments and interventions. Commercially available assays that detect the dengue virus protein NS1 in the plasma/serum of patients offers the possibility of early and rapid diagnosis. METHODOLOGY/PRINCIPAL FINDINGS: The sensitivity and specificity of the Pan-E Dengue Early ELISA and the Platelia Dengue NS1 Ag assays were compared against a reference diagnosis in 1385 patients in 6 countries in Asia and the Americas. Platelia was more sensitive (66%) than Pan-E (52%) in confirmed dengue cases. Sensitivity varied by geographic region, with both assays generally being more sensitive in patients from SE Asia than the Americas. Both kits were more sensitive for specimens collected within the first few days of illness onset relative to later time points. Pan-E and Platelia were both 100% specific in febrile patients without evidence of acute dengue. In patients with other confirmed diagnoses and healthy blood donors, Platelia was more specific (100%) than Pan-E (90%). For Platelia, when either the NS1 test or the IgM test on the acute sample was positive, the sensitivity versus the reference result was 82% in samples collected in the first four days of fever. NS1 sensitivity was not associated to disease severity (DF or DHF) in the Platelia test, whereas a trend for higher sensitivity in DHF cases was seen in the Pan-E test (however combined with lower overall sensitivity). CONCLUSIONS/SIGNIFICANCE: Collectively, this multi-country study suggests that the best performing NS1 assay (Platelia) had moderate sensitivity (median 64%, range 34-76%) and high specificity (100%) for the diagnosis of dengue. The poor sensitivity of the evaluated assays in some geographical regions suggests further assessments are needed. The combination of NS1 and IgM detection in samples collected in the first few days of fever increased the overall dengue diagnostic sensitivity.

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INTRODUCTION: dengue is only a disease with a wide clinical spectrum including undifferentiated fever or fever with malaise and general manifestations, and severe dengue, induced mainly by plasma extravasation leading to prolonged or recurrent shock and death. Medical care organization during epidemics is crucial to prevent fatalities and includes at least five components: 1. Training of medical and nurse personnel. It is an investment that shall be programmed, controlled and evaluated. The time and resources for training must be considered as the equivalent of the expenses in still unavailable vaccines or drugs against dengue. 2. Health education. To involve patients and their families in their own care, so that they can be prepared to ask for medical care at the right time, avoid self medication, identify skin bleedings (petechiae), and look for warning signs. 3. Classification of every suspected dengue case (triage). A good classification of patients should be simple to be used in every place and should be dynamic to allow changes in treatment. Early recognition of warning signs that announce dengue severity and intravenous fluids (crystalloids) given at that very moment can prevent dengue shock and other complications. 4. Rearrangement of medical services and warranty of some resources. It is not correct to think that the preparation to face a dengue epidemic will include big amounts of drugs, blood and blood products. The most important resource continues being the human resource. If doctors and nurses are well trained, the prescription of such drugs and procedures will decrease, including platelet transfusion or blood transfusions. 5. Research. Biomedical and social research are needed, with emphasis on the impact of health education on patients and their families, the natural course of the illness and the best way to do ambulatory treatment. CONCLUSIONS: The future of the severe dengue cases will be usually decided upon not in the Intensive Care Unit but long before, in the Primary Care unit, Hospital Emergency Department or hospital ward. Good health managers can save more lives than physicians or intensive care specialists during dengue epidemics.

INTRODUCCIÓN: el dengue es solo una enfermedad con un amplio espectro clínico que abarca fiebre común o fiebre con malestar y manifestaciones generales, mientras el dengue severo es provocado sobre todo por la extravasión del plasma que ocasiona un shock prolongado o recurrente y finalmente la muerte. La organización de los servicios de atención médica durante una epidemia es crucial para evitar decesos, abarca como mínimo cinco componentes: 1. Preparación del personal médico y de enfermería, constituye una inversión que se programa, se controla y se evalúa. El tiempo y los recursos que se emplean deben considerarse como el equivalente de los gastos en que pudiera incurrirse para adquirir vacunas o medicamentos contra esta enfermedad, que todavía no están disponibles. 2. Educación para la salud. Involucrar a los pacientes y sus familias en el cuidado de su salud, hacer que estén preparados para solicitar atención médica en el momento adecuado, evitar la automedicación, identificar los sangramientos por la piel (petequias), y buscar señales de aviso. 3. Clasificación de cada caso con sospecha de dengue (selección). Una buena clasificación de pacientes debe ser sencilla en todos los lugares y dinámica para permitir modificaciones en el tratamiento. El reconocimiento precoz de las señales de aviso que anuncian la gravedad del dengue y los fluidos intravenosos (cristaloides) administrados en ese preciso momento pueden evitar el shock y otras complicaciones. 4. Reordenamiento de los servicios médicos y aseguramiento de algunos recursos. No es correcto pensar que la preparación para enfrentar la epidemia de dengue incluirá grandes cantidades de medicamentos, volúmenes de sangre y de productos sanguíneos. El recurso más importante continúa siendo el recurso humano. Si los médicos y las enfermeras están bien adiestrados, las prescripciones para el uso de esos medicamentos y la aplicación de métodos disminuirán, incluida la transfusión de plaquetas o las transfusiones de sangre. 5. Realizar estudios investigativos. Son necesarios los estudios investigativos biomédicos y sociales, con énfasis en el efecto de la educación para la salud sobre los pacientes y sus familiares, el desarrollo natural de la enfermedad y la mejor forma de aplicar el tratamiento ambulatorio. CONCLUSIONES: el futuro de los casos graves de dengue se deciden por lo general no en la Unidad de Cuidados Intensivos sino mucho antes, en la Unidad de Atención Primaria, el Departamento de Urgencias Médicas o la sala del hospital. Los buenos directivos del sistema de salud pueden salvar más vidas que los médicos o los especialistas de cuidados intensivos durante la epidemia de dengue.

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BACKGROUND AND AIMS: Gametophytic apomixis is regularly associated with polyploidy. It has been hypothesized that apomixis is not present in diploid plants because of a pleiotropic lethal effect associated with monoploid gametes. Rare apomictic triploid plants for Paspalum notatum and P. simplex, which usually have sexual diploid and apomictic tetraploid races, were acquired. These triploids normally produce male gametes through meiosis with a range of chromosome numbers from monoploid (n = 10) to diploid (n = 20). The patterns of apomixis transmission in Paspalum were investigated in relation to the ploidy levels of gametes. METHODS: Intraspecific crosses were made between sexual diploid, triploid and tetraploid plants as female parents and apomictic triploid plants as male parents. Apomictic progeny were identified by using molecular markers completely linked to apomixis and the analysis of mature embryo sacs. The chromosome number of the male gamete was inferred from chromosome counts of each progeny. KEY RESULTS: The chromosome numbers of the progeny indicated that the chromosome input of male gametes depended on the chromosome number of the female gamete. The apomictic trait was not transmitted through monoploid gametes, at least when the progeny was diploid. Diploid or near-diploid gametes transmitted apomixis at very low rates. CONCLUSIONS: Since male monoploid gametes usually failed to form polyploid progenies, for example triploids after 4x x 3x crosses, it was not possible to determine whether apomixis could segregate in polyploid progenies by means of monoploid gametes.

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OBJECTIVE: To report the clinical, laboratory and sonographic findings in 76 adult cases of dengue hemorrhagic fever (DHF). PATIENTS AND METHODS: A dengue 3 epidemic occurred in Havana City from June 2001 to March 2002. 12,889 cases were reported, with 81 DHF cases. From this, 76 serologically confirmed cases were studied descriptively. RESULTS: Bronchial asthma and white race were important risk factors for the severe form of the disease. Fever (100%), headache (92.1%), myalgia (76.3%), arthralgia (73.7%) and retro-orbital pain (57.7%) were the most frequent general symptoms. Vomiting and abdominal pain were observed in 59.2% and 48.6% of cases, respectively. The most common bleeding site was the vagina (64%), followed by the skin (55.2%). Eighteen patients (23.6%) had shock syndrome. Laboratory findings included thrombocytopenia (100%), hemoconcentration (93.4%), an increase in liver enzymes (82.8%), and leukopenia (71%). Ultrasound detected thickening of the gallbladder wall in 35.1%, pleural effusion in 20.3%, and splenomegaly in 12.9% of cases. CONCLUSION: These findings contribute to a better understanding of the clinical aspects of DHF in adult patients due to the dengue 3 virus.

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The pathogenesis associated with Dengue haemorrhagic fever, has yet to be fully elucidated, with no definitive in vivo evidence. The exceptional epidemiological circumstances in Cuba allow the evaluation of different mediators in a well-defined situation. In the present study, we describe the determination of levels of IL-12, IL-10 and RANTES in the sera of Cuban patients hospitalised with Dengue fever or Dengue haemorrhagic fever. The results showed that levels of serum IL-10 were higher in patients than controls, and those patients with secondary infections had consistently higher levels. All the Dengue haemorrhagic fever patients had increased levels of IL-10. In contrast, levels of IL-12 did not differ between patients and controls. Finally, RANTES serum levels detected in patients were lower than those observed in the controls. The association of increased levels of IL-10 in Dengue patients with a sequential infection suggests a possible role of this cytokine in the pathogenesis of Dengue disease.

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El objetivo principal de este informe fue describir la reaparición del serotipo 3 del dengue en las Américas después de 17 años de ausencia, tal como se observó recientemente en Nicaragua. Se examinaron en total 356 muestras de suero obtenidas por medio del sistema nicaragüense de vigilancia del dengue durante una epidemia en octubre de 1994. En 43% de las muestras se detectaron anticuerpos IgM contra el dengue y los sueros de 12 de las 18 áreas atendidas por los sistemas locales integrales de salud dieron resultados positivos. Además, se aislaron virus de dengue en 5 de 24 sueros de pacientes con síntomas hemorrágicos: en 3 se aisló el serotipo 3 y en 2, el serotipo 1. Mediante pruebas de laboratorio, en 26 de 39 pacientes hospitalizados en León y Managua se consideró probable o se confirmó el diagnóstico de dengue con manifestaciones hemorrágicas o dengue hemorrágico. En 18 pacientes diagnosticados de dengue con manifestaciones hemorrágicas, los síntomas más comunes fueron fiebre, cefalea, vómito, mialgia, artralgia y epistaxis. Los ocho pacientes restantes, en los que se diagnosticó dengue hemorrágico probable, tuvieron fiebre, malestar general, hemorragias, trombocitopenia y hemoconcentración, y los títulos de anticuerpos a la prueba de inhibición de la hemaglutinación oscilaron de 640 a 20 480. Se confirmó así la reintroducción del serotipo 3 del dengue en la Región y su capacidad para producir casos de dengue hemorrágico. En Nicaragua, por lo menos, es evidente que la reintroducción del serotipo 3 del dengue ha producido un aumento de los casos de dengue clásico y dengue hemorrágico. Si no se presta atención urgente al control del mosquito vector de la enfermedad, la experiencia descrita podría constituir el preludio lúgubre de futuros acontecimientos similares en las Américas

The principal aim of the report presented here is to describe the reappearance of dengue serotype 3 in the Americas, following a 17-year absence, through the recent experience of Nicaragua. In all, 356 serum samples obtained through Nicaragua's dengue monitoring system in October 1994 during an epidemic were examined. Anti-dengue IgM antibodies were detected in 43% of these, with sera from 12 of the 18 areas covered by Nicaragua's local integrated health care systems yielding positive results. In addition, dengue virus was isolated from 5 of 24 sera obtained from patients with hemorrhagic symptoms, dengue 3 being isolated from 3 of these samples and dengue 1 from the other 2. A diagnosis of dengue with hemorrhagic manifestations or of hemorrhagic dengue was supported or confirmed by laboratory findings obtained from 26 of 39 patients hospitalized in León or Managua. The most frequent symptoms of 18 patients diagnosed as having dengue with hemorrhagic manifestations were fever, headache, vomiting, myalgia, arthralgia, and epistaxis. The remaining eight patients, diagnosed as having probable hemorrhagic dengue, exhibited fever, general malaise, hemorrhaging, thrombocytopenia, hemoconcentration, and hemagglutination-inhibition antibody titers ranging from 640 to 20 480. Overall, the reappearance of dengue serotype 3 in the Region was confirmed, together with its ability to produce cases of hemorrhagic dengue. At least in Nicaragua, it is apparent that the introduction of dengue serotype 3 has prompted an increase in the number of classical dengue and hemorrhagic dengue cases, a scenario that might constitute the grim prelude to future developments in the Americas if urgent attention is not given to controlling the disease's mosquito vector

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