AMAZON REGION SPECIAL SECTION LETTERS

Suspected elementary schools of Anajás dur- several days by open boat at ambient ing July–September 2007. We found temperature (≈35 ºC) in improvised Brazilian Purpuric 7 children with illnesses that met our containers without an incubator. Se- Fever, Brazilian case defi nition. rum and CSF samples were thawed Amazon Region From 2 children with nonfatal ill- and refrozen repeatedly for removal of ness, we collected blood, serum, con- aliquots before testing. Microbiologic To the Editor: Brazilian pur- junctival swabs, and cerebrospinal fl uid and virologic testing was conducted at puric fever (BPF), a (CSF). All specimens were submitted the Pará State Health Laboratory and aegyptius–caused febrile hemorrhagic for bacterial culture in half agar choco- Evandro Chagas Institute. Serum and illness of children that begins with late without bacitracin; serum and CSF CSF samples were tested by PCR at and has a case-fatality were also subjected to real-time PCR Adolfo Lutz Institute. rate of 40%–90% (1,2), was fi rst rec- for detection of Neisseria meningitides, We identifi ed 7 case-patients (me- ognized during a 1984 outbreak. Be- Streptococcus pneumoniae, and Hae- dian age 4 years, range 2–8 years): 6 fore June 2007, 69 cases were reported mophilus infl uenzae serotypes a, b, c, from review of charts at the local hos- worldwide; 65 were from Brazil (1–3). and d and to conventional PCR for the pital and 1 from active search in the To our knowledge, the disease had not ompP2 gene of H. infl uenzae. All serum rural community. Onset of illness was been reported in the Amazon region samples were also tested by hemag- August 1 for the fi rst case-patient and until this investigation, which was glutination inhibition for Flavivirus, August 31 for the last. Five (71%) did precipitated by the report of 5 cases Oropouche, Catu, Caraparu, Tacaiuma, not receive antimicrobial drugs and of a compatible syndrome in Anajás, Mayaro, Mucambo, western equine en- died within 24 hours after fever onset; Pará State, Brazil, in August 2007. cephalitis, eastern equine encephalitis, 2 were treated with amoxicillin within To determine whether recent re- Guaroa, Maguari, Ilhéus, Rocio, and St. 24 hours after fever onset and survived ports of BPF were accurate, we re- Louis encephalitis; by immunoglobulin (Table). viewed medical records of the hospi- M antibody-capture ELISA for dengue Laboratory tests showed leuko- tal in Anajás. We identifi ed cases by and yellow fever; and, when reactive penia on the day of hospital admis- using the following defi nition: fever for dengue, by reverse transcription– sion (Table). All case-patients had >38.5ºC , abdominal pain, vomiting, PCR for dengue types 1, 2, 3, and 4. antecedent conjunctivitis. All except , and antecedent conjuncti- Because of the remoteness of the fi rst case-patient had had physical vitis during July 1–September 30, the outbreak site, samples for bacte- contact with a previous case-patient 2007, in a child 3 months–10 years rial culture were collected on locally through school or family; 5 were re- of age; absence of signs or symptoms available blood agar enriched with lated (siblings or cousins). The period of in those children; and rabbit serum without antimicrobial from exposure to onset of fever was laboratory exclusion of meningococ- drug–selective agents, rather than on 8–21 days. cal infection. In addition, we searched the recommended chocolate agar en- Of 1,598 elementary school pu- retrospectively and prospectively for riched with horse serum and bacitra- pils investigated for conjunctivitis, 111 conjunctivitis among pupils of the cin (1). Samples were transported over (7%) reported symptoms of conjunc-

Table. Characteristics of 7 case-patients with suspected Brazilian purpuric fever, Amazon region, Brazil, August 2007* Date of Antimicrobial Case- Sex/age, conjunctivitis Date admitted Hospitalization, drug Date of Type of sample(s) patient no. y onset to hospital d treatment death collected WBC/mL 1 M/2 Aug 1 Aug 5 <1 No Aug 5 NC NT 2 F/3 Aug 10 Aug 13 <1 No Aug 14 Blood 3,700 3 M/3 Aug 14 Unknown Unknown No Aug 21 NC NT 4 M/6 Jul 19 Aug 22 <1 No Aug 23 Blood 2,300 5† M/8 Unknown Sep 3 7 Yes – CSF, conjunctival 9,060 swab 6 F/4 Aug 23 Aug 26 <1 No Aug 26 CSF, blood‡ 2,000 7 F/4 Aug 31 Sept 3 12 Yes – Oropharyngeal 4,800 and conjunctival swabs, CSF, blood, serum *Case-patients 5 and 7 underwent testing for dengue and yellow fever by immunoglobulin M antibody-capture ELISA, for dengue by reverse transcription– PCR, and for , Streptococcus pneumoniae, and serotypes a, b, c, and d and conventional PCR for detecting the ompP2 gene. All tests were negative. WBC, white blood cells; NC, not collected; NT, not tested; CSF, cerebrospinal fluid. †Sample collected 20 days after admission. ‡Non-standard collection, transport, storage, or processing.

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 4, April 2009 675 THE AMAZON REGION LETTERS tivitis during July–September 2007. preceded by conjunctivitis, immediate Address for correspondence: Eucilene Reported treatment included home treatment, contact prophylaxis, and A. Santana-Porto, Ministry of Health— remedies and a nonprescription, local- appropriate prompt laboratory testing Secretariat Surveillance of Health, SCS ly available, cream containing a sulfa are essential for continued control of quadra 04 Bloco A Edifi cio Central 6ª drug. Review of municipal hospital BPF in this region. andar, Brasilia, Distrito Federal 70304000, records during June 1–September 30, Brazil; e-mail: [email protected] 2007, identifi ed no additional cases of Eucilene A. Santana-Porto, conjunctivitis. After the last case-pa- Adriana A. Oliveira, tient died, 17 other persons were iden- Marcos R.M. da Costa, tifi ed with purulent conjunctivitis: 4 at Amiraldo Pinheiro, the municipal hospital and 13 during Consuelo Oliveira, active case-fi nding in schools and the Maria L. Lopes, Luiz E. Pereira, community. All were treated with oral Claudio Sacchi, amoxicillin and optic Wildo N. Aráujo, Hepatitis C Virus solution, and 76 contacts were treated and Jeremy Sobel in Blood Donors, prophylactically with oral rifampin. Author affi liations: Ministry of Health, Brasí- Brazil No further suspected BPF cases were lia, Brazil (E.A. Santana-Porto, A.A. Olivei- detected. Test results for acute arbovi- ra, W.N. Aráujo, J. Sobel); Municipal Sec- To the Editor: The Fundação rus infection and PCR were negative retariat of Health, Anajás, Brazil (M.R.M. de Hematologia e Hemoterapia do for all patients (Table). da Costa); Secretariat of Health of Pará Amazonas is a public health service This outbreak of highly fatal ill- State, Belém, Brazil (A. Pinheiro); Ministry in Manaus, Brazil, that is responsible ness is clinically compatible with BPF. of Health, Belém (C. Oliveira, M.L. Lopes); for serologic screening the serum of Compatible features included young Instituto Adolfo Lutz, Secretariat of Health all blood donations in the region. In age, antecedent purulent conjunctivitis, of São Paulo State, São Paulo, Brazil (L.E. the state of Amazon, 9.0% of donated signs and symptoms (i.e., antecedent Pereira, C. Sacchi); and Centers for Dis- blood is discarded on the basis of se- conjunctivitis, fever 39.5Cº–41.0Cº, ease Control and Prevention, Atlanta, GA, rologic fi ndings; discarding because abdominal pain, nausea, vomiting, USA (J. Sobel) of hepatitis C virus (HCV) antibod- ies declined from 1.25% in 1995 to petechiae or ecchymoses), and high DOI: 10.3201/eid1504.090014 case-fatality rate. Epstein-Barr infec- 0.32% in 2007. The aim of this study was to characterize the serologic and tion has reportedly produced simi- References lar symptoms (4) but with an illness molecular profi le of HCV-antibody– lasting >7 days in contrast to the <24 1. Tondella ML, Paganelli CH, Bortolotto positive blood donors from the Funda- hours for our case-patients. IM, Takano OA, Irino K, Brandileone ção de Hematologia e Hemoterapia do MC, et al. Isolation of Haemophilus ae- Amazonas. We did not detect H. aegyptius in gyptius associated with Brazilian purpu- peripheral blood by culture or in se- ric fever, of Chloropidae (Diptera) of the For the study, 154 donors were rum or CSF by PCR in the 2 surviv- genera Hippelates and Liohippelates [in selected from a routine database of ing children and in contacts of case- Portuguese]. Rev Inst Med Trop Sao Pau- voluntary blood donors who had do- lo. 1994;36:105–9. DOI: 10.1590/S0036- nated from September 2005 through patients. One reason could be the 46651994000200002 remoteness of the investigation site, 2. Kerr-Pontes LR, Ruffi no-Neto A. Epi- April 2007 (82,851 donations). Fresh which resulted in improper sample demiological study of Brazilian purpuric plasma samples were sent to the labo- collection, storage, and processing fever. Epidemic in a locality of São Paulo ratory in Manaus through the usual state (Brazil), 1986 [in Portuguese]. Rev transportation systems for regular do- in the fi eld before samples reached Saude Publica. 1991;25:375–80. DOI: reference laboratories. Hemaggluti- 10.1590/S0034-89101991000500009 nations; i.e., samples from 27 cities nation tests for arboviruses have low 3. Harrison LH, Simonsen V, Waldman EA. are transported by air for ≈2 hours, specifi city. Therefore, another known Emergence and disappearance of a virulent and samples from 21 localities are clone of Haemophilus infl uenzae biogroup transported by boat or road, all under or novel pathogen could have caused aegyptius, cause of Brazilian purpuric these cases. fever. Clin Microbiol Rev. 2008;21:594– refrigerated conditions. Timely treatment with antimicro- 605. DOI: 10.1128/CMR.00020-08 An in-house standardized nested- bial drugs for patients with suspected 4. Virata M, Rosenstein NE, Hadler JL, PCR was used to detect HCV RNA (1). Barrett NL, Tondella ML, Mayer LW, et Genotype assignment was based on disease, prophylaxis of contacts, and al. Suspected Brazilian purpuric fever in treatment of children with conjunctivi- a toddler with overwhelming Epstein- type-specifi c motifs on the sequenced tis resulted in no additional cases. In- Barr virus infection. Clin Infect Dis. amplicons delimited by primers HC11/ tensive surveillance for febrile illness 1998;27:1238–40. DOI: 10.1086/514988 HC18 from the 5′ untranslated region

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