LETTERS

Author affi liation: University of the Punjab, Address for correspondence: Muhammad having received multiple mosquito Lahore, Pakistan Idrees, Division of Molecular Virology and bites during the preceding weeks. Molecular Diagnostics, National Centre of At admission, she had a DOI: 10.3201/eid1708.100950 Excellence in Molecular Biology, University temperature of 101.3°F, pulse rate of Punjab, 87 West Canal Bank Rd, Thokar of 92 beats/min, blood pressure of References Niaz Baig, Lahore 53700, Pakistan; email: 130/80 mm Hg, and respiratory rate of 1. Idrees M, Lal A, Naseem M, Khalid M. [email protected] 16 breaths/min. She appeared mildly High prevalence of hepatitis C virus infec- ill but was alert and oriented with no tion in the largest province of Pakistan. nuchal rigidity, photophobia, rash, or J Dig Dis. 2008;9:95–103. doi:10.1111/ j.1751-2980.2008.00329.x limb weakness. Results of a physical 2. Martell M, Esteban JI, Quer J, Genesca examination were unremarkable, and J, Weiner A, Gomez J. Hepatitis C virus results of a neurologic examination circulates as a population of different but were notable only for stuttering. closely related genomes: quasispecies na- ture of HCV genome distribution. J Virol. Laboratory test results included a West Nile Virus 3 1992;66:3225–9. leukocyte count of 12,300 cells/mm 3. Jarvis LM, Ludlam CA, Simmonds P. Hep- Aseptic Meningitis (63% neutrophils, 29% lymphocytes, atitis C virus genotypes in multi-transfused 7% monocytes, 1% basophils) and individuals. Haemophilia. 1995;1(Sup- and Stuttering in pl):3–7. doi:10.1111/j.1365-2516.1995. a platelet count of 204,000 cells/ Woman 3 tb00123.x mm . Other laboratory values 4. Forns X, Maluenda MD, Lopez-Labrador To the Editor: West Nile virus were unremarkable, and levels of FX, Ampurdanes S, Olmedo E, Costa J, et serum transaminases and creatinine al. Comparative study of three methods (WNV), a mosquito-borne fl avivirus, is for genotyping hepatitis C virus strains in closely related to St. Louis encephalitis phosphokinase were within reference samples from Spanish patients. J Clin Mi- virus and Japanese encephalitis virus ranges. Cerebrospinal fl uid (CSF) was crobiol. 1996;34:2516–21. (JEV). Most cases of WNV have been clear and contained 37 leukocytes/mm3 5. Lau JY, Mizokami M, Kolberg JA, Davis (2% neutrophils, 78% lymphocytes, GL, Prescott LE, Ohno T, et al. Applica- mild, but neuroinvasive disease has 3 tion of six hepatitis C virus genotyping been observed, especially among older 20% monocytes), 2 erythrocytes/mm , systems to sera from chronic hepatitis persons and immunocompromised a glucose level of 68 mg/dL, a protein C patients in the United States. J In- persons (1,2). The most common level of 36 mg/dL, and a lactic acid fect Dis. 1995;171:281–9. doi:10.1093/ level of 2.1 meq/L. No abnormalities infdis/171.2.281 neurologic manifestations of 6. Idrees M. Development of an improved WNV are aseptic meningitis, were found on a cranial computed genotyping assay for the detection of hep- meningoencephalitis, and encephalitis tomography scan. atitis C virus genotypes and subtypes in with or without acute fl accid paralysis The patient began treatment with Pakistan. J Virol Methods. 2008;150:50– acyclovir, 10 mg/kg intravenously, 6. doi:10.1016/j.jviromet.2008.03.001 (3). Other less common neurologic 7. Idrees M, Riazuddin S. Evaluation of three manifestations include Guillain-Barré every 8 hours for 3 days. On hospital different HCV typing methods for the syndrome, chorioretinitis, stroke-like day 2, she underwent magnetic detection of mixed genotype infections. symptoms, and unilateral brachial resonance imaging of the brain; J Dig Dis. 2011; (in press). doi:10.1111/ results were within reference limits. j.1751-2980.2011.00496.x plexopathy (4,5). 8. Zarkesh-Esfahani SH, Kardi MT, Edalati We report a case of WNV On hospital day 3, her headache began M. Hepatitis C virus genotype frequency aseptic meningitis in a 39-year-old to improve and she became afebrile, in Isfahan province of Iran: a descriptive immunocompetent woman who but she still stuttered occasionally. cross-sectional study. Virol J. 2010;7:69. Results of CSF tests for enterovirus, doi:10.1186/1743-422X-7-69 had severe headache with new- 9. Silva MB, Andrade TM, Silva LK, Rodart onset stuttering. Her medical history herpes simplex viruses 1 and 2, and IF, Lopes GB, Carmo TM, et al. Preva- included lumbar disc herniation and varicella zoster virus and PCR for lence and genotypes of hepatitis C virus migraines, for which she was taking human herpesvirus 6 were negative, among injecting drug users from Salva- and acyclovir was discontinued. On dor-BA, Brazil. Mem Inst Oswaldo Cruz. sumatriptan. Her symptoms started 2010;105:299–303. doi:10.1590/S0074- ≈2 weeks before hospitalization hospital day 5, she was discharged. 02762010000300009 and included a severe generalized Three days later, serum and CSF 10. Viazov S, Widell A, Nordenfelt E. headache initially thought to be a ELISA results for WNV were positive. Mixed infection with two types of hepa- A WNV ELISA was performed at titis C virus is probably a rare event. migraine, but sumatriptan resulted in Infection. 2000;28:21–5. doi:10.1007/ no improvement. A few days later, ViroMed Laboratories (Minnetonka, s150100050005 she had fever and was intermittently MN, USA) by using a Focus Test Kit stuttering. She denied recent travel (Focus Diagnostics, Cypress, CA, or animal exposure but admitted to USA), and the result was positive. The

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 8, August 2011 1567 LETTERS patient subsequently reported that her 2. Klein NC, Johnson DH, Cunha BA, Min- sylvatic Aedes spp. mosquitoes (1). stuttering had ceased. niganti V, Hansen E. West Nile encephali- Despite occasionally severe tis: the Long Island experience. Infectious A high degree of clinical Diseases in Clinical Practice. 2000;9:303– clinical forms, human dengue suspicion for WNV infection should 8. doi:10.1097/00019048-200009070- usually consists of a self-limited be considered in patients with a recent 00008 febrile disease often associated with history of mosquito bites and an 3. Sejvar JJ, Marfi n AA. Manifestations of asthenia, headache, rash, arthralgia, West Nile neuroinvasive disease. Rev acute febrile illness associated with Med Virol. 2006;16:209–24. doi:10.1002/ and myalgia. DENV is widely neurologic signs and symptoms (5). rmv.501 distributed throughout Asia, the Typical CSF fi ndings of infection 4. Weiss D, Carr D, Kellachan J, Tan C, Phil- Pacifi c, Central and South America, with WNV include lymphocytic lips M, Bresnitz E, et al. Clinical fi ndings the Middle East, and Africa (2,3). In of West Nile virus infection in hospital- pleocytosis, elevated protein level, ized patients, New York and New Jersey, Africa, most DENV outbreaks have reference glucose and lactic acid 2000. Emerg Infect Dis. 2001;7:654–8. been reported in the eastern regions, levels, and no erythrocytes (6). doi:10.3201/eid0704.010409 and episodic cases have occurred in The clinical presentation of 5. Cunha BA. Differential diagnosis of West western regions. However, few data Nile encephalitis. Curr Opin Infect Dis. WNV infection varied widely from 2004;17:413–20. doi:10.1097/00001432- are available for central regions. asymptomatic seroconversion to fatal 200410000-00005 In Gabon, concurrent of trans- encephalitis. It is possible, but unlikely, 6. Tyler KL, Pape J, Goody RJ, Corkill M, mission of DENV and chikungunya that the stuttering in the patient was an Kleinschmidt-DeMasters BK. CSF fi nd- virus was documented in 2007 during ings in 250 patients with serologically indication of a migraine aura. Initially, confi rmed West Nile virus meningitis and a large outbreak of dengue (4). This the patient reported that the headache encephalitis. Neurology. 2006;14:361–5. outbreak affected Libreville and major might have been a migraine, but later doi:10.1212/01.wnl.0000195890.70898.1f cities in northwestern Gabon and was reported that its associated symptoms, 7. Chen WH, Peng MC. Acquired stutter- caused by DENV-2. DENV isolates ing in a patient with encephalitis [in Chi- e.g., photophobia, were not as severe nese]. Gaoxiong Yi Xue Ke Xue Za Zhi. were closely related to strains from and did not last as long as her usual 1993;9:183–5. Asia, suggesting that the outbreak migraines. Further argument against resulted from recent introduction of migraine aura is the lack of response Address for correspondence: Burke A. Cunha, the virus. Epidemic DENV strains are to her migraine medication and the Infectious Disease Division, Winthrop- constantly moving from one region to fact that the stuttering continued after University Hospital, Suite 432, 222 Station another, and local DENV transmission the headache resolved. Plaza North, Mineola, NY 11501, USA; email: from sylvatic to urban areas has been Because WNV resembles JEV, [email protected] documented in some countries in it is interesting to note that a case of Africa (5,6). stuttering in a young adult infected To examine possible circulation with JEV has been reported (7). of DENV in Gabon, we tested the However, the mechanism of stuttering following for antibodies against associated with WNV is unknown. dengue: villagers living in rural areas, One possible explanation is myoclonic pet monkeys in the same areas, and contractions of the tongue, i.e., vocal wild monkeys killed in forests for myoclonus. No Evidence of bushmeat. A total of 4,341 persons and Dengue Virus 186 pet monkeys were sampled during Nardeen Mickail, Circulation in Rural July 2005–May 2008 in 220 randomly Natalie C. Klein, selected villages, which represented and Burke A. Cunha Gabon 10.3% of all villages in Gabon. Fifty Author affi liations: Winthrop-University To the Editor: Dengue virus wild monkeys were also sampled Hospital, Mineola, New York, USA; and (DENV) is a mosquito-borne during October 2009–August 2010 in State University of New York School of RNA virus belonging to the family different regions of Gabon (Table). Medicine, Stony Brook, New York, USA Flaviviridae. It is composed of 4 DENV-specifi c immunoglobulin DOI: 10.3201/eid1708.101691 closely related serotypes designated (Ig) G and IgM were detected by using DENV-1–4. There are 2 transmission capture ELISA kits (Panbio; Brisbane, References cycles for this virus. The endemic/ Queensland, Australia) (7) according epidemic cycle involves humans and the manufacturer’s instructions. All 1. Kramer LD, Li J, Shi PY. West Nile vi- the mosquito species Aedes aegypti samples were tested with an IgG rus. Lancet Neurol. 2007;6:171–81. assay, which was designed to detect doi:10.1016/S1474-4422(07)70030-3 and Ae. albopictus. The zoonotic or sylvatic cycle involves monkeys and high antibody titers usually associated

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