LETTERS from randomized controlled trials are 9. Haagmans BL, Kuiken T, Matrina BE, for parasitemia at 0.038 per 100 ery- lacking. All of our patients had been Fouchier RA, Rimmelzwaan GF, van throcytes. The patient was given 500 Amerongen G, et al. Pegylated interferon- previously healthy, with no coexisting alpha protects type 1 pneumocytes against mg of oral quinine three times daily; conditions identified as poor prognos- SARS coronavirus infection in macaques. intravenous quinine was administered tic risk factors (2,10). These three Nat Med. 2004;10:290–3. 15 hours after admission because she cases, together with the case of Wong 10. Booth CM, Matuka LM, Tomlinson GA, became nauseated. Her malaise per- Rachlis AR, Rose DB, Dwosh HA, et al. et al. (1), suggested that at least a sub- Clinical features and short term outcomes sisted for 3 days, but she did not show set of SARS adult patients can have a of 144 patients with SARS in the Greater any signs of malaria. She recovered relatively benign clinical course and Toronto area. JAMA. 2003;289:2801–9. completely and was discharged on uneventful recovery, without any spe- day 6 of hospitalization. cific treatment other than antimicro- Address for correspondence: Johnny W.M. The patient had not traveled out- bial agents. Chan, Department of Medicine, Queen side France except to the United Elizabeth Hospital, 30, Gascoigne Road, Kingdom years earlier. She did not Johnny W. M. Chan* Kowloon, Hong Kong; fax: 852-28736962; live near an airport, nor had she been and Samuel Lee* email: [email protected] to one recently. She had vacationed in *Queen Elizabeth Hospital, Hong Kong the south of France from June 23 to Special Administrative Region, People’s June 26 but had traveled by car. She Republic of China had been certified as a registered nurse on May 28 and had been work- References ing as a substitute employee at vari- 1. Wong RSM, Hui DS. Index patient and Occupational ous hospitals in the greater Paris area. SARS outbreak in Hong Kong. Emerg On June 21, 2001, she sustained an Infect Dis [serial on the Internet]. 2004 Feb Malaria Following [cited Jan 8 2004]. Available from accidental needlestick injury while http://www.cdc.gov/ncidod/EID/vol10no2/ Needlestick Injury taking a blood sample with an 03-0645.htm To the Editor: A 24-year-old 18-gauge, peripheral venous catheter 2. Chan JW, Ng CK, Chan YH, Mok TY, Lee that had no safety feature. She S, Chu SY, et al. Short term outcome and female nurse was admitted to the removed the catheter stylet and stuck risk factors for adverse clinical outcomes in emergency room at Bichat University adults with severe acute respiratory syn- Hospital in Paris, France, on July 4, herself as she crossed her hands to drome (SARS). Thorax. 2003;58:686–9. 2001, with fever, nausea, and general discard the stylet in a sharps contain- 3. Van Vonderen MGA, Bos JC, Prins JM, er. The needlestick pierced the nurse’s Wertheim-van Dillen P, Speelman P. malaise. She had no notable medical glove and caused a deep, blood-let- Ribavirin in the treatment of severe acute history, except spontaneously regres- respiratory syndrome (SARS). The sive Schönlein-Henloch purpura at 9 ting injury on the anterior aspect of Netherlands Journal of Medicine. months of age. On admission, after the left wrist. She had no previous 2003;61:238–41. history of needlestick injury. She 4. Oba Y. The use of corticosteroids in SARS. she was given paracetamol, her axil- notified the hospital occupational N Engl J Med. 2003;348:2034–5. lary temperature was 37.6°C. She was 5. Chu CM, Cheng VCC, Hung IFN, Wong slightly jaundiced and reported a mild medicine department of her injury on MML, Chan KH, Chan KS, et al. Role of headache but showed no resistance to the day it occurred and was given a lopinair/ritonavir in the treatment of SARS: postexposure interview. In accor- initial virological and clinical findings. head flexion. Her abdomen was dance with national postexposure Thorax. 2004;59:252–6. depressible but tender. Urinalysis did 6. Li J, Li SD, Du N. Clinical study on treat- not show hematuria or signs of uri- management guidelines, she was test- ment of severe acute respiratory syndrome nary infection. Biologic tests indicat- ed for HIV and hepatitis C virus with integrated Chinese and Western medi- (HCV) antibody, and results were cine approach. Zhongguo Zhong Xi Yi Jie ed normal values except the follow- negative at baseline; her immuniza- He Za Zhi. 2004;24:28–31. ing: platelets 47.4 x 103/µL, aspartate 7. Stroher U, DiCaro A, Li Y, Strong JE, aminotransferase 307 U/L (normal tion against hepatitis B virus (HBV) Plummer F, Jones SM, et al. Severe acute value <56), alanine aminotransferase was confirmed. The risk of infection respiratory syndrome coronavirus is inhib- by pathogens other than HBV, HCV, ited by interferon-alpha. J Infect Dis. 239 U/L (normal value <56), total or HIV following a needlestick injury 2004;189:1164–7. bilirubin 58 µmol/L (normal value 8. Sui J, Li W, Murakami A, Tamin A, <24), and γ-glutamyl transpeptidase was not discussed during her postex- Matthews LJ, Wong SK, et al. Potent neu- 57 U/L (normal value <35). Results of posure interview, and the nurse was tralization of severe acute respiratory syn- not made aware of that risk. The drome (SARS) coronavirus by a human an abdominal echogram were normal. injured nurse did not inform the man- MAb to S1 protein that blocks receptor Result of a blood film to identify association. Proc Natl Acad Sci U S A. Plasmodium falciparum was positive aging physician that the injury had 2004;101:2536–41. occurred while she was drawing

1878 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 10, No. 10, October 2004 LETTERS blood from a patient to determine if source patient had been discarded by should consider the probability of the patient was infected with malaria. the time the injured nurse became ill. occupational P. falciparum malaria. By July 1, 10 days after exposure, P. falciparum is a bloodborne fatigue, malaise, and fever developed; pathogen, and malaria is a well-docu- Acknowledgments her temperature was lowered to mented complication of transfusion We thank Mrs. Emma Finn-Quilliam 38.6°C by taking paracetamol. Her (1). Malaria has also been diagnosed for her invaluable editorial assistance. condition returned to normal on July 2 after intravenous drug use (2,3) and before a second bout of fever and breaches in infection control proce- Arnaud P. Tarantola,* myalgia occurred during the night. dures (4–6), as well as occupational Anne C. Rachline,* Cyril Konto,* She had to leave work early on July 3 exposures (1–5). Occupational P. fal- Sandrine Houzé,* Sylvie Lariven,* because of generalized pain and a tem- ciparum infection after a needlestick Anika Fichelle,* David Ammar,* perature of 39°C. The patient’s mother injury may be rare; however, such an Christiane Sabah-Mondan,† is a biologist and was aware that her injury can be potentially severe in Hélène Vrillon,‡ Oliver Bouchaud,* daughter had sustained a needlestick nonimmune healthcare workers in Frank Pitard,* injury while drawing blood from a countries where malaria is not endem- Elisabeth Bouvet,*and Groupe patient in whom malaria was suspect- ic, especially if the occupationally d'Etude des Risques d'Exposition des Soignants aux ed. The mother insisted that a blood infected person is pregnant. This situ- agents infectieux*1 smear be performed at a private labo- ation may also become more common *The Accidental Blood Exposure Study ratory in Paris. The smear was qualita- as malaria spreads and as increasing Task Force (GERES), France; †Bichat- tively determined positive for P. vivax. international travel brings potential Claude Bernard University Hospital, Paris, Subsequently, the patient was admit- source patients to hospitals in malar- France; ‡Hôpital Esquirol, Saint-Maurice, ted to Bichat-Claude Bernard ia-endemic countries. France; and §Hôpital National de Saint- University Hospital with suspected HBV, HCV, and HIV are the Maurice, Saint Maurice, France malaria. A repeat blood smear con- pathogens most often transmitted in ducted there identified P. falciparum. documented cases of occupational References The source patient was a 28- infection following needlestick 1. Lettau LA. Nosocomial transmission and weeks’ pregnant, 30-year-old woman injuries in industrialized countries. infection control aspects of parasitic and of Kenyan origin who resided in Testing for infection by these ectoparasitic diseases. Part II. Blood and tissue parasites. Infect Control Hosp France; she had visited Kenya and pathogens does not include all the Epidemiol. 1991;12:111–21. returned to France on June 1, 2001. On possible infections that can result 2. Biggam AG. Malignant malaria associated June 21, she was admitted to the gyne- from occupational exposure (1,7,8). with the administration of heroin intra- cology-obstetrics emergency room at a Although conducting a thorough venously. Trans R Soc Trop Med Hyg. 1929;23:147–55. greater Paris area hospital with fever investigation of the circumstances 3. Most H. Malignant malaria among drug and malaise. Blood sampling and thin surrounding any needlestick injury is addicts. Epidemiological, clinical and labo- and thick blood smears were per- a challenge in the daily clinical set- ratory studies. Trans R Soc Trop Med Hyg. formed by the nurse. The source ting, an investigation should always 1940;34:139–49. 4. Abulrahi HA, Bohlega EA, Fontaine RE, al patient’s level of parasitemia was esti- be carried out. As in this case-patient, Seghayer SM, al Ruwais AA. Plasmodium mated at 0.05 per 100 erythrocytes, the treatment of occupational P. falci- falciparum malaria transmitted in hospital and oral quinine was initiated. The parum infection may be delayed through heparin locks. Lancet. physician who interviewed the nurse because physicians do not immediate- 1997;349:23–5. 5. Alweis RL, DiRosario K, Conidi G, Kain after the needlestick injury verified ly consider malaria as a possible diag- KC, Olans R, Tully JL. Serial nosocomial that the source patient was HIV- and nosis. Furthermore, healthcare work- transmission of Plasmodium falciparum HCV-antibody negative and that the ers with neurologic symptoms caused malaria from patient to nurse to patient. nurse was immunized against HBV. by P. falciparum malaria may be too Infect Control Hosp Epidemiol. 2004;25:55–9. On June 23, although the results of her ill to tell the treating physician about 6. Moro ML, Romi R, Severini C, Casadio test for Plasmodium were negative, their occupational exposure. Such GP, Sarta G, Tampieri G, et al. Patient-to- she was transferred to another tertiary infections must be diagnosed prompt- patient transmission of nosocomial malaria care center where IV quinine was ly as they are potentially lethal, and in Italy. Infect Control Hosp Epidemiol. 2002;23:338–41. administered for nausea and vomiting, presumptive treatment is readily and she could be monitored more available and well tolerated. closely. She recovered fully and was Clinicians managing healthcare or 1Members of the Groupe d'Etude des Risques d'Exposition des Soignants aux agents infectieux discharged on June 27. Unfortunately, laboratory workers with a febrile ill- include: Arnaud P. Tarantola, Anne C. Rachline, all blood samples or smears from the ness or in a postexposure setting Anika Fichelle, and Elisabeth Bouvet.

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 10, No. 10, October 2004 1879 LETTERS

7. Collins CH, Kennedy DA. Microbiological nesses before he left Hungary to go to patients. The female patient had never hazards of occupational needlestick and Thailand. On examination, laboratory traveled to a dengue-endemic region. “sharps” injuries. J Appl Bacteriol. 1987;62:385–402. results indicated leukopenia (3,300 Serologic and virologic evidence 8. Herwaldt BL. Laboratory-acquired parasitic leukocytes/mm3) and mild thrombo- confirmed the clinical diagnosis. infections from accidental exposures. Clin cytopenia (119,000 platelets/mm3). Acute-phase serum samples from each Microbiol Rev. 2001;14:659–88. Leukopenia is characteristic of patient were tested for immunoglobu- dengue virus and has been associated lin (Ig) M and IgG antibodies to Address for correspondence: Arnaud Tarantola, with suppression of bone marrow pro- dengue viruses by using a commercial Département International et Tropical Institut duction (6). We conducted additional enzyme-linked immunosorbent assay de Veille Sanitaire, 12 rue du Val d’Osne, 94415 tests because thrombocytopenia could kit. IgM, but not IgG, antibodies to Saint Maurice Cedex, France; fax: 33-1-55-12- have been the first sign of a more dengue viruses were detected in the 53-35; email: [email protected] severe form of dengue infection, serum sample from the male patient 7 dengue hemorrhagic fever, which is days after the onset of his illness; a associated with hemorrhagic diathesis convalescent-phase serum sample was and shock (6). Lymphocytosis and not available for further testing. The monocytosis with 26% atypical lym- first serum sample was obtained from phocytes and a high-normal level of the female patient 6 days after onset of Nosocomial alanine aminotransferase (56 U/L) her illness. IgM and IgG antibodies Transmission of were found. The C-reactive protein were not found in that sample. In the level and the erythrocyte sedimenta- serum sample obtained from the Dengue tion rate were normal. Blood smears female patient 12 days after onset, To the Editor: Four viruses form for malarial parasites were negative. IgM, but not IgG, antibodies to dengue the dengue complex of mosquito- Examination of the patient showed viruses were found. Both IgM and IgG borne viruses (family Flaviviridae, a maculopapular rash, pharyngitis, antibodies were found in serum sam- genus Flavivirus). Any of these virus- and conjunctivitis. Dengue fever was ples from this patient 3 weeks after es can cause dengue fever, an uncom- the clinical diagnosis based on the onset of her illness. plicated febrile illness with rash; how- patient’s history of a mosquito bite in Diagnosis was also confirmed by ever, these viruses are not transmitted a dengue-endemic country, the reverse transcription–polymerase person to person. The principal mos- patient’s symptoms, and the laborato- chain reaction assays of early serum quito vector of these viruses is Aedes ry results. The patient’s general samples of both patients by using uni- aegypti. These viruses are not known condition was relatively good, so we versal flavivirus primers. Ampli- to exist in Europe; therefore, dengue treated him on an outpatient basis and fication products were directly virus infections in Europe are seen in recommended that he return for daily sequenced (GenBank accession no. patients returning from dengue- examinations. AY538627 and AY538628). The endemic areas (1). Nosocomial trans- On September 7, while collecting a nucleotide sequences were identified missions of dengue viruses by needle- blood sample from the patient, the with a BLAST search (http://www. stick have been reported in three patient’s sister, also a physician, acci- ncbi.nlm.nih.gov/BLAST/) using the instances (2–4) and by bone marrow dentally stuck her finger with the nee- GenBank database. Highest similarity transplant in one instance (5). We dle, which was contaminated with the was with dengue virus type 2 strain describe the first case of nosocomial patient’s blood. Seven days later she ThNH76/93, which had been isolated dengue fever diagnosed and treated in became ill, with fever, headache, dif- from a patient in northeast Thailand Hungary. fuse maculopapular rash, myalgia, during the epidemic season of 1993 On September 6, 2003, a 46-year- cervical lymphadenopathy, and (7). The virus- specific nucleotide old physician sought care from the malaise. Her laboratory tests showed sequences detected in the Hungarian Department of Infectology, (“Baranya leukopenia with a normal thrombo- patients showed 98% nucleotide iden- County Hospital” Pécs, Hungary); he cyte level, C-reactive protein level, tity with the corresponding sequences reported a 4-day history of fever, liver function tests, and erythrocyte of the Thai strain. headache, malaise, maculopapular sedimentation rate. On physical Viremia and simultaneous anti- rash, and pharyngitis. He had recently examination, painfully enlarged cervi- body production has been observed in returned from a trip to Thailand and cal lymph nodes and conjunctivitis several studies of dengue (6,8,9). recalled having been bitten by a mos- were found. No complications were Virus isolation is possible in dengue quito at Bangkok airport 11 days ear- observed and the disease resolved infections early in the illness, and in lier. The patient had no history of ill- within 10 days after onset in both our experience, virus RNA was

1880 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 10, No. 10, October 2004