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Dengue Virus, Nepal LETTERS 10. Wininger DA, Fass RJ. Antibiotic ce- and Aedes aegypti, domestic day-bit- hospital in Birgunj. Patients with se- ment and beads for orthopedic infections. ing mosquitoes. Dengue virus induces vere symptoms were referred to Sukr- Antimicrob Agents Chemother. 1996;40: 2675–9. clinical illness, which ranges from a araj Tropical and Infectious Disease nonspecifi c viral syndrome (dengue Hospital, Kathmandu, for diagnosis Address for correspondence: Jason J. Schafer, fever [DF]) to severe and fatal hem- and treatment. The clinical features UPMC St. Margaret, Department of Pharmacy, orrhagic disease (dengue hemorrhagic in most patients were consistent with 815 Freeport Rd, Pittsburgh, PA 15215, USA; fever [DHF]). DF/DHF occurs primar- signs of DF, but some patients showed email: [email protected] ily in tropical and subtropical areas of signs (high fever, rash, ecchymosis, the world. Domestic dengue virus in- epistaxis, positive tourniquet test, liv- fection occurs in >100 countries; >2.5 er dysfunction, and thrombocytopenia billion persons live in these areas. Ap- [platelet count <100,000/mm3]) con- proximately 100 million cases of DF, sistent with the World Health Organi- 500,000 cases of DHF, and several zation (WHO) defi nition of DHF. As- thousand deaths occur annually world- cites and plural effusion developed in wide (1). During the past decades, 2 patients. Blood specimens were col- Dengue Virus, dengue virus has emerged in south- lected from all patients at the time of Nepal ern Asia; DF/DHF epidemics have admission to the local hospitals. Par- occurred in Bhutan, India, Maldives, ticle agglutination (PA) assay (Pentax To the Editor: Dengue virus be- Bangladesh, and Pakistan (2–4). Ltd, Tokyo, Japan) (5) and immuno- longs to the genus Flavivirus, family From August through November globulin (Ig) M–capture ELISA (Den- Flaviviridae. It has 4 serotypes: den- 2006, the number of febrile patients gue/JE IgM Combo ELISA kit, Panbio gue virus type 1 (DENV-1), dengue increased in 4 major hospitals in the Ltd, Brisbane, Queensland, Australia) virus type 2 (DENV-2), dengue virus Terai region of Nepal: Nepalgunj were performed. Dengue virus–specif- type 3 (DENV-3), and dengue virus Medical College, Bheri Zonal Hospi- ic IgM was detected in 11 patients who type 4 (DENV-4). Dengue virus is tal in Nepalgunj, Tribhuban Hospital had fever, headache, and rash (Table). maintained in a cycle between humans in Dang, and Narayani subregional Each of these patients had negative Table. Clinical and laboratory data for 11 patients admitted to hospitals and diagnosed with dengue fever or dengue hemorrhagic fever, Nepal, 2006* Patient Month Initial Travel Clinical signs and age, y/Sex admitted Location diagnosis history symptoms Selected laboratory and other test results 20/M Sep Kathmandu DF Yes Fever, headache, Hb 15.4 g/dL; TLC 10,500/mm3; nausea Plt 185,000/mm3; blood culture for salmonellae negative; ALT 38 IU/L 27/F Sep Bardiya Viral fever No Fever, headache, TLC 5,600/mm3; blood culture for vomiting salmonellae negative 3/M Sep Salayan Encephalitis No Fever, vomiting, Widal negative; TLC 4,700/mm3 convulsions 13/M Oct Sindhuli Typhoid No Fever, headache Widal negative; TLC 4,500/mm3; blood fever culture for salmonellae negative; Brucella antigen negative; chest radiograph normal 22/M Oct Birgunj DHF No Fever, headache, Bil 0.8 mg/dL; ALT 80 IU/L; Plt 22,000/mm3; vomiting, ascites chest radiograph normal 55/F Oct Dang DF No Fever, headache, Plt 51,000/mm3; TLC 7,600/mm3; MP muscular pain negative; ESR 20 mm/h; Bil 0.7 mg/dL 22/F Oct Birgunj Viral fever No Fever, headache, Brucella negative; Widal negative; body ache TLC 5,600/mm3 13/M Nov Dang DF No Fever, headache, Plt 95,000/mm3; TLC 4,700/mm3; rashes Hb 13.1 g%; Bil 0.8mg/dL; ALT 26 IU/L 35/F Nov Birgunj DHF No Fever, headache, Bil 0.81mg/dL; Plt 31,000/mm3; bruises; tourniquet: PT 2 min 30 s (control 14) positive 40/M Nov Birgunj DF No Fever, headache, ALT 127IU/L; Plt 110,000 /mm3; rashes PCV 38.8%;TLC 5,500/mm3; ultrasonography liver size, 16.8 cm 42/M Nov Dang DF No Fever, headache, Bil 0.7 mg/dL; Widal test negative; rashes TLC 6,800/mm3; Plt 164,000/mm3 *Blood specimens were collected at time of hospital admission. Diagnosis was confirmed by using immunoglobulin M–capture ELISA. DF, dengue fever; Hb, hemoglobulin;TLC, total leukocyte count; Plt, platelets; ALT, alanine aminotransferase; DHF, dengue hemorrhagic fever Bil, bilirubin; MP, malaria parasites; ESR, erythrocyte sedimentation rate; PT, prothrombin time; PCV, packed cell volume. 514 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 14, No. 3, March 2008 LETTERS results for Japanese encephalitis vi- this region. The emerging DENV-2 10. Epidemiology and Disease Control Divi- rus–specifi c IgM. Of the 11 patients, is likely to have been introduced into sion, Ministry of Health Nepal. The annual report of malaria, Kala-azar and Japanese 10 had no history of travel to India or Nepal from India. encephalitis in Nepal, 2005. Kathmandu, other dengue-endemic countries. DF or Nepal: Ministry of Health; 2006. DHF was initially diagnosed for 7 pa- Basu Dev Pandey,* tients, and viral encephalitis, typhoid Kouichi Morita,† Address for correspondence: Basu Dev Pandey, fever, or viral fever was diagnosed for Santa Raj Khanal,‡ Tropical and Infectious Disease Hospital, Teku others without serologic tests. Reverse Tomohiko Takasaki,§ Road, GPO Box 9045, Kathmandu, Nepal; transcription–PCR and virus isolation Isao Miyazaki,¶ email: [email protected] were performed at Institute of Tropi- Tetsuro Ogawa,¶ cal Medicine, Nagasaki University, Shingo Inoue,† Nagasaki, Japan, but the dengue virus and Ichiro Kurane§ genome was not detected, and no virus *Tropical and Infectious Disease Hospital, was isolated, likely because sample Kathmandu, Nepal; †Nagasaki University, collection was delayed and the sample Nagasaki, Japan; ‡Tribhuban University, was transported to Japan in a deterio- Kathmandu, Nepal; §National Institute of rated condition. Infectious Diseases, Tokyo, Japan; and Human DF/DHF have been considered ¶Pentax Company Limited, Tokyo, Japan Tuberculosis to be a possible public health threat Caused by to Nepal because DF/DHF epidemics References have occurred recently in India and Mycobacterium 1. World Health Organization. Dengue and Pakistan, which reported several thou- dengue haemorrhagic fever. Fact sheet bovis, Taiwan sand cases and >100 deaths (6). The no.117; revised 2002 Apr [cited 2006 Oct fi rst DF case in Nepal was reported 31]. Available from http://www.who.int/ To the Editor: Mycobacterium in 2004 (7). Further, the fi rst DENV- mediacentre/factsheets/fs117/en bovis is one of the causative agents 2. World Health Organization. Dengue out- 2 strain of Nepal origin was isolated of tuberculosis (TB) in humans and break in Bhutan. Communicable Disease animals. Drinking unpasteurized milk, from a Japanese traveler who visited Newsletter. 2007;4(1). Nepal and in which DF developed af- 3. Islam MA, Ahmed M, Begum N, Choud- eating undercooked meat, and close ter the patient returned to Japan. The hury N, Khan A, Parquet C, et al. Molecu- contact with infected animals are the lar characterization and clinical evaluation isolated DENV-2 (GenBank accession main sources of infection for humans. of dengue outbreak in 2002 in Bangladesh. Currently, 119 M. bovis spoligotypes no. AB194882) was 98% homologous Jpn J Infect Dis. 2006;59:85–91. with DENV-2 isolated in India (8). The 4. Jamil B, Hasan R, Zafar A, Bewley K, are contained in the fourth internation- prevalence of dengue virus antibody Chamberlain J, Mioulet V, et al. Dengue al spoligotyping database (SpolDB 4) virus serotype, Karachi, Pakistan. Emerg was reported to be 10.4% in the south- and are categorized into 3 main sublin- Infect Dis. 2007;13:182-3. eages corresponding to ST prototypes western region of Nepal (9). These 5. Pandey B, Yamamoto A, Morita K, Kuro- reports suggest that dengue virus has sawa Y, Rai S, Adhikari S, et al. Serodi- 482, 683, and 479 (1). been circulating in Nepal for several agnosis of Japanese encephalitis among Although an M. bovis surveillance Nepalese patients by the particle aggluti- years. Thus, DF/DHF has likely been program for farm animals has been nation assay. Epidemiol Infect. 2003;131: implemented by the Taiwan Council misdiagnosed and illness caused by 881–5 . dengue virus underestimated in Ne- 6. Gupta E, Dar L, Kapoor G, Broor S. The of Agriculture, no surveillance system pal. In contrast, Japanese encephali- changing epidemiology of dengue in Del- exists for human TB cases caused by hi. Virol J. 2006;3:92. tis has been a public health problem M. bovis. To monitor the epidemiol- 7. Pandey BD, Rai SK, Morita K, Kurane I. ogy of M. bovis in domestic animals, in southwestern region of Nepal, and First case of dengue in Nepal. Nepal Med large epidemics have occurred almost Coll J. 2004;6:157–9. a regular tuberculin skin test (TST) every year since 1978 (10). Nepal has 8. Takasaki T, Kotaki A, Nishimura K, Sato is compulsory for cattle and sheep Y , Tokuda A, Lim C, et al. Dengue virus no dengue surveillance programs, and and optional for deer in Taiwan (2). type 2 from an imported dengue patient in In 2005, screening of Mycobacterium health professionals do not usually Japan. First isolation of dengue virus from consider dengue as a differential diag- Nepal. J Travel Med. 2007;14:445–8 spp. infections by TST was performed nosis. 9. Sherchand JB, Pandey BD, Haruki K, for 111,412 cattle and 73,396 caprint Jimba M. Sero-diagnosis of Japanese en- The emergence occurred in the and ovine herds, of which 188 (0.17%) cephalitis and dengue virus infection from and 148 (0.2%), respectively, were lowland Terai belt region, which bor- clinically suspected patients of Nepal.
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