sign in sign up
<<
Home , Arenavirus, Lassa fever

LETTERS

9. da Silva AK, Le Saux JC, Parnaudeau S, to obstructive uropathy. His baseline Patient B, a 45-year-old Ma- Pommepuy M, Elimelech M, Le Guyader creatinine level was 300–400 μmol/L. laysian–Chinese man with diabetes FS. Evaluation of removal of during wastewater treatament, using real For 3 years, he had ingested tradi- mellitus, had undergone a cadaveric time RT-PCR: different behaviors of tional Chinese medicine, which we liver transplant in 2001 for hepatitis genogroups I and II. Appl Environ Mi- suspect was contaminated by steroids B liver cirrhosis. He was receiving crobiol. 2007;73:7891–7. DOI: 10.1128/ because he appeared cushingoid. An immunosuppressants (azathioprine AEM.01428-07 10. Lees D. and bivalve shellfi sh. Int J outbreak of CHIKV infection was and prednisolone). He was admitted Food Microbiol. 2000;59:81–116. DOI: reported at his workplace. He was in August 2008 after experiencing fe- 10.1016/S0168-1605(00)00248-8 admitted to National University Hos- ver, , and abdominal bloat- pital, Singapore, in July 2008 with ing for 3 days. He had no neurologic Address for correspondence: Jesús L. Romalde, , , and symptoms. Acute self-limiting febrile Departamento de Microbiología y Parasitología, of 1 day. He had no joint symptoms. illnesses with arthritis had occurred Centro de Investigaciones Biológicas (CIBUS)– Clinically, he had systemic infl amma- in his hometown; CHIKV infections Facultad de Biología, Universidad Santiago de tory response syndrome complicated were suspected. Compostela, 15782, Santiago de Compostela, by acute-on-chronic renal failure. His Results of his examination on Spain; email: [email protected] creatinine level was elevated at 921 admission were normal, except for bi- μmol/L on admission. A complete lateral enlarged cervical lymph nodes. blood count showed leukocytosis Chest radiograph results were unre- (19.24 × 109 cells/L) with neutro- markable. He had mild transaminitis philia and (62 × (alanine aminotransferase 173 U/L, 109 cells/L). Initial blood and aspartate aminotransferase 170 U/L), cultures and serologic results were elevated C-reactive (107 Atypical negative for , but serum mg/L), and thrombocytopenia (120 reverse –PCR (RT-PCR) × 109 cells/L) without leukocytosis. Virus and indirect immunofl uorescent as- Results of comprehensive serum and Infections in say for immunoglobulin G (IgG) urine microbial studies were negative Immuno- (Euroimmun Medizinische Labor- for posttransplant infections. Results diagnostika, Lubeck, Germany) and of serum RT-PCR were negative for compromised IgM (CTK Biotech, Inc, San Diego, CHIKV, but IgG and IgM tests were Patients CA, USA) were positive for CHIKV positive for CHIKV. (3,4). Computed tomographic scans Brain magnetic resonance im- To the Editor: Chikungunya fe- of the abdomen showed dilated small aging was performed because of the ver was fi rst described in Tanganyika bowel loops. patient’s persistent severe headache (now Tanzania) in 1952 and is now An urgent laparotomy did not and transient drowsiness. It showed emerging in Southeast Asia. Chi- show bowel perforation, but peritone- several nonspecifi c areas of enhance- kungunya virus (CHIKV) infection, al cultures yielded Klebsiella pneumo- ment, which suggested , a self-limiting febrile illness, shares niae, Escherichia coli, and Candida given the clinical scenario (Figure). similarities with such glabrata, and RT-PCR from the con- However, a lumbar puncture was not as headache and . Addition- centrated peritoneal fl uid was positive performed, and hence, whether the ally, patients with CHIKV infection for CHIKV (3). He was administered patient’s cerebrospinal fl uid contained typically have arthralgia, arthritis, appropriate antimicrobial drugs. He CHIKV could not be determined. and tenosynovitis (1). Although usu- required repeat laparotomies because Bilateral frontoparietal white mat- ally benign, CHIKV infection may of elevated intraabdominal pres- ter lesions with restricted diffusion on rare occasions lead to neurologic sure. He subsequently received broad has been suggested as an early sign and hepatic manifestations with high spectrum antimicrobial drugs to treat of (5). However, a illness and mortality rates (2). We re- secondary intraabdominal infections retrospective series demonstrated that, port 2 immunocompromised patients caused by P. aeruginosa and Entero- in CHIKV encephalitis, abnormalities with CHIKV infection associated with coccus faecalis. on magnetic resonance imaging were peritonitis, encephalitis, and second- Ventilator-associated pneumonia uncommon, and no pathognomonic ary bacterial infections. also developed. Despite maximal sup- features were found (6). Patient A, a 66-year-old Singa- port and prolonged antimicrobial ther- Hospital-acquired pneumonia also porean-Chinese man, had a history apy, this patient died after 5 months of developed and was treated with broad- of chronic renal disease secondary hospitalization. spectrum antimicrobial drugs. Bron-

1038 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 16, No. 6, June 2010 LETTERS

Adrian C.L. Kee, Samantha Yang, and Paul Tambyah Author affl iation: National University Hospi- tal, Singapore

DOI: 10.3201/eid1606.091115

References

1. Simon F, Parola P, Grandadam M, Four- cade S, Oliver M, Brouqui P, et al. Chi- kungunya infection: an emerging rheuma- tism among travelers returned from Indian Ocean islands. Report of 47 cases. Medi- cine (Baltimore). 2007;86:123–37. DOI: 10.1097/MD/0b013e31806010a5 2. Lemant J, Boisson V, Winer A, Thibault L, André H, Tixier F, et al. Serious acute chikungunya virus infection requiring intensive care during the Reunion Is- land outbreak in 2005–2006. Crit Care Med. 2008;36:2536–41. DOI: 10.1097/ CCM.0b013e318183f2d2 3. Leo YS, Chow AL, Tan LK, Lye DC, Lin L, Ng LC. Chikungunya outbreak, Singapore, 2008. Emerg Infect Dis. 2009;15:836–7. DOI: 10.3201/eid1505.081390 4. Thein S, La Linn M, Aaskov J, Aung MM, Aye M, Zaw A, et al. Development of a simple indirect enzyme-linked im- munosorbent assay for the detection of Figure. Magnetic resonance imaging of the brain of patient B, showing several nonspecifi c in serum areas of enhancement (arrows), which suggests encephalitis, given the clinical scenario. from patients following an outbreak of chikungunya virus infection in Yangon, Myanmar. Trans R Soc Trop Med Hyg. choscopic cultures were negative for nosocomial infections. We note that 1992;86:438–42. DOI: 10.1016/0035- CHIKV. The patient responded well other viral infections have been asso- 9203(92)90260-J to antimicrobial drugs, and his men- ciated with bacterial translocation and 5. Ganesan K, Diwan A, Shankar SK, Desai tal status was normal on discharge. secondary nosocomial infections (8). SB, Sainani GS, Katrak SM. Chikungu- nya encephalomyeloradiculitis: report of 2 He possibly had encephalitis associ- Whether these infections were linked cases with neuroimaging and 1 case with ated with CHIKV infection, compli- to CHIKV infection or to the underly- autopsy fi ndings. AJNR Am J Neurora- cated by secondary hospital acquired ing chronic immunosuppressed state diol. 2008;29:1636–7. DOI: 10.3174/ajnr. pneumonia. is unclear. A1133 6. Robin S, Ramful D, Le Seach F, Jaf- In this case, CHIKV was detected Both of our patients did not have far-Bandjee MC, Rigou G, Alessan- in peritoneal fl uid, but because of the the joint manifestations that are char- dri JL. Neurologic manifestations of positive bacterial cultures, we are not acteristic of CHIKV infection (9). pediatric chikungunya infection. J confi dent about its causative role in More prospective studies are required Child Neurol. 2008;23:1028–35. DOI: 10.1177/0883073808314151 Patient A’s peritonitis. Although a to determine the full spectrum of clini- 7. Palanivelu C, Rangarajan M, Rajapandian series reported that 6 patients with cal features of CHIKV infection in im- S, Maheshkumaar GS, Madankumar MV. CHIKV infection had perforated jeju- munocompromised patients. Recently Perforation of jejunal diverticula in ste- nal diverticula while receiving long- identifi ed biomarkers may predict roids and nonsteroidal anti-infl ammatory drug abusers: a case series. World J Surg. term nonsteroidal antiinfl ammatory patients at risk for complications but 2008;32:1420–4. DOI: 10.1007/s00268- drugs and steroids (7), the perforations we were unable to study them in our 008-9469-0 were likely secondary to prolonged ste- patients (10). Although most cases of 8. Lahiri M, Fisher D, Tambyah PA. Dengue roid use rather than CHIKV infection. CHIKV infection are self-limiting, cli- mortality: reassessing the risks in transi- tion countries. Trans R Soc Trop Med In addition, both immunocompromised nicians should be alert to atypical pre- Hyg. 2008;102:1011–6. DOI: 10.1016/j. patients in our study had their CHIKV sentations and severe complications in trstmh.2008.06.005 infections secondarily complicated by immunosuppressed patients.

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 16, No. 6, June 2010 1039 LETTERS

9. Parola P, de Lamballerie X, Jourdan J, Ro- samples were sent to Lagos, or staff patient 3 took care of case-patient 2 very C, Vaillant V, Minodier P, et al. Novel from Lagos collected samples on site. and slept in the same room with her chikungunya virus variant in travelers re- turning from Indian Ocean islands. Emerg Confi rmatory testing, sequencing, and for 4 days. was confi rmed Infect Dis. 2006;12:1493–9. virus isolation were performed at the in case-patients 3 and 4 by RT-PCR 10. Ng LF, Chow A, Sun YJ, Kwek DJ, Lim Bernhard Nocht Institute for Tropi- as well as by IgM and IgG serocon- PL, Dimatatac F, et al. IL-1beta, IL-6, and cal Medicine in Hamburg, Germany. version in the surviving patient (case- RANTES as biomarkers of chikungunya severity. PLoS One. 2009;4:e4261. DOI: Primary testing was done by reverse patient 3). Case-patient 4, a pregnant 10.1371/journal.pone.0004261 transcription–PCR (RT-PCR) that nurse, had a spontaneous abortion and targeted the glycoprotein (GP) gene died on day 9 of hospitalization. Se- Address for correspondence: Paul Tambyah, (5,6). An RT-PCR that targeted the quencing the GP and L gene PCR frag- Department of Medicine, National University large (L) gene was used as a second- ments showed that case-patients 3 and Hospital, 5 Lower Kent Ridge Rd, Singapore ary test (7), and PCR products were 4 were infected with the same virus 119074; email: paul_anantharajah_tambyah@ sequenced. Serologic testing for Lassa strain (100% identity). In March and nuhs.edu.sg virus–specifi c immunoglobulin (Ig) April 2005, blood was collected from G and IgM was performed by immu- 50 hospital staff members (including nofl uorescent antibody test using Vero those who had had contact with the cells infected with Lassa virus. Virus case-patients) and screened for Lassa isolation with Vero cells was conduct- virus–specifi c IgM and IgG. No posi- ed in the BioSafety Level 4 laboratory tive blood samples were found, which in Hamburg. indicated that no additional staff mem- From 2005 through 2008, 10 cases bers were involved in the outbreak. Lassa Fever, of Lassa fever were confi rmed by vi- Case-patients 5 and 6 were admit- , 2005–2008 rus detection (cases 3–10) or implicat- ted to EBSUTH in 2008 on January 17 ed by epidemiologic investigation and and March 5, respectively. Both were To the Editor: Lassa fever affects serologic testing (cases 1 and 2) (on- medical doctors, one at a local hospi- ≈100,000 persons per year in West Af- line Appendix Table, www.cdc.gov/ tal and the other at EBSUTH, and both rica (1). The disease is caused by Las- EID/content/16/6/1040-appT.htm). died. Encephalopathy with general- sa virus, an , and is associ- Case-patients 1–4 were involved in ized seizures and loss of conscious- ated with and organ failure. a nosocomial outbreak that occurred ness preceded death in both cases. The case-fatality rate in hospitalized in February 2005 at the Ebonyi State The source of infection is unknown, patients is 10%–20%. The reservoir University Teaching Hospital (EB- although it is likely that they became of the virus is multimammate mice SUTH) in Abakaliki. Retrospective infected while they treated patients (Mastomys natalensis). Investigations investigation suggests the following without knowing they had Lassa fever. in the 1970s and 1980s pointed to the transmission chain. The presumed In agreement with the epidemiology, existence of 3 disease-endemic zones index case-patient was a male nurse the from the 2 patients were within Nigeria: the northeastern re- living in Onitsha, who became ill on similar, though not identical (89% and gion around Lassa, the central region January 21, 2005, and traveled ≈200 87% identity in the GP and L genes, around Jos, and the southern region km to EBSUTH for better medical respectively). around Onitsha (2,3). The current treatment. The detection of Lassa vi- Cases 7 to 10 occurred in Abuja epidemiologic situation is less clear rus–specifi c IgM during his convales- and Jos from December 2007 through because no surveillance system is in cent phase indicates that he had Lassa March 2008. Healthcare workers ap- place. fever. The second case-patient was a peared not to be involved, and no In 2003 and 2004, we conducted a female nurse who had contact with molecular epidemiologic evidence hospital-based survey in Irrua, which the index case-patient on February 4. indicated that transmission occurred demonstrated ongoing transmission She was admitted on February 7 and among the 3 case-patients from Jos of the virus in Edo State, Nigeria (4). died 6 days later. Her clinical features (94–97% and 90–94% identity in the Since then, laboratory capacity at the were compatible with Lassa fever, but GP and L genes, respectively). University of Lagos for diagnosing laboratory confi rmation is lacking be- In conjunction with our previ- Lassa fever has been improved and cause specimens were not collected. ous report (4), the cases presented used for small-scale passive surveil- Two additional case-patients among here demonstrate current Lassa fever lance in other parts of the country. hospital staff (case-patients 3 and 4) activity in the states of Edo, Ebonyi, offi cials or hospital were seen on February 21; each had Federal Capital Territory, and Plateau. staff reported suspected cases. Blood had contact with case-patient 2. Case- These fi ndings correspond to early re-

1040 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 16, No. 6, June 2010