Zika Virus Infection in a Massachusetts Resident After Travel to Costa Rica: A Case Report
Authors: Lin H. Chen
Journal: Annals of Internal Medicine (2016)

Letters19 April 2016Zika Virus Infection in a Massachusetts Resident After Travel to Costa Rica: A Case ReportFREELin H. Chen, MDLin H. Chen, MDFrom Mount Auburn Hospital, Harvard Medical School, and GeoSentinel Surveillance Network, Cambridge, Massachusetts.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/L16-0075 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: Zika, a mosquito-borne flavivirus, has rapidly spread through South and Central America and the Caribbean since being recognized in Brazil in 2015 (1, 2) (Table and Figure 1). Here, we describe a case in a U.S. resident after travel to Costa Rica.Figure 1. Countries and territories with active Zika virus transmission as of 5 February 2016.Available at www.cdc.gov/zika/geo/index.html. Download figure Download PowerPoint Table. Spread of Zika VirusCase Report: On 2 to 3 January 2016, a previously healthy 55-year-old male Massachusetts resident presented to the walk-in clinic at Mount Auburn Hospital in Cambridge, Massachusetts, with rash, conjunctivitis, and arthralgia. He had traveled to Costa Rica with 2 family members from 19 to 26 December 2015 and stayed in Nosara, on the northwestern coast. He reported having had many mosquito bites. The patient noted mild myalgia and subjective fever starting 30 December, followed by a red rash of the trunk and arms, redness of the face and eyes, headache, and arthralgia.Examination revealed conjunctival injection; maculopapular rash involving the face, trunk, and arms; and redness of the hard palate. Laboratory tests found leukopenia (leukocyte count of 3.65 × 109 cells/L [reference range, 4.00 to 10.80 × 109 cells/L]), lymphopenia (lymphocytes accounted for 13.0% of all leukocytes [reference range, 20.0% to 40.0%]), and bandemia (band cells accounted for 19% of all leukocytes [reference range, 1% to 10%]) but normal erythrocyte and platelet counts, normal basic metabolic profile, and negative results on rapid streptococcal testing and malaria smears. The C-reactive protein level was mildly elevated at 178.10 nmol/L (reference range, 0.76 to 28.50 nmol/L). Serologic tests found immunity to rubella but not rubeola. Tests for IgM and IgG antibodies to dengue and chikungunya viruses were sent, and negative results were reported 2 weeks later.The patient was referred for evaluation to Mount Auburn Hospital Travel Medicine Center, a GeoSentinel site, and was seen on 7 January (day 9 of illness). He was afebrile but had backache, nonpurulent conjunctivitis, and a faint residual erythematous maculopapular rash on the face and trunk (Figure 2). Complete blood count and differential were unremarkable, and leukopenia, lymphopenia, and bandemia had resolved. Assays for IgM and IgG antibodies to rubeola remained negative. Serologic testing for antibodies to dengue and chikungunya viruses was repeated and later showed positive enzyme-linked immunosorbent assay results of IgM antibodies to dengue virus of 2.23 (reference range, <0.90) and negative results for IgG antibodies to dengue virus and IgM and IgG chikungunya virus.Figure 2. Faint residual erythematous maculopapular rash on the trunk. Download figure Download PowerPoint Enzyme-linked immunosorbent assay for IgM antibodies and plaque reduction neutralization antibody tests for Zika and dengue viruses were done at the Centers for Disease Control and Prevention in Fort Collins, Colorado. On 26 January, IgM antibodies to Zika and dengue viruses were reported as positive. Plaque reduction neutralization antibody test titers were greater than 5120 for Zika virus and less than 10 for dengue virus. Given the consideration of Zika virus infection, the patient was advised on his initial visit to the travel medicine center on day 9 of illness about the possibility of sexual transmission and to practice safe sex.The patient had recovered completely when he was seen again on 25 January (day 27 of illness). He reported that the 2 family members who had traveled to Costa Rica remained well as of 8 February 2016.Discussion: Results of plaque reduction neutralization antibody tests confirmed the diagnosis of Zika virus infection in a traveler who returned to the United States from Costa Rica and had mild illness consistent with that reported in persons infected with Zika virus (1, 2). There was cross-reactivity of serologic results of dengue virus with those of Zika virus. Both are mosquito-borne flaviviruses. Zika virus infection had not been documented in Costa Rica as of 26 January, the date when infection in this patient was confirmed.This case shows that Zika virus is probably circulating more widely than has been officially reported in the Americas and illustrates the role of travelers as sentinels for outbreaks and for the potential expansion of pathogens to new geographic areas (3). GeoSentinel sites worldwide are reporting cases of Zika virus infection in returning travelers (Hamer D, Schlagenhauf P. Personal communication).The current outbreak of Zika virus resembles the rapid spread of chikungunya fever in the Americas since 2013 (4). Costa Rica is a popular travel destination and has the Aedes mosquitoes that are also responsible for transmitting dengue and chikungunya viruses. Travelers to all areas where these mosquitoes are present, including Costa Rica, should be advised to avoid day-biting mosquitoes to prevent dengue, Zika, and chikungunya virus infections. The Centers for Disease Control and Prevention (www.cdc.gov/zika), the Pan American Health Organization (www.paho.org), and other health authorities have posted recommendations for mosquito bite protection and information about the possible association of Zika virus with microcephaly in infected pregnant women (1, 2, 5).References1. Chen LH, Hamer DH. Zika virus: rapid spread in the Western hemisphere. Ann Intern Med. 2016 [Epub ahead of print].. doi:10.7326/M16-0150 LinkGoogle Scholar2. Hennessey M, Fischer M, Staples JE. Zika virus spreads to new areas—region of the Americas, May 2015-January 2016. MMWR Morb Mortal Wkly Rep. 2016;65:55-8. [PMID: 26820163] doi:10.15585/mmwr.mm6503e1 CrossrefMedlineGoogle Scholar3. Chen LH, Wilson ME. The role of the traveler in emerging infections and magnitude of travel. Med Clin North Am. 2008;92:1409-32. [PMID: 19061759] doi:10.1016/j.mcna.2008.07.005 CrossrefMedlineGoogle Scholar4. Hamer DH, Chen LH. Chikungunya: establishing a new home in the Western hemisphere. Ann Intern Med. 2014;161:827-8. [PMID: 25244354]. doi:10.7326/M14-1958 LinkGoogle Scholar5. Oduyebo T, Petersen EE, Rasmussen SA, Mead PS, Meaney-Delman D, Renquist CM, et al. Update: interim guidelines for health care providers caring for pregnant women and women of reproductive age with possible Zika virus exposure—United States, 2016. MMWR Morb Mortal Wkly Rep. 2016;65:1-6. doi:10.15585/mmwr.mm6505e2er CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From Mount Auburn Hospital, Harvard Medical School, and GeoSentinel Surveillance Network, Cambridge, Massachusetts.This article was published at www.annals.org on 10 February 2016.Acknowledgment: The author thanks Drs. Davidson Hamer and Patrician Schlagenhauf for critical review of the paper and Drs. Beth A. Zeeman and Irmgard Behlau for patient evaluation in the walk-in center.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=L16-0075. 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Esposito, MD, MPH, for the GeoSentinel Surveillance Network*Flavivirus NS2B/NS3 Protease: Structure, Function, and InhibitionZika virus infection in a newly married Greek coupleZika Virus: Pathology From the PandemicZika virus disease: a current review of the literatureTimes to key events in Zika virus infection and implications for blood donation: a systematic reviewAssessing the global threat from Zika virus 19 April 2016Volume 164, Issue 8Page: 574-576KeywordsAntibodiesDengue feverFeversHealth information technologyHospital medicineLymphopeniaMeaslesMosquitoesRashesZika virus ePublished: 10 February 2016 Issue Published: 19 April 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...