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Volume 22, Number 7—July 2016
Letter

Clinical Manifestations of Zika Virus Infection, Rio de Janeiro, Brazil, 2015

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To the editor: Zika virus infection, which has been associated with microcephaly and other neurologic disorders, has reached the level of public health emergency of international concern (1). Zika virus (family Flaviviridae, genus Flavivirus) is transmitted by mosquitos of the genus Aedes (2). The virus was first isolated from a serum specimen from a rhesus monkey in the Zika Forest of Uganda in 1947 (3). After 2007, a rapid geographic expansion of the virus was observed, including outbreaks in the Pacific region (4) and, more recently, in South America. Brazil reported the first autochthonous case of Zika virus disease in April 2015 (5), and subsequently, increasing numbers of cases have been reported, especially in northeastern Brazil (6).

Studies on the natural history of Zika virus infection are scarce. Previous research defined Zika virus infection as a dengue-like illness, typically characterized by fever, maculopapular rash, arthralgia, and conjunctivitis (4). Although some patients have all of these symptoms during early onset, fever is not an early symptom for all. Here we describe the frequency of signs and symptoms from a sample of clinic patients in Rio de Janeiro, Brazil, who were later confirmed to have Zika virus disease by using real-time reverse transcription PCR (rRT-PCR).

We retrospectively collected clinical data on a convenience sample of 57 patients found to be Zika virus–positive by rRT-PCR who had medical attention at the 24-hour acute care clinic of Manguinhos in Rio de Janeiro during April 28–June 8, 2015. Data were collected from electronic medical records and surveillance reports. Data were anonymized and included age, sex, and signs and symptoms documented on the first clinic visit of patients who reported acute rash, dengue-like illness, or both. Fever was documented either through direct measurement in the clinic or by patient self-report. Pregnancy status was not assessed. We collected blood samples for serum sample testing during each patient’s initial visit to the clinic and tested for Zika virus using rRT-PCR as described by Lanciotti et al. (7); all samples were collected within 7 days of illness onset. Patients were not tested for dengue or chikungunya viruses. We did not measure the duration of any sign or symptom.

Of the 57 Zika virus disease case-patients, median age was 34 years; 63% were women (Table). The most common sign or symptom was exanthema (98%), followed by headache (67%), fever (67%), arthralgias (58%), myalgias (49%), and joint swelling (23%) (Table). Conjunctivitis was observed in 39% case-patients and retro-orbital eye pain was reported by 40%. Among 30 patients who had fever assessed by clinic staff, median temperature was 38°C (range 37.5°C –38.5°C). One patient had no rash or joint swelling but did have all other symptoms. One patient’s sole symptom was rash. No patients were referred for hospitalization.

Our clinic-based study of 57 rRT-PCR–confirmed cases of Zika virus disease found rash to be the most common symptom for which patients sought care (98%); fever, generally low-grade, was reported or observed in 67%. Because our study design was retrospective in nature, wherein we reviewed records for selected patients in whom Zika was subsequently found to be laboratory-confirmed by using rRT-PCR, we may have introduced selection bias to our sample, limiting the generalizability and comparability of our results. For example, clinic staff may have seen patients with mild symptoms but decided not to test for the virus, leading to a bias toward testing patients with more severe rash. It is also possible, considering the retrospective nature of our data collection, that some data points were not accurately recorded and could not be validated. Despite these limitations, our data suggest the term “Zika fever” is not a helpful substitute term for Zika virus disease. Furthermore, referring to the illness caused by this virus as “Zika fever” (8) may be misleading and should probably be avoided until further more systematic studies clarify the frequency of fever as a symptom.

Although patient sampling and laboratory testing methods are not directly comparable to our study, a 2015–2016 assessment in Puerto Rico detected Zika virus in 30 of 155 case-patients in whom Zika virus disease was suspected. In that study, laboratory-confirmed disease was defined as detection of Zika virus RNA by using rRT-PCR or IgM by using ELISA. Among the 30 confirmed cases, the most frequently reported signs and symptoms were rash (77%), myalgia (77%), arthralgia (73%), and fever (73%) (9). The February 12, 2015, interim case definition published by the World Health Organization describes a suspected case-patient as a person with rash, fever, or both, in addition to 1 of 3 other listed symptoms (10). Like the Puerto Rico report, our report supports the established World Health Organization case definition indicating that the presence of rash, fever, or both should be emphasized as primary characteristics of Zika virus disease.

Dr. Cerbino-Neto is an infectious diseases specialist and epidemiologist, a researcher at Oswaldo Cruz Foundation in Brazil, and Deputy Director of Clinical Care at the National Institute of Infectious Diseases. His primary research interests are immunization, health surveillance systems, and emerging infectious diseases.

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José Cerbino-NetoComments to Author , Emersom Cicilini Mesquita, Thiago Moreno L. Souza, Viviane Parreira, Bernardo Bastos Wittlin, Betina Durovni, Maria Cristina Ferreira Lemos, Alexandre Vizzoni, Jan Felix Drexler, Simone Alves Sampaio, Bianca de Santis Gonçalves, and Fernando A. Bozza
Author affiliations: Fundação Oswaldo Cruz, Rio de Janeiro, Brazil (J. Cerbino-Neto, E.C. Mesquita, T.M.L. Souza, V. Parreira, A. Vizzoni, A.M. Bispo de Filippis, S.A. Sampaio, B. de Santis Gonçalves, F.A. Bozza); Secretaria Municipal de Saúde do Estado do Rio de Janeiro, Rio de Janeiro (B.B. Wittlin, B. Durovni, M.C.F. Lemos)

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References

  1. World Health Organization. Zika situation report. 2016 March 31 [cited 2016 Apr 1]. http://www.who.int/emergencies/zika-virus/situation-report/31-march-2016/en/
  2. Grard  G, Caron  M, Mombo  IM, Nkoghe  D, Mboui Ondo  S, Jiolle  D, Zika virus in Gabon (Central Africa)—2007: a new threat from Aedes albopictus? Charrel R, editor. PLoS Negl Trop Dis. 2014;8(2):e2681. DOIGoogle Scholar
  3. Dick  GWA, Kitchen  SF, Haddow  AJ. Zika virus. I. Isolations and serological specificity. Trans R Soc Trop Med Hyg. 1952;46:50920. DOIGoogle Scholar
  4. Duffy  MR, Chen  T-H, Hancock  WT, Powers  AM, Kool  JL, Lanciotti  RS, Zika virus outbreak on Yap Island, Federated States of Micronesia. N Engl J Med. 2009;360:253643. DOIPubMedGoogle Scholar
  5. Zanluca  C, de Melo  VCA, Mosimann  ALP, dos Santos  GIV, dos Santos  CND, Luz  K. First report of autochthonous transmission of Zika virus in Brazil. Mem Inst Oswaldo Cruz. 2015;110:56972. DOIPubMedGoogle Scholar
  6. Campos  GS, Bandeira  AC, Sardi  SI. Zika virus outbreak, Bahia, Brazil. Emerg Infect Dis. 2015;21:18856.PubMedGoogle Scholar
  7. Lanciotti  RS, Kosoy  OL, Laven  JJ, Velez  JO, Lambert  AJ, Johnson  AJ, Genetic and serologic properties of Zika virus associated with an epidemic, Yap State, Micronesia, 2007. Emerg Infect Dis. 2008;14:12329. DOIPubMedGoogle Scholar
  8. Martínez de Salazar  P, Suy  A, Sánchez-Montalvá  A, Rodó  C, Salvador  F, Molina  I. Zika fever. Enferm Infecc Microbiol Clin. 2016. In press. DOIPubMedGoogle Scholar
  9. Thomas  DL, Sharp  TM, Torres  J, Armstrong  PA, Munoz-Jordan  J, Ryff  KR, Local transmission of Zika virus—Puerto Rico, November 23, 2015–January 28, 2016. MMWR Morb Mortal Wkly Rep. 2016;65:1548. DOIPubMedGoogle Scholar
  10. World Health Organization. Zika virus disease. 2015 Feb 12 [cited 2016 Mar 10]. http://www.who.int/csr/disease/zika/case-definition/en/

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Cite This Article

DOI: 10.3201/eid2207.160375

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Table of Contents – Volume 22, Number 7—July 2016

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Please use the form below to submit correspondence to the authors or contact them at the following address:

José Cerbino-Neto, Instituto Nacional de Infectologia Evandro Chagas (INI) Fiocruz, Av Brasil 4365, Manguinhos, Rio de Janeiro, RJ, Brazil, 21045-900

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Page created: June 14, 2016
Page updated: June 14, 2016
Page reviewed: June 14, 2016
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
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