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[h=1]Fatal Zika Virus Infection with Secondary Nonsexual Transmission[/h] September 28, 2016DOI: 10.1056/NEJMc1610613
Article Metrics [h=3]To the Editor:[/h] ...Here, we report a rapidly progressive, fatal ZIKV infection acquired outside the United States and secondary local transmission in the absence of known risk factors for ZIKV infection.
...
Five days after Patient 1 died, Patient 2, a previously healthy 38-year-old man with no known coexisting illnesses who had visited Patient 1 in the hospital, reported having conjunctivitis, fevers, myalgia, and facial maculopapular rash. The rash became generalized but resolved within 7 days. On day 7 after the onset of symptoms, urinalysis was positive for ZIKV but serum was negative on PCR assay. Serum IgM antibody to ZIKV was positive. Patient 2 reported having assisted a nurse in repositioning Patient 1 in bed without using gloves. Patient 2 also reported having wiped Patient 1?s eyes during the hospitalization but reported having had no other overt contact with blood or other body fluids, including splashes or mucous membrane exposure. No health care workers who had contact with Patient 1 reported having symptomatic illness.
It is likely that Patient 2 acquired the infection from Patient 1, since Patient 2 had not traveled to an area in which ZIKV is endemic in more than 9 months and had not had sex with a partner who had traveled to such areas. Given the very high level of viremia in Patient 1, infectious levels of virus may have been present in sweat or tears, both of which Patient 2 contacted without gloves. Transmission of the infection through a mosquito bite appears to be unlikely, since aedes species that are known to transmit ZIKV have not been detected in the Salt Lake City area.4 In addition, the second case occurred 7 to 10 days after contact with the index patient in the hospital, which implicates direct contact during hospitalization.
These two cases illustrate several important points. The spectrum of those at risk for fulminant ZIKV infection may be broader than previously recognized, and those who are not severely immunocompromised or chronically ill may nevertheless be at risk for fatal infection. The effect of previous infection with related flaviviruses cannot be assessed and may increase the risk of severe ZIKV infection. The transmission of flaviviruses through intact skin or mucous membranes, although uncommon, has been shown in experimental animal models and in at least one human case.5 Whether contact with highly infectious body fluids from patients with severe ZIKV infection poses an increased risk of transmission is an important question that requires further research.
Sankar Swaminathan, M.D.
Robert Schlaberg, M.D., M.P.H.
Julia Lewis, D.O.
Kimberly E. Hanson, M.D., M.H.S.
Marc R. Couturier, Ph.D.
University of Utah School of Medicine, Salt Lake City, UT
sankar.swaminathan@hsc.utah.edu
Supported by a grant from the National Institutes of Health (RO1-CA-8133, to Dr. Swaminathan).
Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.
This letter was published on September 28, 2016, at NEJM.org.
Full text:
http://www.nejm.org/doi/full/10.1056/NEJMc1610613
[h=1]Fatal Zika Virus Infection with Secondary Nonsexual Transmission[/h] September 28, 2016DOI: 10.1056/NEJMc1610613
Article Metrics [h=3]To the Editor:[/h] ...Here, we report a rapidly progressive, fatal ZIKV infection acquired outside the United States and secondary local transmission in the absence of known risk factors for ZIKV infection.
...
Five days after Patient 1 died, Patient 2, a previously healthy 38-year-old man with no known coexisting illnesses who had visited Patient 1 in the hospital, reported having conjunctivitis, fevers, myalgia, and facial maculopapular rash. The rash became generalized but resolved within 7 days. On day 7 after the onset of symptoms, urinalysis was positive for ZIKV but serum was negative on PCR assay. Serum IgM antibody to ZIKV was positive. Patient 2 reported having assisted a nurse in repositioning Patient 1 in bed without using gloves. Patient 2 also reported having wiped Patient 1?s eyes during the hospitalization but reported having had no other overt contact with blood or other body fluids, including splashes or mucous membrane exposure. No health care workers who had contact with Patient 1 reported having symptomatic illness.
It is likely that Patient 2 acquired the infection from Patient 1, since Patient 2 had not traveled to an area in which ZIKV is endemic in more than 9 months and had not had sex with a partner who had traveled to such areas. Given the very high level of viremia in Patient 1, infectious levels of virus may have been present in sweat or tears, both of which Patient 2 contacted without gloves. Transmission of the infection through a mosquito bite appears to be unlikely, since aedes species that are known to transmit ZIKV have not been detected in the Salt Lake City area.4 In addition, the second case occurred 7 to 10 days after contact with the index patient in the hospital, which implicates direct contact during hospitalization.
These two cases illustrate several important points. The spectrum of those at risk for fulminant ZIKV infection may be broader than previously recognized, and those who are not severely immunocompromised or chronically ill may nevertheless be at risk for fatal infection. The effect of previous infection with related flaviviruses cannot be assessed and may increase the risk of severe ZIKV infection. The transmission of flaviviruses through intact skin or mucous membranes, although uncommon, has been shown in experimental animal models and in at least one human case.5 Whether contact with highly infectious body fluids from patients with severe ZIKV infection poses an increased risk of transmission is an important question that requires further research.
Sankar Swaminathan, M.D.
Robert Schlaberg, M.D., M.P.H.
Julia Lewis, D.O.
Kimberly E. Hanson, M.D., M.H.S.
Marc R. Couturier, Ph.D.
University of Utah School of Medicine, Salt Lake City, UT
sankar.swaminathan@hsc.utah.edu
Supported by a grant from the National Institutes of Health (RO1-CA-8133, to Dr. Swaminathan).
Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.
This letter was published on September 28, 2016, at NEJM.org.
Full text:
http://www.nejm.org/doi/full/10.1056/NEJMc1610613