Instructive reading. More detail on a VHF case than I have ever seen before.
I'm not sure if this posting is in the right place, as the agent is Marburg, not Ebola, but other VHF threads have been put in this forum before.
http://www.promedmail.org/pls/otn/f..._BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1000,80526
Archive Number 20091218.4276
Published Date 18-DEC-2009
Subject PRO/AH/EDR> Marburg hemorrhagic fever - USA ex Uganda 2008 (02)
MARBURG HEMORRHAGIC FEVER - UNITED STATES OF AMERICA ex UGANDA 2008 (02)
************************************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>
Date: Thu 18 Dec 2009
Source: MMWR Morb Mortal Wkly Rep 2009; 58(49): 1377-81 [edited]
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5849a2.htm?s_cid=mm5849a2_e>
Imported case of Marburg hemorrhagic fever -- Colorado, 2008
------------------------------------------------------------
Marburg hemorrhagic fever (MHF) is a rare viral hemorrhagic fever (VHF);
the causative agent is an RNA virus in the family _Filoviridae_, and
growing evidence demonstrates that fruit bats are the natural reservoir of
Marburg virus (MARV) (1,2). On 9 Jan 2008, an infectious disease physician
notified the Colorado Department of Public Health and Environment (CDPHE)
of a case of unexplained febrile illness requiring hospitalization in a
woman who had returned from travel in Uganda. Testing of early convalescent
serum demonstrated no evidence of infection with agents that cause tropical
febrile illnesses, including VHF. Six months later, in July 2008, the
patient requested repeat testing after she learned of the death from MHF of
a Dutch tourist who had visited the same bat-roosting cave as the patient,
the Python Cave in Queen Elizabeth National Park, Uganda (3).
The convalescent serologic testing revealed evidence of prior infection
with MARV, and MARV RNA was detected in the archived early convalescent
serum. A public health investigation did not identify illness consistent
with secondary MHF transmission among her contacts, and no serologic
evidence of infection was detected among the 6 tested of her 8 tour
companions. The patient might have acquired MARV infection through exposure
to bat secretions or excretions while visiting the Python Cave. Travelers
should be aware of the risk for acquiring MHF in caves or mines inhabited
by bats in endemic areas in sub-Saharan Africa. Health care providers
should consider VHF among travelers returning from endemic areas who
experience unexplained febrile illness.
Case report
-----------
On 1 Jan 2008, the patient, a woman aged 44 years with no remarkable past
medical history, returned to the United States from a 2-week safari in
Uganda, where her activities included camping, white-water rafting,
visiting local villages, and viewing wildlife. She had taken malaria
prophylaxis with atovaquone-proguanil, as prescribed. On 4 Jan 2008 she
experienced severe headache, chills, nausea, vomiting, and diarrhea. She
self-treated for traveler's diarrhea with 2 doses of ciprofloxacin, and
developed a diffuse rash. On 6 and 7 Jan 2008, she was seen as an
outpatient, had laboratory testing performed, and was treated with
antiemetics. A complete blood count on 6 Jan 2008 revealed an abnormally
low white blood cell count of 900/microlitre (normal range: 4500--10
500/microlitre).
She returned to her primary-care physician's clinic on 8 Jan 2008,
complaining of persistent diarrhea and abdominal pain, as well as worsening
fatigue, generalized weakness, and confusion. On physical examination, she
appeared pale and fatigued, and had decreased bowel sounds; the remainder
of her examination was unremarkable. Laboratory results received on 8 Jan
2008 revealed hepatitis (aspartate aminotransaminase 9660 U/dL [normal
range: 15-41 U/L] and alanine aminotransferase 4823 U/dL [normal range:
14-54 U/L]) and renal failure (creatinine 2.3 mg/dL [normal range: 0.7-1.2
mg/dL]). The patient was admitted to a community hospital for further
management. The admission diagnosis was acute hepatitis, nausea, and
vomiting of unknown etiology.
On admission, the patient was afebrile (temperature 96.2 deg F [35.7 deg
C]). She was treated with intravenous fluids and was started on doxycycline
for possible leptospirosis. Her hospital course was characterized by
pancytopenia, coagulopathy, myositis, pancreatitis, and encephalopathy, all
of which are complications that have been associated with MHF. She had no
signs of gross hemorrhage other than vaginal bleeding attributed to menses.
During her hospitalization, she underwent cholecystectomy for acalculous
cholecystitis. Testing was negative for leptospirosis, viral hepatitis,
malaria, arboviral infection, acute schistosomiasis, rickettsial infection,
and VHFs (including Marburg and Ebola hemorrhagic fever).
Early convalescent serum collected on 14 Jan 2008 (10 days after illness
onset) was submitted to CDC for testing and demonstrated no evidence of
MARV infection by virus isolation, antigen-detection enzyme-linked
immunosorbent assay (ELISA), or anti-MARV immunoglobulin M (IgM) and IgG
ELISA. The patient was discharged on 19 Jan 2008 and had a prolonged
recovery over the following year because of persistent abdominal pain,
fatigue, and "mental fog", but had no long term sequelae such as chronic
hepatitis or chronic renal disease. She received a blood transfusion for
persistent anemia after she was discharged.
In July 2008, the patient requested repeat testing after she learned of the
fatal case of MHF in a Dutch tourist who recently had visited the same cave
she had visited in Uganda, the Python Cave. The Colorado patient had
visited the cave on 25 Dec 2007, 10 days before onset of her initial
symptoms. Serum collected on 15 Jul 2008 tested positive for anti-MARV IgG
by ELISA, prompting additional testing of the archived day 10 serum.
Traditional reverse-transcriptase polymerase chain reaction (RT-PCR) was
negative, and real-time (Taqman) RT-PCR was equivocal; however, nested
RT-PCR* confirmed the presence of MARV RNA fragments in the day 10 sample.
Public health response
----------------------
On 22 Jan 2009, CDC notified the World Health Organization and Uganda
Ministry of Health of the imported MHF case. The Python Cave had already
been closed to visitors in July 2008, during the response to the Dutch MHF
case. CDPHE and CDC conducted a public health investigation during
January--February 2009. Interviews were conducted with the patient and her
spouse, the patient's medical records were reviewed, and a retrospective
contact investigation was conducted to identify possible secondary
transmission. A contact was defined as a person who had physical contact
with the patient, her body fluids, or contaminated materials or was in the
same room as the patient during her acute illness (4-19 Jan 2008). Contacts
included health care workers (including health care providers, housekeeping
staff, and hospital laboratory staff), commercial laboratory staff, and
social contacts.
To limit the effect of recall bias and to identify secondary cases of MHF,
a contact-tracing protocol (4) was modified for retrospective use to
identify contacts who had a high-risk exposure to the patient's body fluids
(through splash, percutaneous, or nonintact skin exposure), or prolonged
absenteeism of more than 6 days as indicated by review of health and
payroll records. The contact investigation identified about 260 contacts:
220 health care workers, about 30 commercial laboratory workers from 5
laboratories, and 10 social contacts. No high-risk exposure or severe
febrile illness was identified.
The patient and her spouse reported spending about 15-20 minutes in the
cave and recalled seeing bats flying overhead. Neither remembered her
having contact with a bat or sustaining an injury in the cave. However, the
patient reported touching guano-covered rocks while climbing into the cave
and surmised that she might have covered her mouth and nose with her hands
once inside because of the unpleasant smell.
CDC, with assistance from public health agencies in Illinois, Uganda,
Belgium, and the United Kingdom, conducted an investigation of the 8 tour
companions who accompanied the patient when she visited the Python Cave.
From February to July 2009, participants were interviewed using a
standardized questionnaire by telephone or email and were offered serologic
testing by anti-MARV IgG ELISA. Questionnaires were completed for all 8
tour companions. All 8 reported having entered the cave (at least under the
cave ceiling), and 6 reported climbing over a crop of boulders further
inside as the patient had done; however, none reported direct contact with
bats or bat guano/urine. Serum samples were provided by 6 of the tour
companions; none had evidence of prior MARV infection by anti-MARV IgG.
MMWR editorial note
-------------------
Before the case described in this report, the only human cases of VHF
imported into the United States were single cases of Lassa fever (an
arenaviral hemorrhagic fever) in Chicago, Illinois, in 1989 (5) and in
Trenton, New Jersey, in 2004 (4). No previous cases of imported filovirus
(MARV or Ebola virus) infections have been reported in the United States,
making this the 1st imported case of a filoviral hemorrhagic fever in the
United States.
The patient described in this report was 1st diagnosed by convalescent
serology because initial testing of the day 10 sample was negative by virus
isolation, antigen-detection, and IgM and IgG ELISA. After the Dutch
patient was diagnosed with MHF, retesting of the archived specimen with
more sensitive molecular methods was performed, including a nested RT-PCR
assay that detected viral RNA [Nested RT-PCR is more sensitive and specific
than traditional RT-PCR. A portion of the product produced from the 1st
round of amplification is used in the 2nd round of amplification along with
a different set of primers]. This, along with the positive convalescent
serology and compatible clinical course, confirmed the diagnosis.
To obtain a rapid diagnosis during the acute illness, patients with
suspected VHF should have paired acute blood specimens (ideally collected
during days 0-4 and days 4-9 of the acute illness) tested at a World
Reference Laboratory (such as CDC) with biosafety level 4 capability using
multiple methods as appropriate for the timing of the sample, including
virus isolation, RT-PCR, and IgM and IgG ELISA. Because the incubation
period for MARV is 2-21 days, daily contact tracing is recommended to
contain outbreaks. This involves following all contacts of patients
suspected of having MHF, and isolating and testing those that experience
fever within 21 days after their last contact.
Other sporadic cases of MHF have been reported outside of Africa: 2
laboratory-acquired cases in Russia and 2 cases imported from endemic areas
(3,6). These imported cases occurred in a patient hospitalized in South
Africa who likely acquired the disease while camping in Zimbabwe in 1975
(6) and the 2nd in the previously described Dutch patient hospitalized in
the Netherlands who died of MHF after visiting the Python Cave in Uganda in
2008 (3). Case fatality rates of 83 to 90 per cent have been reported for
widespread outbreaks of MHF in Africa (1,7).
Virologic and serologic evidence of MARV infection has been documented
among cave-dwelling bats, particularly the Egyptian fruit bat _Rousettus
aegyptiacus_ (2); this evidence has implicated bats as the likely natural
reservoir for MARV. _R. aegyptiacus_ bats have a wide range covering most
of Africa, indicating that risk for zoonotic infection might exist beyond
areas with previously documented cases. The precise route of MARV
transmission from the putative bat reservoir to humans has not been
determined and might include direct or indirect exposure to bat excretions
and secretions. MHF outbreaks have resulted from exposure to caves or mines
inhabited by bats (1,8) and subsequent human-to-human transmission through
direct contact with infectious body fluids and contaminated materials,
primarily affecting caregivers and health-care workers (8,9). Isolation of
suspected patients and implementation of droplet and contact precautions
are recommended to prevent person-to-person spread.
Although the Python Cave is closed and no additional MHF cases have been
reported, travelers should be aware of the risk for acquiring MHF in
endemic areas in Africa and should avoid entering caves or mines inhabited
by bats in these areas (10). Health care providers should have a low
threshold of suspicion for VHF among travelers returning from endemic
areas, promptly implement appropriate infection control measures, and
rapidly report suspected cases. Suspected cases of VHF are nationally
notifiable and should be reported immediately to local and state health
departments and to CDC's Special Pathogens Branch at 404-639-1115
(770-488-7100 after hours) to obtain guidance on testing, management, and
response. Additional information regarding Marburg hemorrhagic fever,
[<http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/marburg.htm>],
travelers' health, [available at <http://wwwn.cdc.gov/travel>. and VHF
infection-control guidelines are available online.
References
----------
1. Swanepoel R, Smit S, Rollin P, et al. Studies of reservoir hosts for
Marburg virus. Emerg Infect Dis 2007; 13: 1847-51.
2. Towner JS, Amman BR, Sealy TK, et al. Isolation of genetically diverse
Marburg viruses from Egyptian fruit bats. PLoS Pathog 2009; 5: e1000536.
3. Timen A, Koopmans M, Vossen A, et al. Response to imported case of
Marburg hemorrhagic fever, the Netherlands. Emerg Infect Dis 2009; 15: 1171-5.
4. CDC. Imported Lassa fever -- New Jersey, 2004. MMWR 2004; 53: 894-7.
5. Holmes GP, McCormick JB, Trock SC, et al. Lassa fever in the United
States: Investigation of a case and new guidelines for management. N Engl J
Med 1990; 323: 1120-3.
6. Slenczka W, Klenk HD. Forty years of Marburg virus. J Infect Dis 2007;
196(suppl 2): S131-5.
7. Towner JS, Khristova ML, Sealy TK, et al. Marburg virus genomics and
association with a large hemorrhagic fever outbreak in Angola. J Virol
2006; 80: 6497-516.
8. Bausch DG, Borchert M, Grein T, et al. Risk factors for Marburg
hemorrhagic fever, Democratic Republic of the Congo. Emerg Infect Dis 2003;
9: 1531-7.
9. Borchert M, Mulangu S, Lefvre P, et al. Use of protective gear and the
occurrence of occupational Marburg hemorrhagic fever in health workers from
Watsa Health Zone, Democratic Republic of the Congo. J Infect Dis 2007;
196(suppl 2): S168-75.
10. CDC. Viral hemorrhagic fevers. In: CDC health information for
international travel 2010. Atlanta, GA: US Department of Health and Human
Services, Public Health Service; 2009: 406-9.
--
communicated by:
ProMED-mail
<promed@promedmail.org>
[This is an instructive account of the late diagnosis of the 1st and so far
only case of Marburg hemorrhagic fever imported into the United States from
an endemic area in Africa. In January 2008 a tourist developed illness 4
days after returning to Colorado from Uganda, was hospitalized, and later
discharged as recovered. Initial testing of samples collected during the
patient's acute illness in January 2008 did not show evidence of Marburg
virus infection. However, the patient made only a slow recovery and in July
2008, she requested reinvestigation of her illness after learning of the
death from Marburg hemorrhagic fever of a Dutch tourist who recently had
visited the same cave she had visited in Uganda, the now notorious Python Cave.
The subsequent retrospective examination confirmed that she indeed had
contracted Marburg hemorrhagic fever, and fortunately there was no evidence
of onward transmission of the virus to any of her contacts in the United
States.
Nonetheless it does illustrate how easily a foreign pathogen can evade even
the best surveillance systems. - Mod.CP]
[see also:
Ebola & Marburg hemorrhagic fever, Egyptian fruit bat - W. Africa
20091006.3469
Marburg hemorrhagic fever - USA ex Uganda 2008 20090131.0423
2008
---
Marburg hemorrhagic fever - The Netherlands ex Uganda (02) 20080711.2115
Marburg hemorrhagic fever - The Netherlands ex Uganda 20080710.2107]
...................cp/ejp/sh
I'm not sure if this posting is in the right place, as the agent is Marburg, not Ebola, but other VHF threads have been put in this forum before.
http://www.promedmail.org/pls/otn/f..._BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1000,80526
Archive Number 20091218.4276
Published Date 18-DEC-2009
Subject PRO/AH/EDR> Marburg hemorrhagic fever - USA ex Uganda 2008 (02)
MARBURG HEMORRHAGIC FEVER - UNITED STATES OF AMERICA ex UGANDA 2008 (02)
************************************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>
Date: Thu 18 Dec 2009
Source: MMWR Morb Mortal Wkly Rep 2009; 58(49): 1377-81 [edited]
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5849a2.htm?s_cid=mm5849a2_e>
Imported case of Marburg hemorrhagic fever -- Colorado, 2008
------------------------------------------------------------
Marburg hemorrhagic fever (MHF) is a rare viral hemorrhagic fever (VHF);
the causative agent is an RNA virus in the family _Filoviridae_, and
growing evidence demonstrates that fruit bats are the natural reservoir of
Marburg virus (MARV) (1,2). On 9 Jan 2008, an infectious disease physician
notified the Colorado Department of Public Health and Environment (CDPHE)
of a case of unexplained febrile illness requiring hospitalization in a
woman who had returned from travel in Uganda. Testing of early convalescent
serum demonstrated no evidence of infection with agents that cause tropical
febrile illnesses, including VHF. Six months later, in July 2008, the
patient requested repeat testing after she learned of the death from MHF of
a Dutch tourist who had visited the same bat-roosting cave as the patient,
the Python Cave in Queen Elizabeth National Park, Uganda (3).
The convalescent serologic testing revealed evidence of prior infection
with MARV, and MARV RNA was detected in the archived early convalescent
serum. A public health investigation did not identify illness consistent
with secondary MHF transmission among her contacts, and no serologic
evidence of infection was detected among the 6 tested of her 8 tour
companions. The patient might have acquired MARV infection through exposure
to bat secretions or excretions while visiting the Python Cave. Travelers
should be aware of the risk for acquiring MHF in caves or mines inhabited
by bats in endemic areas in sub-Saharan Africa. Health care providers
should consider VHF among travelers returning from endemic areas who
experience unexplained febrile illness.
Case report
-----------
On 1 Jan 2008, the patient, a woman aged 44 years with no remarkable past
medical history, returned to the United States from a 2-week safari in
Uganda, where her activities included camping, white-water rafting,
visiting local villages, and viewing wildlife. She had taken malaria
prophylaxis with atovaquone-proguanil, as prescribed. On 4 Jan 2008 she
experienced severe headache, chills, nausea, vomiting, and diarrhea. She
self-treated for traveler's diarrhea with 2 doses of ciprofloxacin, and
developed a diffuse rash. On 6 and 7 Jan 2008, she was seen as an
outpatient, had laboratory testing performed, and was treated with
antiemetics. A complete blood count on 6 Jan 2008 revealed an abnormally
low white blood cell count of 900/microlitre (normal range: 4500--10
500/microlitre).
She returned to her primary-care physician's clinic on 8 Jan 2008,
complaining of persistent diarrhea and abdominal pain, as well as worsening
fatigue, generalized weakness, and confusion. On physical examination, she
appeared pale and fatigued, and had decreased bowel sounds; the remainder
of her examination was unremarkable. Laboratory results received on 8 Jan
2008 revealed hepatitis (aspartate aminotransaminase 9660 U/dL [normal
range: 15-41 U/L] and alanine aminotransferase 4823 U/dL [normal range:
14-54 U/L]) and renal failure (creatinine 2.3 mg/dL [normal range: 0.7-1.2
mg/dL]). The patient was admitted to a community hospital for further
management. The admission diagnosis was acute hepatitis, nausea, and
vomiting of unknown etiology.
On admission, the patient was afebrile (temperature 96.2 deg F [35.7 deg
C]). She was treated with intravenous fluids and was started on doxycycline
for possible leptospirosis. Her hospital course was characterized by
pancytopenia, coagulopathy, myositis, pancreatitis, and encephalopathy, all
of which are complications that have been associated with MHF. She had no
signs of gross hemorrhage other than vaginal bleeding attributed to menses.
During her hospitalization, she underwent cholecystectomy for acalculous
cholecystitis. Testing was negative for leptospirosis, viral hepatitis,
malaria, arboviral infection, acute schistosomiasis, rickettsial infection,
and VHFs (including Marburg and Ebola hemorrhagic fever).
Early convalescent serum collected on 14 Jan 2008 (10 days after illness
onset) was submitted to CDC for testing and demonstrated no evidence of
MARV infection by virus isolation, antigen-detection enzyme-linked
immunosorbent assay (ELISA), or anti-MARV immunoglobulin M (IgM) and IgG
ELISA. The patient was discharged on 19 Jan 2008 and had a prolonged
recovery over the following year because of persistent abdominal pain,
fatigue, and "mental fog", but had no long term sequelae such as chronic
hepatitis or chronic renal disease. She received a blood transfusion for
persistent anemia after she was discharged.
In July 2008, the patient requested repeat testing after she learned of the
fatal case of MHF in a Dutch tourist who recently had visited the same cave
she had visited in Uganda, the Python Cave. The Colorado patient had
visited the cave on 25 Dec 2007, 10 days before onset of her initial
symptoms. Serum collected on 15 Jul 2008 tested positive for anti-MARV IgG
by ELISA, prompting additional testing of the archived day 10 serum.
Traditional reverse-transcriptase polymerase chain reaction (RT-PCR) was
negative, and real-time (Taqman) RT-PCR was equivocal; however, nested
RT-PCR* confirmed the presence of MARV RNA fragments in the day 10 sample.
Public health response
----------------------
On 22 Jan 2009, CDC notified the World Health Organization and Uganda
Ministry of Health of the imported MHF case. The Python Cave had already
been closed to visitors in July 2008, during the response to the Dutch MHF
case. CDPHE and CDC conducted a public health investigation during
January--February 2009. Interviews were conducted with the patient and her
spouse, the patient's medical records were reviewed, and a retrospective
contact investigation was conducted to identify possible secondary
transmission. A contact was defined as a person who had physical contact
with the patient, her body fluids, or contaminated materials or was in the
same room as the patient during her acute illness (4-19 Jan 2008). Contacts
included health care workers (including health care providers, housekeeping
staff, and hospital laboratory staff), commercial laboratory staff, and
social contacts.
To limit the effect of recall bias and to identify secondary cases of MHF,
a contact-tracing protocol (4) was modified for retrospective use to
identify contacts who had a high-risk exposure to the patient's body fluids
(through splash, percutaneous, or nonintact skin exposure), or prolonged
absenteeism of more than 6 days as indicated by review of health and
payroll records. The contact investigation identified about 260 contacts:
220 health care workers, about 30 commercial laboratory workers from 5
laboratories, and 10 social contacts. No high-risk exposure or severe
febrile illness was identified.
The patient and her spouse reported spending about 15-20 minutes in the
cave and recalled seeing bats flying overhead. Neither remembered her
having contact with a bat or sustaining an injury in the cave. However, the
patient reported touching guano-covered rocks while climbing into the cave
and surmised that she might have covered her mouth and nose with her hands
once inside because of the unpleasant smell.
CDC, with assistance from public health agencies in Illinois, Uganda,
Belgium, and the United Kingdom, conducted an investigation of the 8 tour
companions who accompanied the patient when she visited the Python Cave.
From February to July 2009, participants were interviewed using a
standardized questionnaire by telephone or email and were offered serologic
testing by anti-MARV IgG ELISA. Questionnaires were completed for all 8
tour companions. All 8 reported having entered the cave (at least under the
cave ceiling), and 6 reported climbing over a crop of boulders further
inside as the patient had done; however, none reported direct contact with
bats or bat guano/urine. Serum samples were provided by 6 of the tour
companions; none had evidence of prior MARV infection by anti-MARV IgG.
MMWR editorial note
-------------------
Before the case described in this report, the only human cases of VHF
imported into the United States were single cases of Lassa fever (an
arenaviral hemorrhagic fever) in Chicago, Illinois, in 1989 (5) and in
Trenton, New Jersey, in 2004 (4). No previous cases of imported filovirus
(MARV or Ebola virus) infections have been reported in the United States,
making this the 1st imported case of a filoviral hemorrhagic fever in the
United States.
The patient described in this report was 1st diagnosed by convalescent
serology because initial testing of the day 10 sample was negative by virus
isolation, antigen-detection, and IgM and IgG ELISA. After the Dutch
patient was diagnosed with MHF, retesting of the archived specimen with
more sensitive molecular methods was performed, including a nested RT-PCR
assay that detected viral RNA [Nested RT-PCR is more sensitive and specific
than traditional RT-PCR. A portion of the product produced from the 1st
round of amplification is used in the 2nd round of amplification along with
a different set of primers]. This, along with the positive convalescent
serology and compatible clinical course, confirmed the diagnosis.
To obtain a rapid diagnosis during the acute illness, patients with
suspected VHF should have paired acute blood specimens (ideally collected
during days 0-4 and days 4-9 of the acute illness) tested at a World
Reference Laboratory (such as CDC) with biosafety level 4 capability using
multiple methods as appropriate for the timing of the sample, including
virus isolation, RT-PCR, and IgM and IgG ELISA. Because the incubation
period for MARV is 2-21 days, daily contact tracing is recommended to
contain outbreaks. This involves following all contacts of patients
suspected of having MHF, and isolating and testing those that experience
fever within 21 days after their last contact.
Other sporadic cases of MHF have been reported outside of Africa: 2
laboratory-acquired cases in Russia and 2 cases imported from endemic areas
(3,6). These imported cases occurred in a patient hospitalized in South
Africa who likely acquired the disease while camping in Zimbabwe in 1975
(6) and the 2nd in the previously described Dutch patient hospitalized in
the Netherlands who died of MHF after visiting the Python Cave in Uganda in
2008 (3). Case fatality rates of 83 to 90 per cent have been reported for
widespread outbreaks of MHF in Africa (1,7).
Virologic and serologic evidence of MARV infection has been documented
among cave-dwelling bats, particularly the Egyptian fruit bat _Rousettus
aegyptiacus_ (2); this evidence has implicated bats as the likely natural
reservoir for MARV. _R. aegyptiacus_ bats have a wide range covering most
of Africa, indicating that risk for zoonotic infection might exist beyond
areas with previously documented cases. The precise route of MARV
transmission from the putative bat reservoir to humans has not been
determined and might include direct or indirect exposure to bat excretions
and secretions. MHF outbreaks have resulted from exposure to caves or mines
inhabited by bats (1,8) and subsequent human-to-human transmission through
direct contact with infectious body fluids and contaminated materials,
primarily affecting caregivers and health-care workers (8,9). Isolation of
suspected patients and implementation of droplet and contact precautions
are recommended to prevent person-to-person spread.
Although the Python Cave is closed and no additional MHF cases have been
reported, travelers should be aware of the risk for acquiring MHF in
endemic areas in Africa and should avoid entering caves or mines inhabited
by bats in these areas (10). Health care providers should have a low
threshold of suspicion for VHF among travelers returning from endemic
areas, promptly implement appropriate infection control measures, and
rapidly report suspected cases. Suspected cases of VHF are nationally
notifiable and should be reported immediately to local and state health
departments and to CDC's Special Pathogens Branch at 404-639-1115
(770-488-7100 after hours) to obtain guidance on testing, management, and
response. Additional information regarding Marburg hemorrhagic fever,
[<http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/marburg.htm>],
travelers' health, [available at <http://wwwn.cdc.gov/travel>. and VHF
infection-control guidelines are available online.
References
----------
1. Swanepoel R, Smit S, Rollin P, et al. Studies of reservoir hosts for
Marburg virus. Emerg Infect Dis 2007; 13: 1847-51.
2. Towner JS, Amman BR, Sealy TK, et al. Isolation of genetically diverse
Marburg viruses from Egyptian fruit bats. PLoS Pathog 2009; 5: e1000536.
3. Timen A, Koopmans M, Vossen A, et al. Response to imported case of
Marburg hemorrhagic fever, the Netherlands. Emerg Infect Dis 2009; 15: 1171-5.
4. CDC. Imported Lassa fever -- New Jersey, 2004. MMWR 2004; 53: 894-7.
5. Holmes GP, McCormick JB, Trock SC, et al. Lassa fever in the United
States: Investigation of a case and new guidelines for management. N Engl J
Med 1990; 323: 1120-3.
6. Slenczka W, Klenk HD. Forty years of Marburg virus. J Infect Dis 2007;
196(suppl 2): S131-5.
7. Towner JS, Khristova ML, Sealy TK, et al. Marburg virus genomics and
association with a large hemorrhagic fever outbreak in Angola. J Virol
2006; 80: 6497-516.
8. Bausch DG, Borchert M, Grein T, et al. Risk factors for Marburg
hemorrhagic fever, Democratic Republic of the Congo. Emerg Infect Dis 2003;
9: 1531-7.
9. Borchert M, Mulangu S, Lefvre P, et al. Use of protective gear and the
occurrence of occupational Marburg hemorrhagic fever in health workers from
Watsa Health Zone, Democratic Republic of the Congo. J Infect Dis 2007;
196(suppl 2): S168-75.
10. CDC. Viral hemorrhagic fevers. In: CDC health information for
international travel 2010. Atlanta, GA: US Department of Health and Human
Services, Public Health Service; 2009: 406-9.
--
communicated by:
ProMED-mail
<promed@promedmail.org>
[This is an instructive account of the late diagnosis of the 1st and so far
only case of Marburg hemorrhagic fever imported into the United States from
an endemic area in Africa. In January 2008 a tourist developed illness 4
days after returning to Colorado from Uganda, was hospitalized, and later
discharged as recovered. Initial testing of samples collected during the
patient's acute illness in January 2008 did not show evidence of Marburg
virus infection. However, the patient made only a slow recovery and in July
2008, she requested reinvestigation of her illness after learning of the
death from Marburg hemorrhagic fever of a Dutch tourist who recently had
visited the same cave she had visited in Uganda, the now notorious Python Cave.
The subsequent retrospective examination confirmed that she indeed had
contracted Marburg hemorrhagic fever, and fortunately there was no evidence
of onward transmission of the virus to any of her contacts in the United
States.
Nonetheless it does illustrate how easily a foreign pathogen can evade even
the best surveillance systems. - Mod.CP]
[see also:
Ebola & Marburg hemorrhagic fever, Egyptian fruit bat - W. Africa
20091006.3469
Marburg hemorrhagic fever - USA ex Uganda 2008 20090131.0423
2008
---
Marburg hemorrhagic fever - The Netherlands ex Uganda (02) 20080711.2115
Marburg hemorrhagic fever - The Netherlands ex Uganda 20080710.2107]
...................cp/ejp/sh