Gert van der Hoek
In Memoriam - Editor, Senior Moderator
Eurosurveillance, Volume 20, Issue 31, 06 August 2015
Rapid communications
ROSS RIVER VIRUS DISEASE IN TWO DUTCH TRAVELLERS RETURNING FROM AUSTRALIA, FEBRUARY TO APRIL 2015
C Reusken (
)[SUP]1[/SUP], N Cleton[SUP]1[/SUP][SUP],2[/SUP], M Medon?a Melo[SUP]3[/SUP], C Visser[SUP]4[/SUP], C Geurts van Kessel[SUP]1[/SUP], P Bloembergen[SUP]5[/SUP], M Koopmans[SUP]1[/SUP][SUP],2[/SUP], J Schmidt-Chanasit[SUP]6[/SUP][SUP],7[/SUP], P van Genderen[SUP]3[/SUP]
Citation style for this article: Reusken C, Cleton N, Medon?a Melo M, Visser C, Geurts van Kessel C, Bloembergen P, Koopmans M, Schmidt-Chanasit J, van Genderen P. Ross River virus disease in two Dutch travellers returning from Australia, February to April 2015. Euro Surveill. 2015;20(31)
ii=21200. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=21200
Date of submission: 17 July 2015
We report two cases of Ross River virus (RRV) infection in Dutch travellers who visited Australia during February to April 2015. These cases coincided with the largest recorded outbreak of RRV disease in Australia since 1996. This report serves to create awareness among physicians to consider travel-related RRV disease in differential diagnosis of patients with fever, arthralgia and/or rash returning from the South Pacific area, and to promote awareness among professionals advising travellers to this region.
Case presentation
Case 1
A woman in her early 50s with a history of polymyalgia rheumatica visited the outpatient department of a hospital in Rotterdam because of persistent joint pains after travel to Australia. She had stayed in Australia from 30 January until 5 March, where she mainly stayed in the surroundings of Perth. From 7 February, she stayed in Cairns for six days. She recalled having had multiple mosquito bites during her stay in Cairns. Seven days after her return to Perth (on 20 February), she developed fever, fatigue, frontal headache, muscle aches and arthralgia of her hands, wrists, feet and ankles. In addition, she noticed an itchy papular rash on her face, neck and trunk. She was treated with prednisone by a local general practitioner for a presumed recurrence of her polymyalgia, pending the results of serological investigations. Serology for RRV was IgM positive, therefore treatment with prednisone was discontinued.
Two months after returning to the Netherlands, she still experienced debilitating arthralgia and an unsteady gait, frequently necessitating the use of a walking aid. In addition, she reported a subfebrile temperature and sweating. On physical examination, no abnormalities were seen. She had a normal body temperature of 36.9 ?C and her joints did not show any sign of arthritis. Laboratory investigation revealed an elevated erythrocyte sedimentation rate (ESR) of 32 mm/hr, a normal leukocyte count of 6.6 x 10[SUP]9[/SUP]/L, no abnormalities in the differential morphology of the leukocytes and a C-reactive protein (CRP) level of 6 mg/L (norm: <10 mg/L). Serological testing for RRV on convalescent serum (taken 7 April) showed the presence of IgM and seroconversion for IgG antibodies specific for RRV (Table). RRV aetiology was further confirmed by comparative indirect immunofluorescence assay (IIFA) for RRV, Barmah Forest virus (BFV), chikungunya virus (CHIKV) and Sindbis virus (SINV), and virus neutralization (Table). BFV, CHIKV and SINV are alphaviruses causing symptoms comparable to those caused by RRV, which are endemic to the region.
Case 2
A woman in her late 60s visited her general practitioner on 11 May 2015 with complaints of fatigue, myalgia, arthralgia and a maculopapular rash but no fever. The patient had visited Australia from 29 March to 9 May 2015, where she stayed in New South Wales (in Sydney, Armidale and a mangrove forest near Coff Harbour). She recalled having been bitten by mosquitoes during a trip on 14 April. The first symptoms of wrist pains appeared around 21 April, followed by a rash a few days later. The patient visited a local physician on 27 April and treatment with meloxicam was initiated. Laboratory investigation revealed a normal erythrocyte sedimentation rate of 5 mm/hr. Diagnostics for RRV, BFV, Epstein?Barr virus, B19 parvovirus and connective tissue disease were negative.
Upon the patient?s return to the Netherlands, the rash reappeared (Figure) and the joint pains in her hands and knees increased. Treatment with naproxen was started. Serology for Borrelia burgdorferi showed IgM but no IgG; however, this diagnosis remained inconclusive as it was not confirmed by analysis of a second serum sample. Serological testing for RRV and BFV on a convalescent serum taken on 20 May showed the presence of IgM and IgG antibodies specific for RRV (Table). A second serum sample taken on 24 June showed decreasing IgM and increasing IgG titres. RRV aetiology was further confirmed by comparative IIFA for RRV, BFV, CHIKV and SINV, and by virus neutralisation (Table).
Rapid communications
ROSS RIVER VIRUS DISEASE IN TWO DUTCH TRAVELLERS RETURNING FROM AUSTRALIA, FEBRUARY TO APRIL 2015
C Reusken (
- Department of Viroscience, WHO Collaborating Centre for Arbovirus and Haemorrhagic Fever Reference and Research, Erasmus MC, Rotterdam, the Netherlands
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
- Institute for Tropical Diseases, Harbour Hospital, Rotterdam, the Netherlands
- General practice Havelte, Havelte, the Netherlands
- Laboratory for Medical Microbiology and Infectious diseases, Isala Clinics, Zwolle, the Netherlands
- Bernhard Nocht Institute for Tropical Medicine, WHO Collaborating Centre for Arbovirus and Haemorrhagic Fever Reference and Research, Hamburg, Germany
- German Centre for Infection Research (DZIF), Hamburg-Luebeck-Borstel, Hamburg, Germany
Citation style for this article: Reusken C, Cleton N, Medon?a Melo M, Visser C, Geurts van Kessel C, Bloembergen P, Koopmans M, Schmidt-Chanasit J, van Genderen P. Ross River virus disease in two Dutch travellers returning from Australia, February to April 2015. Euro Surveill. 2015;20(31)
ii=21200. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=21200Date of submission: 17 July 2015
We report two cases of Ross River virus (RRV) infection in Dutch travellers who visited Australia during February to April 2015. These cases coincided with the largest recorded outbreak of RRV disease in Australia since 1996. This report serves to create awareness among physicians to consider travel-related RRV disease in differential diagnosis of patients with fever, arthralgia and/or rash returning from the South Pacific area, and to promote awareness among professionals advising travellers to this region.
Case presentation
Case 1
A woman in her early 50s with a history of polymyalgia rheumatica visited the outpatient department of a hospital in Rotterdam because of persistent joint pains after travel to Australia. She had stayed in Australia from 30 January until 5 March, where she mainly stayed in the surroundings of Perth. From 7 February, she stayed in Cairns for six days. She recalled having had multiple mosquito bites during her stay in Cairns. Seven days after her return to Perth (on 20 February), she developed fever, fatigue, frontal headache, muscle aches and arthralgia of her hands, wrists, feet and ankles. In addition, she noticed an itchy papular rash on her face, neck and trunk. She was treated with prednisone by a local general practitioner for a presumed recurrence of her polymyalgia, pending the results of serological investigations. Serology for RRV was IgM positive, therefore treatment with prednisone was discontinued.
Two months after returning to the Netherlands, she still experienced debilitating arthralgia and an unsteady gait, frequently necessitating the use of a walking aid. In addition, she reported a subfebrile temperature and sweating. On physical examination, no abnormalities were seen. She had a normal body temperature of 36.9 ?C and her joints did not show any sign of arthritis. Laboratory investigation revealed an elevated erythrocyte sedimentation rate (ESR) of 32 mm/hr, a normal leukocyte count of 6.6 x 10[SUP]9[/SUP]/L, no abnormalities in the differential morphology of the leukocytes and a C-reactive protein (CRP) level of 6 mg/L (norm: <10 mg/L). Serological testing for RRV on convalescent serum (taken 7 April) showed the presence of IgM and seroconversion for IgG antibodies specific for RRV (Table). RRV aetiology was further confirmed by comparative indirect immunofluorescence assay (IIFA) for RRV, Barmah Forest virus (BFV), chikungunya virus (CHIKV) and Sindbis virus (SINV), and virus neutralization (Table). BFV, CHIKV and SINV are alphaviruses causing symptoms comparable to those caused by RRV, which are endemic to the region.
Case 2
A woman in her late 60s visited her general practitioner on 11 May 2015 with complaints of fatigue, myalgia, arthralgia and a maculopapular rash but no fever. The patient had visited Australia from 29 March to 9 May 2015, where she stayed in New South Wales (in Sydney, Armidale and a mangrove forest near Coff Harbour). She recalled having been bitten by mosquitoes during a trip on 14 April. The first symptoms of wrist pains appeared around 21 April, followed by a rash a few days later. The patient visited a local physician on 27 April and treatment with meloxicam was initiated. Laboratory investigation revealed a normal erythrocyte sedimentation rate of 5 mm/hr. Diagnostics for RRV, BFV, Epstein?Barr virus, B19 parvovirus and connective tissue disease were negative.
Upon the patient?s return to the Netherlands, the rash reappeared (Figure) and the joint pains in her hands and knees increased. Treatment with naproxen was started. Serology for Borrelia burgdorferi showed IgM but no IgG; however, this diagnosis remained inconclusive as it was not confirmed by analysis of a second serum sample. Serological testing for RRV and BFV on a convalescent serum taken on 20 May showed the presence of IgM and IgG antibodies specific for RRV (Table). A second serum sample taken on 24 June showed decreasing IgM and increasing IgG titres. RRV aetiology was further confirmed by comparative IIFA for RRV, BFV, CHIKV and SINV, and by virus neutralisation (Table).