Published Date: 2013-12-27 20:28:57
Subject: PRO/EDR> Zika virus – Germany ex Thailand
Archive Number: 20131227.2139786
Date: Fri 27 Dec 2013
From: Jonas Schmidt-Chanasit <email@example.com> [edited]
A previously healthy 53-year-old man consulted at the Saarland University Medical Center on 22 Nov 2013 after returning from travel to Thailand. During his 3-week round trip (31 Oct-20 Nov 2013), including visits to Phuket, Krabi, Ko Jum, and Ko Lanta, he developed joint pain and swelling on his left ankle and foot on 12 Nov 2013 after several mosquito bites, followed by a maculopapular rash on his rear and front trunk that spread to the face and the upper as well as lower extremities over the next 4 days before fading. Accompanying symptoms were malaise, fever, and shivering, of which the latter 2 appeared only for one day. He and his travel partner, who never had any comparable symptoms, were using insect repellent during travel. Upon presenting in Germany, which was intended as a check for tropical diseases and included taking blood samples, no clinical signs could be found, and the only subjective complaint was continuing tiredness.
Initially, the 1st serum sample collected 10 days after disease onset gave a positive result in the dengue IgM antibody tests (IFA and rapid test), although tests for dengue IgG antibody (IFA and rapid test) and dengue NS 1 antigen (ELISA and rapid test) were negative. However, the isolated positive result for dengue IgM antibodies prompted us to investigate a probable flavivirus etiology through a serological approach. Serological tests for Japanese encephalitis virus, West Nile virus, yellow fever virus, tick-borne encephalitis virus, and Zika virus were performed by the WHO Collaborating Centre for Arbovirus and Haemorrhagic Fever Reference and Research (WHOCC), Hamburg, Germany. IFAs gave positive results for Zika virus IgG and IgM antibodies, demonstrating an acute or recent Zika virus [ZIKV] infection of the patient. In contrast, IFAs gave negative results for the other flaviviruses tested as well as for chikungunya virus. Real-Time RT-PCR for ZIKV RNA (in-house) was negative. The presence of ZIKV-specific neutralizing antibodies was confirmed by a virus neutralization assay, and an IgM titer decrease in IFA was demonstrated in the 2nd serum sample collected 31 days after disease onset.
This is the 1st laboratory confirmed case of ZIKV reported in Germany and Europe and the 2nd case reported from Thailand. Thus, differential diagnosis in febrile returning travelers from the south of Thailand (Phuket, Krabi, Ko Jum, and Ko Lanta) should include Zika virus infection.
Jonas Schmidt-Chanasit, Petra Emmerich, Dennis Tappe, Martin Gabriel, Stephan Gunther: Bernhard Nocht Institute for Tropical Medicine, WHO Collaborating Centre for Arbovirus and Haemorrhagic Fever Reference and Research, National Reference Centre for Tropical Infectious Diseases, Hamburg, Germany.
Jorgen Rissland, Gerhard Held, Sigrun Smola: Saarland University Medical Center, Homburg/Saar, Germany
[ProMED thanks Jonas Schmidt-Chanasit and colleagues for sending in this interesting, firsthand report.
This is the 2nd ProMED-mail report of a Zika virus infection originating in Thailand. The virus was 1st isolated in 1947 from sentinel rhesus monkey serum in Uganda. Fortunately, the probability of ongoing transmission from this case in Germany is nil.
This is another example of long-distance international travel involving an individual who acquired a tropical arbovirus disease who was seen in a temperate zone clinic halfway around the world. The above case is an excellent example of a thorough laboratory approach to establishing a diagnosis of a disease exotic to Germany. It also underscores the importance of taking a good travel history for these types of cases. It also indicates that Zika virus transmission is active in Thailand and could be confused easily with a dengue virus infection without comprehensive laboratory testing. This report along with the earlier one this year  make one wonder how many Zika virus infections in Thailand and other Southeast Asian countries are mistakenly diagnosed as dengue virus infections.
A HealthMap/ProMED-mail map of Thailand can be accessed at http://healthmap.org/r/1l5W. – Mod.TY]
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