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Thrombocytopenia and subcutaneous bleedings In Zika case - Lancet

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Figure

Skin and tissue symptoms

(A) Swelling of the hand and wrists, and (B) skin rash during acute illness (day 2). Photos courtesy of the patient. (C,D) Subcutaneous haematomas on day 18, when the patient was recovering from acute illness. Photos taken at the Academic Medical Center, Amsterdam, Netherlands.

 

 
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PCR analysis, at the Academic Hospital of Paramaribo, of a blood sample taken on day 2 of her illness was positive for Zika virus. The patient treated herself symptomatically with paracetamol 1000 mg three times a day from day 0 to day 2, and no concomitant medication, particularly no aspirin, was taken. On day 10, she developed watery diarrhoea, vomited twice without any visible traces of blood, and had subcutaneous haematomas on both arms and legs without preceding trauma (figure).

On first examination in our clinic on day 17, 3 days after her return to the Netherlands, she had several haematomas on both arms and legs. The haematomas varied from 2 cm to 6 cm in diameter, and two fresh ones developed on the day of presentation, with no evidence of petechial bleedings. Physical examination was otherwise normal. Our differential diagnosis included complications of acute Zika virus infection, concomitant dengue virus infection, and post-infectious immune thrombocytopenia.

Laboratory examination showed slight microcytic anaemia (haemoglobin concentration 7·2 mmol/L) but a normal haematocrit, and a profound thrombocytopenia of 20 × 109 platelets per L, with normal coagulation parameters. A watch-and-wait decision was made. On day 29, she developed gum bleeding, at a thrombocyte count of 10 × 109 platelets per L. At this point, we decided to treat her presumed immune-mediated thrombocytopenia with intravenous immunoglobulins, upon which her thrombocyte count increased to 80 × 109 platelets per L within a few days. Concentrations of thrombocyte antibodies and thrombopoietin have been measured, and results are still pending.

In follow-up PCR analyses at the AMC on days 17 and 18, her blood sample was negative for Zika virus and her urine sample was positive. Dengue serology (Panbio Dengue Duo Cassette, Alere, Tilburg, Netherlands) was positive for IgG and weakly positive for IgM. A rapid immunochromatographic dengue antigen test (Bio-Rad, Veenendaal, Netherlands) on blood and urine samples was also negative. Additionally, PCR analysis of all dengue virus serotypes was negative on urine samples. The patient did not recall a previous disease episode that was suggestive of dengue infection. She had received her latest yellow fever vaccination in 2000.

Zika virus is a Flavivirus transmitted to human beings primarily through the bites of Aedes spp. The present outbreak in the Americas is spreading quickly, causing an increase in Zika virus infections among travellers returning from endemic areas.1, 2 As of Feb 7, 2016, 410 cases have been confirmed in Suriname, with many more suspected or unconfirmed cases (Codrington J, unpublished). The clinical syndrome is usually mild and self-limiting, and lasts for 4–7 days after an incubation period of a maximum of 2 weeks. Mild thrombocytopenia (139 × 109 platelets per L) has been described only once in the past;3 however, unconfirmed preliminary clinical reports from the ongoing outbreak suggest moderate thrombocytopenia as an infrequent, but not uncommon, finding (Vreden SGS, unpublished).

The positive dengue virus IgG suggests the presence of high titres against the virus, since the test is designed to detect secondary dengue virus infection. Whether a primary Zika virus infection can induce high-titre cross-reactivity is unknown, but cross-reactivity in Flavivirus serology is a well known occurrence, which might also explain the weakly positive dengue IgM.4 Furthermore, positive dengue serology is a very frequent finding in first-generation Surinamese immigrants in the Netherlands.5 The absence in urine of dengue virus antigen and RNA, which are known to remain detectable for up to 3–4 weeks, makes concomitant dengue virus infection less likely. The presumed immune-mediated thrombocytopenia is therefore most likely related to Zika virus monoinfection, with probable dengue virus infection in the past.

In summary, we report a patient with Zika virus infection that was related to clinically relevant thrombocytopenia and subcutaneous haematomas. Experience from the field and heightened vigilance among returned travellers are necessary to understand the clinical significance of this complication.

We declare no competing interests. We thank our patient for agreeing to the publication of her case report and Richard Molenkamp (Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands) for setting up the Zika PCR assay.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00502-X/fulltext?rss%3Dyes

 

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References

  1. Goorhuis, A, von Eije, KJ, Douma, RA et al. Zika virus and the risk of imported infection in returned travelers: implications for clinical care. Travel Med Infect Dis. 2016;DOI: http://dx.doi.org/10.1016/j.tmaid.2016.01.008(published online Jan 27.)
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First US death linked to Zika reported from Puerto Rico

Aedes-aegypti_GettyImages-507237716-500x

MARIO TAMA/GETTY IMAGES

An Aedes aegypti mosquito is seen through a microscope.

By HELEN BRANSWELL @HelenBranswell

 
 
 

An elderly man in Puerto Rico who contracted the Zika virus has died of the infection, according to the US Centers for Disease Control and Prevention.

The man in his 70s developed a severe case of a condition calledthrombocytopenia — a blood clotting problem that can lead to internal bleeding.

This is the first Zika-related death reported among the more than 1,000 cases that have been diagnosed in the United States and US territories.

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“It is a rare outcome,” said Tyler Sharp, acting head epidemiologist at the CDC’s dengue branch, which is based in the Puerto Rican capital of San Juan.

Most people who contract Zika have either no symptoms or quite mild illness. “But there are some manifestations of Zika virus infection that are associated with potentially fatal outcomes,” Sharp noted — including birth defects like microcephaly, neurological disorders like Guillain-Barré syndrome, and blood problems like those suffered by the man who died.

CDC officials reported the case Friday in the agency’s Morbidity and Mortality Weekly Review.

Sharp said the man had appeared to recover from his infection, but then developed a particular type of thrombocytopenia called immune thrombocytopenic purpura, or ITP, in which the man’s immune system attacked the platelets in his blood, leading to a clotting disorder.

Dutch researchers in February reported a very similar fatal case in a 54-year-old woman who was infected by Zika in Suriname.

In Colombia, health officials have also reported four deaths, three of which involved thrombocytopenia. But there aren’t enough details of those cases in the medical literature to know if they were the same kind of the condition suffered by the man in Puerto Rico, Sharp said. The deaths in Colombia crossed the age spectrum, involving a 2-year-old girl, a 30-year-old woman, a 61-year-old man, and a 72-year-old woman.

Sharp said the Zika virus continues to surprise researchers who are studying its impact.

“Certainly the association with the autoimmune condition Guillain-Barré syndrome was surprising. And now we appear to be seeing an association with another autoimmune condition, ITP, that is also a little bit surprising,” he said.

“So each day that goes by we continue to learn more about Zika and better understand it so we can best combat it and provide the appropriate medical interventions for infected individuals.’’

Puerto Rico, which is expected to be hard hit by the Zika virus, has diagnosed707 cases of Zika infection so far. Of those, 89 are among pregnant women, according to the territory’s Department of Health.

So far, none of the women who contracted Zika during pregnancy have been diagnosed as carrying a fetus with microcephaly, according to Sharp.

A total of 19 people in Puerto Rico have been hospitalized with complications caused by Zika infection. There have also been five reported cases of Zika-related Guillain-Barré.

In the 50 states, 426 Zika cases have been diagnosed, 36 of them pregnant women. All the cases were people infected abroad or who were infected byhaving sex with someone who had returned to the United States infected with Zika.

https://www.statnews.com/2016/04/29/zika-death-puerto-rico/

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