Example of zika virus

Zika wasn't even on Dr. Sankar Swaminathan's mind when he first examined a severely ill
73-year-old man in a Salt Lake City hospital in June. The patient had just returned from a
visit to Mexico when he suddenly fell violently ill.
"We were not thinking about Zika at all because Zika usually does not cause severe illness, in
fact it almost never does," says Swaminathan, chief of the division of infectious diseases at
the University of Utah.
"His symptoms were really what is often the end point of many, many severe infections."
He had a high fever and low blood pressure. His kidneys and lungs were failing. "This
happens with many bacterial infections," says Swaminathan, "and it's often referred to as
sepsis."
In addition to the patient's bacterial infection, Swaminathan thought the man might have
picked up a powerful case of malaria or dengue. But tests for those diseases came back
negative. Actually every test they tried came back negative.
Then they finally tested for Zika. The result came back positive and the level of virus in
his blood was astronomical.
"In this particular case the level of virus was probably a hundred thousand times what you or
I might have in our blood if we were having acute Zika infection," Swaminathan says. "We
estimated 200 million copies [of virus] in a milliliter of blood. That level is really quite high.
We see that in some other viral illnesses but not many. For instances in most viral illnesses a
million would be considered very, very high."
Swaminathan writes about this highly unusual Zika case in the New England Journal of
Medicine.
Four days after the patient was admitted to the hospital, he died. Five days later his 38-yearold son, who had helped care for him in the ward, also came down with Zika. The son hadn't
recently traveled to areas with Zika, and mosquitoes that spread Zika aren't present in Utah so
that ruled out transmission by mosquito.
According to the NEJM article, the son had helped a nurse to reposition his father in his bed
and wiped his father's eyes. This raised the question: Could Zika also spread through sweat or
tears?
"I should stress this was an extremely rare event superimposed on a rare event,"
Swaminathan says of the younger man's Zika case. "We've never seen transmission outside of
mosquitoes or sexual transmission. This is one of the areas where research needs to be done
on whether people who are severely ill pose an increased risk of transmission."
So it's still unclear how the son was infected.
The son had what Swaminathan calls "a very normal" case of Zika. He wasn't extremely sick
and he quickly recovered.

The bigger question is what caused his dad to get such a severe form of the disease.
"There are hundreds of thousands of people who've been infected in this outbreak but only
about a dozen people have actually died from it," says Swaminathan. The dozen deaths he
mentions don't include people who got hit with a post-infection syndrome called GuillainBarre in the wake of a Zika virus infection, which can lead to death.
The 73-year-old was originally from Mexico and immigrated to the U.S. in 2003.
Swaminathan says testing at the Salt Lake hospital showed that the man had had dengue
"sometime in the distant past."
Prior exposure to one strain of dengue can make people more likely to get severely ill if
they're hit with another strain of dengue. Swaminathan says exposure to dengue may also
make people more susceptible to a severe case of Zika. "There's laboratory evidence that if
you take blood from people who've had dengue before and you add it to a culture system with
Zika, you increase the infection by Zika virus," he says.
Even looking at those studies, he says that the case of this 73-year-old man was highly
unusual and raises more questions about Zika than it answers.
Indeed, ever since Zika took off in the Americas last year, it has surprised researchers, first
with the devastating effects it can have on fetuses, then by turning out to also be a sexually
transmitted disease and now appearing to find potentially even other ways to spread
Symptoms
Many people infected with Zika virus wont have symptoms or will only have mild
symptoms. The most common symptoms of Zika are Fever,Rash,Joint pain,Conjunctivitis
(red eyes).Other symptoms include: Muscle pain and Headache
How long symptoms last
Zika is usually mild with symptoms lasting for several days to a week. People usually dont
get sick enough to go to the hospital, and they very rarely die of Zika. For this reason, many
people might not realize they have been infected. Symptoms of Zika are similar to other
viruses spread through mosquito bites, like dengue and chikungunya.
How soon you should be tested
Zika virus usually remains in the blood of an infected person for about a week. See your
doctor or other healthcare provider if you develop symptoms and you live in or have recently
traveled to an area with Zika. Your doctor or other healthcare provider may order blood tests
to look for Zika or other similar viruses like dengue or chikungunya. Once a person has been
infected, he or she is likely to be protected from future infections.

When to see a doctor or healthcare provider

See your doctor or other healthcare provider if you have the symptoms described above and
have visited an area with Zika, this is especially important if you are pregnant. Be sure to tell
your doctor or other healthcare provider where you traveled.
If you think you have Zika

See your doctor or other healthcare provider for a diagnosis.

Learn what you can do for treatment.

Learn how you can protect others if you have Zika.

Prevention

No vaccine exists to prevent Zika.

Prevent Zika by avoiding mosquito bites.

Mosquitoes that spread Zika virus bite during the day and night.

Mosquitoes that spread Zika virus also spread dengue and chikungunya viruses.

Zika can be passed through sex from a person who has Zika to his or her sex
partners. Condoms can reduce the chance of getting Zika from sex. Condoms include
male and female condoms.

Local mosquito-borne Zika virus transmission has been reported in two areas of
Miami

Prevention of mosquito bites

Reapply insect repellent as directed.

o

Do not spray repellent on the skin under clothing.

If you are also using sunscreen, apply sunscreen first and insect repellent
second.

Do not use insect repellent on babies younger than 2 months old.

Do not apply insect repellent onto a childs hands, eyes, mouth, and cut or irritated
skin.
Adults: Spray insect repellent onto your hands and then apply to a childs face.

Do not use products containing oil of lemon eucalyptus (OLE) or para-menthane-diol

(PMD) on children under 3 years old.

Dress your child in clothing that covers arms and legs.

Cover crib, stroller, and baby carrier with mosquito netting.

Wear long-sleeved shirts and long pants

Use screens on windows and doors. Repair holes in screens to keep mosquitoes
outside.

Once a week, empty and scrub, turn over, cover, or throw out items that hold water,
such as tires, buckets, planters, toys, pools, birdbaths, flowerpots, or trash containers.
Check inside and outside your home. Mosquitoes lay eggs near water.

Testing for Zika

Diagnosis

Diagnosis of Zika is based on a persons recent travel history, symptoms, and test
results.

A blood or urine test can confirm a Zika infection.

Your doctor or other healthcare provider may order blood tests to look for Zika or
other similar viruses like dengue or chikungunya.

Sexual Transmission and Testing

CDC recommends Zika virus testing for people who may have been exposed to Zika
through sex and who have Zika symptoms.

A pregnant woman with possible exposure to Zika virus from sex should be tested.
Possible exposure to Zika virus from sex includes sex without a barrier to protect against
infection with a partner who traveled to or lives in an area with Zika.

Testing blood, semen, vaginal fluids, or urine is not recommended to determine how
likely a person is to pass Zika virus through sex. This is because there is still a lot we
dont know about the virus and how to interpret test results. Available tests may not
accurately identify the presence of Zika or a persons risk of passing it on.

As we learn more and as tests improve, these tests may become more helpful for
determining a persons risk of passing Zika through sex.

Treatment
There is no specific medicine or vaccine for Zika virus.

Treat the symptoms.

Get plenty of rest.

Drink fluids to prevent dehydration.

Take medicine such as acetaminophen (Tylenol) or paracetamol to reduce fever and

pain.

Do not take aspirin and other non-steroidal anti-inflammatory drugs (NSAIDS) until
dengue can be ruled out to reduce the risk of bleeding.

Example case of zika

Epidemic transmission of Zika virus (ZIKV) has rapidly occurred in the Americas, with most
cases limited to mild or asymptomatic disease.To date, nine deaths from ZIKV infection that
were unrelated to the GuillainBarr syndrome have been confirmed in adults.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.

Patient 1, a 73-year-old man who had emigrated to the United States from Mexico in 2003,
was admitted to a hospital in Salt Lake City with hypotension and abdominal pain. Radiation
therapy for stage IIB prostate cancer had been completed 1 month earlier, and he was

receiving antiandrogen therapy but was otherwise not systemically immunocompromised.

Eight days before admission, he had returned from a 3-week trip to the southwest coast of
Mexico, where ZIKV transmission had been reported. He was well during his trip but
reported being bitten by mosquitoes. After returning home, he reported having abdominal
pain, pharyngitis, and fever, which was followed by conjunctivitis, nonbloody diarrhea, and
myalgias.

On the day of admission, hypotension and dyspnea had developed. The patient was alert and
oriented with no fever but with tachypnea and tachycardia. He remained hypotensive after the
administration of intravenous fluids, and vasopressors and broad-spectrum antibiotics were
initiated. The physical examination was remarkable for marked erythematous conjunctivitis
with profuse tearing and soft-palate petechiae, tachypnea, and moderate, diffuse abdominal
pain with mild guarding. A tourniquet test (which is often performed in patients in whom
dengue is suspected) was negative.

Laboratory testing revealed metabolic acidosis, an elevated venous lactate level, renal
insufficiency, mild hypoglycemia, elevated aminotransferase levels, leukocytosis with 44%
band forms, anemia, and marked thrombocytopenia. (Details are provided in
the Supplementary Appendix, available with the full text of this letter at NEJM.org.) Testing
for malaria and blood cultures were negative. A presumptive diagnosis of dengue shock
syndrome was made. The patients clinical deterioration progressed, with progressive
respiratory and renal failure, metabolic acidosis, and hepatitis. On day 4 of hospitalization,
the patient died shortly after care was withdrawn.

Testing was negative for dengue virus (DENV) on polymerase-chain-reaction (PCR) assay.
Serologic analysis for DENV was consistent with remote infection, with a highly elevated
IgG level and an equivocal IgM level. Serum testing for ZIKV on real-time PCR assay was
positive, with a threshold cycle of 17 and a very high estimated viral load of 2.0108 ZIKV
genome copies per milliliter. High-throughput sequencing of RNA revealed the presence of a
ZIKV strain that shared 99.8% of the genome sequence with a strain isolated from a mosquito
in Chiapas, Mexico, in 2016. No other putative pathogen was detected by routine diagnostic
testing and RNA sequencing.

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 1s 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.