Concomitant Transmission of Dengue, Chikungunya, and Zika Viruses in Brazil: Clinical and Epidemiological Findings From Surveillance for Acute Febrile Illness

Abstract

<jats:title>Abstract</jats:title> <jats:sec> <jats:title>Background</jats:title> <jats:p>Since their emergence in the Americas, chikungunya (CHIKV) and Zika (ZIKV) viruses co-circulate with dengue virus (DENV), hampering clinical diagnosis. We investigated clinical and epidemiological characteristics of arboviral infections during the introduction and spread of CHIKV and ZIKV through northeastern Brazil.</jats:p> </jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>Surveillance for arboviral diseases among febrile patients was performed at an emergency health unit of Salvador, Brazil, between September 2014 and July 2016. We interviewed patients to collect data on symptoms, reviewed medical records to obtain the presumptive diagnoses, and performed molecular and serological testing to confirm DENV, CHIKV, ZIKV, or nonspecific flavivirus (FLAV) diagnosis.</jats:p> </jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Of 948 participants, 247 (26.1%) had an acute infection, of which 224 (23.6%) were single infections (DENV, 32 [3.4%]; CHIKV, 159 [16.7%]; ZIKV, 13 [1.4%]; and FLAV, 20 [2.1%]) and 23 (2.4%) coinfections (DENV/CHIKV, 13 [1.4%]; CHIKV/FLAV, 9 [0.9%]; and DENV/ZIKV, 1 [0.1%]). An additional 133 (14.0%) patients had serological evidence for a recent arboviral infection. Patients with ZIKV presented with rash and pruritus (69.2% each) more frequently than those with DENV (37.5% and 31.2%, respectively) and CHIKV (22.9% and 14.7%, respectively) (P &amp;lt; .001 for both comparisons). Conversely, arthralgia was more common in CHIKV (94.9%) and FLAV/CHIKV (100.0%) than in DENV (59.4%) and ZIKV (53.8%) (P &amp;lt; .001). A correct presumptive clinical diagnosis was made for 9%–23% of the confirmed patients.</jats:p> </jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Arboviral infections are frequent causes of febrile illness. Coinfections are not rare events during periods of intense, concomitant arboviral transmission. Given the challenge to clinically distinguish these infections, there is an urgent need for rapid, point-of-care, multiplex diagnostics.</jats:p> </jats:sec>

Beyond Fever and Pain: Diagnostic Methods for Chikungunya Virus

“…A skin rash develops in 40 to 60% of cases (1,2,25,64,65,68,69), though this may not be present at the initial visit (65,70). Rashes are most often maculopapular and may be pruritic, though bullous and purpuric lesions have been reported (8,25,62,69). Headache and gastrointestinal complaints, such as anorexia, nausea, vomiting, and abdominal pain, are also commonly reported in chikungunya cases (25,57,65,66,69).…”

“…Clinical diagnosis does not reliably differentiate CHIKV infections from other etiologies on the differential, such as other alphaviruses (MAYV, ONNV), flaviviruses (most commonly DENV and ZIKV), and nonviral pathogens, which include, but are not limited to, Plasmodium species, Leptospira, rickettsia, and Salmonella. In settings of CHIKV cotransmission with DENV and ZIKV, a presumptive diagnosis of chikungunya was correct in only 10 to 40% of cases (7,8,31). Clinical prediction algorithms have been evaluated to differentiate CHIKV infections from infections with other etiologies, but these have not been independently validated in separate cohorts (59,63,66,72,76).…”

Imported Arbovirus Infections in Spain, 2009–2018

“…No cases were severe. During periods of intense transmission, coinfections are not infrequent or unexpected (29). A recent study that used reverse transcription PCR to investigate patients with acute undifferentiated febrile illness during the CHIKV outbreak in Haiti found that ≈10% of the children with CHIKV infection during the study period were infected with another arbovirus (ZIKV, DENV, or Mayaro virus) (30).…”

Fatal Zika virus infection in the Americas: A systematic review

“…Fifteen cases, reported in eight articles, addressed questions related to the temporality dimension (Arzuza-Ortega et al, 2016;Azevedo et al, 2016;Dirlikov et al, 2016;Sarmiento-Ospina et al, 2016;Schwartzmann et al, 2017;Sharp et al, 2016;Swaminathan et al, 2016;Zonneveld et al, 2016). In most of these cases, ZIKV infection was confirmed before the evolution to death, and the interval between exposure to ZIKV and the occurrence of related symptoms was typical for arbovirus infections (Arzuza-Ortega et al, 2016;Azevedo et al, 2016;Dirlikov et al, 2016;MM et al, 2018;Sarmiento-Ospina et al, 2016;Schwartzmann et al, 2017;Sharp et al, 2016;Swaminathan et al, 2016;Zonneveld et al, 2016). Remarkably, one of the patients, a 73-year-old man from the USA, developed the clinical picture after a 3-week travel to a ZIKV endemic area.…”