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In Reply—Zika Virus Meningoencelphalitis

      To the Editor:
      We read with interest the letter from Joob and Wiwanitkit
      • Joob B.
      • Wiwanitkit V.
      Zika virus meningoencephalitis.
      which reinforced our interpretation that immunosuppression predisposes the central nervous system (CNS) to infection by Zika virus.
      It is known that some microbial infections of the CNS—such as those caused by toxoplasma, cryptococcus, and cytomegalovirus—can be related to predisposing underlying diseases. In the Brazilian Amazon region, the tropical climate favors the proliferation of large quantities of insect vectors and their vertebrate reservoirs, thus supporting the natural cycles of many arboviruses that can infect humans. In a study done in the state of Amazonas, cerebrospinal fluid (CSF) samples from 110 patients with meningoencephalitis were tested by reverse transcription-polymerase chain reaction (RT-PCR) for Orthobunyavirus and Flavivirus.
      • Bastos Mde S.
      • Figueiredo L.T.
      • Naveca F.G.
      • et al.
      Identification of Oropouche Orthobunyavirus in the cerebrospinal fluid of three patients in the Amazonas, Brazil.
      Lymphomonocytosis predominated in all CSF cell counts. Sequencing of RT-PCR products obtained from 3 patients identified Oropouche virus (Peribunyaviridae). Two of the 3 patients infected with Oropouche virus, a 54-year-old man and a 37-year-old woman, had underlying diseases that affected the CNS or the immune system (neurocysticercosis and AIDS, respectively). In a similar study using RT-PCR
      • de Morais Bronzoni R.V.
      • Baleotti F.G.
      • Ribeiro Nogueira R.M.
      • Nunes M.
      • Moraes Figueiredo L.T.
      Detection and identification of Brazilian alphaviruses and flaviviruses by multiplex RT-PCR.
      followed by nucleotide sequence of amplicons, 2 out of 23 patients from the state of Amazonas had Rocio virus, another Flavivirus, identified in the CSF. They were a 53-year-old man and a 30-year-old woman, both with AIDS. In the above cases, as in the Zika virus reported case,
      • Schwartzmann P.V.
      • Ramalho L.N.
      • Neder L.
      • et al.
      Zika virus meningoencephalitis in an immunocompromised patient.
      it is very likely that CNS invasion was facilitated by immune deficiency or previous blood-brain barrier damage.
      In conclusion, it is important to be aware that in patients who have underlying diseases and additional new CNS manifestations, arbovirus infections should be considered in the differential diagnosis.

      References

        • Joob B.
        • Wiwanitkit V.
        Zika virus meningoencephalitis.
        Mayo Clin Proc. 2017; 92: 1313
        • Bastos Mde S.
        • Figueiredo L.T.
        • Naveca F.G.
        • et al.
        Identification of Oropouche Orthobunyavirus in the cerebrospinal fluid of three patients in the Amazonas, Brazil.
        Am J Trop Med Hyg. 2012; 86: 732-735
        • de Morais Bronzoni R.V.
        • Baleotti F.G.
        • Ribeiro Nogueira R.M.
        • Nunes M.
        • Moraes Figueiredo L.T.
        Detection and identification of Brazilian alphaviruses and flaviviruses by multiplex RT-PCR.
        J Clin Microbiol. 2005; 43: 696-702
        • Schwartzmann P.V.
        • Ramalho L.N.
        • Neder L.
        • et al.
        Zika virus meningoencephalitis in an immunocompromised patient.
        Mayo Clin Proc. 2017; 92: 460-466

      Linked Article

      • Zika Virus Meningoencephalitis
        Mayo Clinic ProceedingsVol. 92Issue 8
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          In the March 2017 issue of Mayo Clinic Proceedings, Schwartzmann et al1 reported on a single case of Zika virus meningoencephalitis and concluded that, “In this case, central nervous system involvement and ZIKV propagation to other organs in a disseminated pattern is quite similar to that observed in other fatal Flaviviridae viral infections.” The patient reported by Schwartzmann et al1 was immunocompromised at the time of Zika virus infection; however, meningoencephalitis accompanying Zika virus infection has also been reported in apparently immunocompetent patients.
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