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Letter
Dual Infection by Dengue Virus
and Shigella sonnei in Patient Returning from India
Rémi. Charrel,*† Mina Abboud,* Jean-Paul Durand,† Philippe
Brouqui,‡ and Xavier De Lamballerie*†
*Laboratoire de Bactériologie-Virologie, Marseille, France; †Faculté de
Médecine, Marseille, France; and ‡AP-HM Nord, Marseille, France
Suggested citation for this article: Charrel
RN, Abboud M, Durand JP, Brouqui P, De Lamballerie X. Dual infection
by dengue virus and Shigella sonnei in patient returning from
India. Emerg Infect Dis [serial online] 2003 Feb [date cited].
Available from: URL: http://www.cdc.gov/ncidod/EID/vol9no2/02-0026.htm
To the Editor: Two days after returning from a 4-week trip in
India, a 44-year-old woman was admitted to a local French hospital with
diarrhea and a fever (40°C). The fever had started 2 days before her return
and was associated with myalgia and backache. The patient had not been
vaccinated against yellow fever and did not take malaria prophylaxis during
her trip. Blood smears were negative for malaria parasites. Biological
analyses (complete blood count, liver enzymes, urine culture, stool culture,
blood cultures) were ordered. She was sent home with an empirical treatment
with ofloxacin (200 mg per day). Biological parameters were within the
normal range, except for her platelet count, which was at the lower limit
(170 G/L). Microbiologic analyses of stools yielded an isolate of Shigella
sonnei serotype 9.
One week later, the patient was admitted to the infectious diseases unit
of a university hospital in Marseilles, France, with persistent fever,
myalgia, and a 7-kg weight loss; she had no digestive manifestations.
Results of viral serology tests were negative, except that immunoglobulin
(Ig)M, but not IgG, specific for dengue virus (formal name: Dengue
virus; [DENV]) was present. This result was obtained with the Dengue
Virus IgM and IgG Rapid Immunochromatographic Card Test (Biotrin, PanBio
Pty. Ltd., Brisbane, Australia) and was confirmed by the Dengue Duo IgM-capture
and IgG-capture enzyme-linked immunosorbent assay (ELISA) (PanBio) and
a previously described in-house IgM antibody capture ELISA tests (1).
Forty days later, a second serum specimen was collected and tested positive
for DENV IgG with the persistence of IgM by three techniques. In light
of these results, the diagnosis of primary dengue infection was established,
according to criteria of the Centers for Disease Control and Prevention
(2). A literature review did not find any documented
case of coinfection by DENV and Shigella.
In India, DENV causes epidemic and sporadic cases year-round, with a
peak in frequency from August to November, during the humid season (3).
During the patient’s trip, she successively visited Mumbai (Bombay); went
north to the Shimla district, Himachal Pradesh, the Agra district, and
Uttar Pradesh; and came back to Bombay 3 days before leaving for France.
If one assumes a 3- to 6-day incubation period, she likely acquired the
dengue infection in Uttar Pradesh; the virus has been reported to circulate
in this area (4).
Although severe forms are increasingly reported, most cases of dengue
fever consist of a mild illness with nonspecific symptoms such as headache,
myalgia, and malaise. Dengue fever may go underdiagnosed in travelers
returning from DENV-endemic areas. This case underlines the importance
of a thorough interview and clinical examination to detect characteristic
signs (photophobia, painful ocular mobilization, skin rash) in patients
returning from areas endemic for dengue fever, when clinical and biological
signs incompletely correlate with the primary diagnosis. Since dengue
fever is the second most frequent cause of febrile illness in persons
returning from tropical areas, such patients should be routinely screened
for the disease.
References
- Saluzzo JF, Cornet M, Adam C, Eyraud M, Digoutte
JP. Dengue
2 in eastern Senegal: serologic survey in simian and human populations,
1974–1985. Bull Soc Pathol Exot Filiales 1986;79:313–22.
- Centers for Disease Control and Prevention. Case definitions for
infectious conditions under public health surveillance. Morb Mortal
Wkly Rep MMWR 1997;46 (RR-10).
- Dar L, Broor S, Sengupta S, Xess I, Seth P. The
first major outbreak of dengue hemorrhagic fever in Dehli, India.
Emerg Infect Dis 1999;5:589–90.
- Mall MP, Kumar A, Malik SV. Sero-positivity
of domestic animals against Japanese encephalitis in Bareilly area,
U.P. J Commun Dis 1995;27:242–6.
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