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Dispatch
Nosocomial Acquisition of
Dengue
Dirk Wagner,* Katja de With,* Daniela Huzly,* Frank Hufert,* Manfred
Weidmann,* Susanne Breisinger,* Sabine Eppinger,* Winfried Vinzent Kern,*
and Tilman Martin Bauer*
*University Hospital, Freiburg, Germany
Suggested
citation for this article
Recent transmission
of dengue viruses has increased in tropical and subtropical areas and
in industrialized countries because of international travel. We describe
a case of nosocomial transmission of dengue virus in Germany by a needlestick
injury. Diagnosis was made by TaqMan reverse transcription–polymerase
chain reaction when serologic studies were negative.
Dengue viruses are transmitted by Aedes mosquitoes in tropical
regions worldwide. The global incidence of epidemic and endemic dengue
fever has increased substantially and is estimated at 50–100 million cases
per year. International travel leads to imported cases in countries of
the Northern Hemisphere (1), where dengue fever is an
important differential diagnosis of fever in travelers returning from
the tropics. Occupational needlestick injuries continue to pose a substantial
risk for healthcare workers and occur at rates of 1.0 to 6.2 per 100 person-years
(2). Common concerns are the transmission of HIV, hepatitis
B virus, and hepatitis C virus. However, other pathogens can be transmitted
as well. We report a case of nosocomial transmission of dengue virus.
The Study
The index patient, a 26-year-old woman, was admitted to the infectious
disease ward of a university hospital with a temperature of 40°C and
myalgias 3 days after she returned from a 3-week trip to Cambodia and
Thailand. Dengue virus infection was subsequently diagnosed, and mild
hepatitis and a rash developed. She was discharged in good condition after
the fever subsided. On the day of admission of the index patient (day
0i), a nurse sustained a needlestick injury with a hollow needle
that had been used for drawing blood from the index patient. The needlestick
resulted in a bleeding puncture wound that was immediately treated with
an antiseptic. The index patient did not report any high-risk activity
for HIV or hepatitis B virus, and the nurse had been immunized against
hepatitis B virus. Therefore, no specific postexposure prophylaxis was
performed. The nurse had previously been in good health and had not traveled
outside Germany in the preceding 12 months.
Four days after the needlestick, headache, myalgias, and arthralgias
developed in the healthcare worker, for which she took ibuprofen. Seven
days later, when she was experiencing an intense headache and noticed
a macular rash on her trunk, she sought treatment from a local doctor
(day 0n). Physical examination showed bilateral cervical lymphadenopathy.
On day 2n, she visited our service, where dengue virus infection
was diagnosed by using a Light Cycler (Roche Diagnostics, Mannheim, Germany)
polymerase chain reaction (PCR) method. Her symptoms lessened gradually
over the course of 4 weeks, and she was on sick leave for 5 weeks. The
time frame of the respective clinical presentation and the virologic results
of the index patient and the nurse are shown in the Figure;
laboratory data are presented in the Table.
Serologic studies were performed with the PanBio dengue immunoglobulin
(Ig) M capture enzyme-linked immunosorbent assay (ELISA) and PanBio dengue
indirect IgG ELISA (PanBio Ltd., Brisbane, Australia) (3);
arbitrary units relative to a simultaneously measured calibrator >11
were considered positive. For detecting virus RNA, RNA was prepared from
140 µL of serum by using the QIAamp Viral RNA Mini Kit (Qiagen,
Hilden, Germany), according to the manufacturer’s instructions. To detect
specific dengue virus RNA, we adapted a TaqMan-reverse transcription (RT)-PCR
(4) to detect any of the four serotypes by using the
following: degenerated forward primer (DEN FP), reverse primer (DEN RP);
and probe (DEN P): DEN FP 5´AAggACTAgAggTTAKAggAgACCC3´, DEN
RP 5´ggCCYTCTgTgCCTggAWTgATg3´ and the probe DEN P 5´
FAM-AACAgCATATTgACgCTgggARAgACC-TAMRA-3´. RT-PCR conditions for
the Light Cycler (Roche Diagnostics) were: RT at 61°C for 20 min,
activation at 95°C for 5 min, and 40 cycles of PCR at 95°C for
15 s, 60°C for 60 s. We used the RNA Master Hybridization Probes Kit
(Roche Diagnostics) with 500-nM primers and 200-nM probes. The kit includes
an aptamer-blocked Thermus thermophilus DNA polymerase, which performs
RT and, once the aptamer drops out at activation, hotstarts PCR amplification.
Conclusions
This is the fourth reported case, to our knowledge, of nosocomial dengue
virus transmission (5–7) and the first in which TaqMan
RT-PCR was used to provide evidence of nosocomial transmission before
the detection of an antibody response. The index patient had acquired
a dengue virus infection in Southeast Asia and experienced typical symptoms.
In particular, she was febrile on admission, when the needlestick injury
of the nurse occurred. In the health care worker who sustained the injury,
cephalgia and myalgias developed after an incubation period of 4 days.
A typical rash appeared after 11 days, when she also had a severe headache.
The absence of fever, the most common sign of dengue fever, is likely
due to the administration of ibuprofen. Both persons completely recovered.
However, the healthcare worker was on sick leave for 5 weeks with resulting
socioeconomic consequences.
The diagnosis was confirmed in both cases by both seroconversion and
detection of dengue viral RNA by TaqMan RT-PCR; the latter gave positive
results in both cases 3 and 6 days, respectively, before serum specimens
were shown to contain antibody. Dengue viremia is known to correlate well
with the presence of fever (8), which was the case in
the index patient. Our report illustrates the potential of percutaneous
nosocomial transmission of dengue viruses. This risk is likely to increase
with the increase in the number of dengue infections imported to countries
where dengue viruses are not endemic.
Dr. Wagner is an
infectious disease specialist at the University Hospital, Freiburg,
Germany. His research interests focus on iron metabolism and intracellular
survival of mycobacteria.
References
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MP, Knobloch J, et al. Epidemiology
and clinical features of imported dengue fever in Europe: sentinel surveillance
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transmission of dengue from a needlestick injury. Lancet. 1998;351:498.
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| Table.
Laboratory data for index patient and health care worker infected
with dengue virusa |
|
| |
Day
|
Leukocytes (mL)
|
Lymphocytes (mL)
|
Thrombocytes (mL)
|
Dengue IgM EIA
|
Dengue IgG EIA (U)
|
Dengue PCR
|
|
|
Index patient
|
0i
|
2.000
|
420
|
137.000
|
–
|
+ (16.4)
|
+
|
|
4i
|
1.900
|
ND
|
55.000
|
+
|
+ (43.0)
|
–
|
|
14i
|
5.000
|
1.650
|
375.000
|
+
|
+ (30.9)
|
ND
|
|
Health care worker
|
2n
|
2.600
|
590
|
136.000
|
–
|
– (2.8)
|
+
|
|
8n
|
4.000
|
1.040
|
174.000
|
+
|
– (5.9)
|
ND
|
|
15n
|
4.200
|
1.190
|
213.000
|
+
|
+ (16.4)
|
ND
|
|
22n
|
4.800
|
1.220
|
215.000
|
+
|
+ (21.7)
|
ND
|
|
| aIg, immunoglobulin;
EIA, enyzyme immunosorbent assay; PCR, polymerase chain reaction;
ND, not done. |
Suggested citation
for this article:
Wagner D, de With K,
Huzly D, Hufert F, Weidmann M, Breisinger S, et al. Nosocomial acquisition
of dengue. Emerg Infect Dis [serial on the Internet]. 2004 Oct [date
cited]. Available from http://www.cdc.gov/ncidod/EID/vol10no10/03-1037.htm
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