Infection DOI 10.1007/s15010-014-0695-0
CASE REPORT
Ross river virus infection in a Thuringian traveller returning from south-east Australia B. T. Schleenvoigt • M. Baier • S. Hagel C. Forstner • R. Ko¨tsche • M. W. Pletz
•
Received: 25 July 2014 / Accepted: 11 October 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Ross River virus (RRV) is an arbovirus transmitted by Aedes and Culex mosquitos. It is endemic in Australia, New Zealand and south-east Asia. Clinical manifestation rates in adults range about 20–40 %. Symptoms involve arthralgia, myalgia, lymphadenopathy, fever and rash. Here we report a case of RRV in a Thuringian traveller who visited the urban South-East of Australia. Keywords Ross River Virus Arbovirus Epidemic polyarthritis Australia Travel-related infection
B. T. Schleenvoigt (&) S. Hagel C. Forstner M. W. Pletz Center for Infectious Diseases and Infection Control, Jena University Hospital, Erlanger Allee 101, Thuringia 07740 Jena, Germany e-mail: [email protected] B. T. Schleenvoigt M. Baier Institute of Medical Microbiology, Jena University Hospital, Jena, Germany S. Hagel Department of Internal Medicine IV, Jena University Hospital, Jena, Germany C. Forstner Division of Infectious Diseases and Tropical Medicine, Department of Medicine I, Medical University of Vienna, Vienna, Austria R. Ko¨tsche Medical Practice, Hinter dem Teichgarten 3, 07774 Dornburg-Camburg, Germany M. W. Pletz Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
A 54-year-old female spent a 4 weeks holiday in Killcare—120 kilometres in the north of Sydney in February and March 2014. She performed daily wilderness trips to a nature reserve at the coast line and reported mosquito bites during the last week of February. During the second week of March she started complaining of headache and painful right wrist and hip lasting for 4 weeks. After returning to Germany and 4 weeks after cessation of the first event, a second episode of symptoms started with joint pain of the right hip, right wrist, proximal interphalangeal joints of the left hand and the metatarsophalangeal joint of the right hallux. Additionally myalgia of the right arm and headache were reported. The affections were not symmetric. There was no appearance of fever and rash. At the time she presented to a general practitioner the clinical examination was unremarkable. CRP, ESR, blood count and differential blood count showed normal values (erythrocytes 4.8 Tpt/l, thrombocytes 199 Gpt/l, leukocytes 6.5 Gpt/l, basophil granulocytes 1 %, eosinophil granulocytes 2 %, neutrophil granulocytes 66 %, lymphocytes 24 %, monocytes 8 %). Serology for Ross River virus was performed and revealed increased titers for IgG and IgM [Ross River Virus indirect immunofluorescence assay (IIFT) IgM 1:2,560 (Ref. \1:20) and IgG IIFT 1:1,280 (Ref. \1:20) (supplier: Bernhard-Nocht-Institute for tropical medicine Hamburg)]. 4 weeks later we saw a significant decrease of specific antibodies [Ross River Virus IgM IIFT 1:320 (Ref. \1:20) and IgG IIFT 1:320 (Ref. \1:20)]. Cross reaction with other viruses from the Togaviridae and Flaviviridae family was ruled out by additional serologic testing (Table 1). Rheumatic affliction was excluded by negative results for cyclic citrullinated peptide antibodies (anti-CCP; supplier: AbbottÒ, Wiesbaden, Germany), rheumatoid factor (supplier: BiokitÒ, Barcelona, Spain) and antistreptolysin O titers (supplier: Beckman Coulter ImmageÒ, Brea, CA,
123
B. T. Schleenvoigt et al. Table 1 results of the arbovirus specific immunodiagnostics
a
Indirect immunofluorescence assay (IIFT)
b
Bernhard-Nocht-Institute for tropical medicine Hamburg, inhouse test
Standard diagnosticsÒ, Hagaldong, Korea c
21 days after return from Australia (11.04.14) Togaviridae
IgM
IgG
IgM
IgG
Reference
Supplier
Barmah Forest Virusa
Negative
Negative
Negative
Negative
\1:20, Negative
BNITMb
Chikungunya Virus
Negative
Negative
Negative
Negative
\1:20, Negative
BNITMb
1:2,560
1:1,280
1:320
1:320
\1:20, Negative
BNITMb
Negative
Negative
Negative
Negative
\1:20, Negative
BNITMb
a
Ross River Virus a
Sindbis Virus Flaviviridae
IgM
IgG
IgM
IgG
Reference
Supplier
Dengue Virus
/
/
Negative
Negative
Negative
SDc
Negative
Negative
Negative
Negative
\1:20, Negative
BNITMb
Negative
Negative
Negative
Negative
\1:20, Negative
BNITMb
Murray Valley Virusa a
West Nil Virus
USA). As there is no specific antiviral treatment available the patient was treated symptomatically with ibuprofen and pantoprazole on demand. Symptoms subsided spontaneously within 6 weeks. Clinical manifestations rates of Ross River virus (RRV), an arbovirus from the Togaviridae family (Genus Alphavirus), in adults range about 20–40 % [1]. The incubation period can take 3–21 days. The most common clinical manifestations are arthralgia, myalgia and lymphadenopathy. Fever and rashes are only in 30–50 % clinically evident. While fever and rash normally vanish within several days, arthralgia and myalgia can persist over month. In 20 % arthralgia is protracted over 1 year [1, 2]. In those cases asymptomatic periods may be interrupted by acute relapses [1]. RRV was first isolated in Aedes mosquitos from the Ross River, Queensland in 1963 [3]. RRV is endemic in Australia with an average of 4,800 reported cases each year [4]. Reports in travellers are rare and only few cases are documented in the literature [5–9]. Urban transmission was reported in the past but most cases are transmitted in the rural northern and south-western parts of Australia [10, 11]. To the best of our knowledge this is the first case report of an RRV infection in a traveller who visited the urban south-east of Australia. We suggest that the presented case of RRV should be discussed as a relevant example since the infection might be missed in returning travellers to Germany due to mild and unspecific symptoms. Acknowledgments This work was supported by Bundesministerium fu¨r Bildung und Forschung (BMBF); Grant to Mathias W. Pletz (KI 011204). Informed Consent Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
123
After 4 weeks (13.05.2014)
Conflict of interest
None for all authors.
References 1. Stocks N, Selden S, Cameron S. Ross river virus infection. diagnosis and treatment by general practitioners in South Australia. Aust Fam Physician. 1997;26:710–7. 2. Flexman JP, Smith DW, Mackenzie JS, Fraser JR, Bass SP, Hueston L, Lindsay MD, Cunningham AL. A comparison of the diseases caused by Ross River virus and Barmah Forest virus. Med J Aust. 1998;169:159–63. 3. Doherty RL, Gorman BM, Whitehead RH, Carley JG. Studies of epidemic polyarthritis: the significance of three group A arboviruses isolated from mosquitoes in Queensland. Australas Ann Med. 1964;13:322–7. 4. Jacups SP, Whelan PI, Currie BJ. Ross river virus and barmah forest virus infections: a review of history, ecology, and predictive models, with implications for tropical northern Australia. Vector Borne Zoonotic Dis. 2008;8:283–97. 5. Wilder-Smith A, Tambyah PA, Hossain I. Ross river virus disease in a traveler to Australia. J Travel Med. 2009;16:420–3. 6. Nothdurft HD, Loscher T, Proll S, Dobler G, Pfeffer M, Jelinek T. Persistent arthralgias in ross-river-virus disease after travel to the South Pacific. Dtsch Med Wochenschr. 1999;124:759–62. 7. Tappe D, Schmidt-Chanasit J, Ries A, Ziegler U, Muller A, Stich A. Ross River virus infection in a traveller returning from northern Australia. Med Microbiol Immunol. 2009;198:271–3. 8. Moi ML, Takasaki T, Tochitani K, Shimizu T, Shinohara K, Tsuchido Y. The first case report of Ross River virus disease in a Japanese patient who returned from Australia. Kansenshogaku Zasshi. 2014;88:155–9. 9. Cramer JP, Kastenbauer U, Loscher T, Emmerich P, SchmidtChanasit J, Burchard GD, von Sonnenburg F. Polyarthritis in two travellers returning from Australia. J Clin Virol. 2011;52:1–3. 10. Harley D, Sleigh A, Ritchie S. Ross river virus transmission, infection, and disease: a cross-disciplinary review. Clin Microbiol Rev. 2001;14:909–32. 11. Rulli NE, Suhrbier A, Hueston L, Heise MT, Tupanceska D, Zaid A, Wilmes A, Gilmore K, Lidbury BA, Mahalingam S. Ross River virus: molecular and cellular aspects of disease pathogenesis. Pharmacol Ther. 2005;107:329–42.
CASE REPORT
Ross river virus infection in a Thuringian traveller returning from south-east Australia B. T. Schleenvoigt • M. Baier • S. Hagel C. Forstner • R. Ko¨tsche • M. W. Pletz
•
Received: 25 July 2014 / Accepted: 11 October 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Ross River virus (RRV) is an arbovirus transmitted by Aedes and Culex mosquitos. It is endemic in Australia, New Zealand and south-east Asia. Clinical manifestation rates in adults range about 20–40 %. Symptoms involve arthralgia, myalgia, lymphadenopathy, fever and rash. Here we report a case of RRV in a Thuringian traveller who visited the urban South-East of Australia. Keywords Ross River Virus Arbovirus Epidemic polyarthritis Australia Travel-related infection
B. T. Schleenvoigt (&) S. Hagel C. Forstner M. W. Pletz Center for Infectious Diseases and Infection Control, Jena University Hospital, Erlanger Allee 101, Thuringia 07740 Jena, Germany e-mail: [email protected] B. T. Schleenvoigt M. Baier Institute of Medical Microbiology, Jena University Hospital, Jena, Germany S. Hagel Department of Internal Medicine IV, Jena University Hospital, Jena, Germany C. Forstner Division of Infectious Diseases and Tropical Medicine, Department of Medicine I, Medical University of Vienna, Vienna, Austria R. Ko¨tsche Medical Practice, Hinter dem Teichgarten 3, 07774 Dornburg-Camburg, Germany M. W. Pletz Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
A 54-year-old female spent a 4 weeks holiday in Killcare—120 kilometres in the north of Sydney in February and March 2014. She performed daily wilderness trips to a nature reserve at the coast line and reported mosquito bites during the last week of February. During the second week of March she started complaining of headache and painful right wrist and hip lasting for 4 weeks. After returning to Germany and 4 weeks after cessation of the first event, a second episode of symptoms started with joint pain of the right hip, right wrist, proximal interphalangeal joints of the left hand and the metatarsophalangeal joint of the right hallux. Additionally myalgia of the right arm and headache were reported. The affections were not symmetric. There was no appearance of fever and rash. At the time she presented to a general practitioner the clinical examination was unremarkable. CRP, ESR, blood count and differential blood count showed normal values (erythrocytes 4.8 Tpt/l, thrombocytes 199 Gpt/l, leukocytes 6.5 Gpt/l, basophil granulocytes 1 %, eosinophil granulocytes 2 %, neutrophil granulocytes 66 %, lymphocytes 24 %, monocytes 8 %). Serology for Ross River virus was performed and revealed increased titers for IgG and IgM [Ross River Virus indirect immunofluorescence assay (IIFT) IgM 1:2,560 (Ref. \1:20) and IgG IIFT 1:1,280 (Ref. \1:20) (supplier: Bernhard-Nocht-Institute for tropical medicine Hamburg)]. 4 weeks later we saw a significant decrease of specific antibodies [Ross River Virus IgM IIFT 1:320 (Ref. \1:20) and IgG IIFT 1:320 (Ref. \1:20)]. Cross reaction with other viruses from the Togaviridae and Flaviviridae family was ruled out by additional serologic testing (Table 1). Rheumatic affliction was excluded by negative results for cyclic citrullinated peptide antibodies (anti-CCP; supplier: AbbottÒ, Wiesbaden, Germany), rheumatoid factor (supplier: BiokitÒ, Barcelona, Spain) and antistreptolysin O titers (supplier: Beckman Coulter ImmageÒ, Brea, CA,
123
B. T. Schleenvoigt et al. Table 1 results of the arbovirus specific immunodiagnostics
a
Indirect immunofluorescence assay (IIFT)
b
Bernhard-Nocht-Institute for tropical medicine Hamburg, inhouse test
Standard diagnosticsÒ, Hagaldong, Korea c
21 days after return from Australia (11.04.14) Togaviridae
IgM
IgG
IgM
IgG
Reference
Supplier
Barmah Forest Virusa
Negative
Negative
Negative
Negative
\1:20, Negative
BNITMb
Chikungunya Virus
Negative
Negative
Negative
Negative
\1:20, Negative
BNITMb
1:2,560
1:1,280
1:320
1:320
\1:20, Negative
BNITMb
Negative
Negative
Negative
Negative
\1:20, Negative
BNITMb
a
Ross River Virus a
Sindbis Virus Flaviviridae
IgM
IgG
IgM
IgG
Reference
Supplier
Dengue Virus
/
/
Negative
Negative
Negative
SDc
Negative
Negative
Negative
Negative
\1:20, Negative
BNITMb
Negative
Negative
Negative
Negative
\1:20, Negative
BNITMb
Murray Valley Virusa a
West Nil Virus
USA). As there is no specific antiviral treatment available the patient was treated symptomatically with ibuprofen and pantoprazole on demand. Symptoms subsided spontaneously within 6 weeks. Clinical manifestations rates of Ross River virus (RRV), an arbovirus from the Togaviridae family (Genus Alphavirus), in adults range about 20–40 % [1]. The incubation period can take 3–21 days. The most common clinical manifestations are arthralgia, myalgia and lymphadenopathy. Fever and rashes are only in 30–50 % clinically evident. While fever and rash normally vanish within several days, arthralgia and myalgia can persist over month. In 20 % arthralgia is protracted over 1 year [1, 2]. In those cases asymptomatic periods may be interrupted by acute relapses [1]. RRV was first isolated in Aedes mosquitos from the Ross River, Queensland in 1963 [3]. RRV is endemic in Australia with an average of 4,800 reported cases each year [4]. Reports in travellers are rare and only few cases are documented in the literature [5–9]. Urban transmission was reported in the past but most cases are transmitted in the rural northern and south-western parts of Australia [10, 11]. To the best of our knowledge this is the first case report of an RRV infection in a traveller who visited the urban south-east of Australia. We suggest that the presented case of RRV should be discussed as a relevant example since the infection might be missed in returning travellers to Germany due to mild and unspecific symptoms. Acknowledgments This work was supported by Bundesministerium fu¨r Bildung und Forschung (BMBF); Grant to Mathias W. Pletz (KI 011204). Informed Consent Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
123
After 4 weeks (13.05.2014)
Conflict of interest
None for all authors.
References 1. Stocks N, Selden S, Cameron S. Ross river virus infection. diagnosis and treatment by general practitioners in South Australia. Aust Fam Physician. 1997;26:710–7. 2. Flexman JP, Smith DW, Mackenzie JS, Fraser JR, Bass SP, Hueston L, Lindsay MD, Cunningham AL. A comparison of the diseases caused by Ross River virus and Barmah Forest virus. Med J Aust. 1998;169:159–63. 3. Doherty RL, Gorman BM, Whitehead RH, Carley JG. Studies of epidemic polyarthritis: the significance of three group A arboviruses isolated from mosquitoes in Queensland. Australas Ann Med. 1964;13:322–7. 4. Jacups SP, Whelan PI, Currie BJ. Ross river virus and barmah forest virus infections: a review of history, ecology, and predictive models, with implications for tropical northern Australia. Vector Borne Zoonotic Dis. 2008;8:283–97. 5. Wilder-Smith A, Tambyah PA, Hossain I. Ross river virus disease in a traveler to Australia. J Travel Med. 2009;16:420–3. 6. Nothdurft HD, Loscher T, Proll S, Dobler G, Pfeffer M, Jelinek T. Persistent arthralgias in ross-river-virus disease after travel to the South Pacific. Dtsch Med Wochenschr. 1999;124:759–62. 7. Tappe D, Schmidt-Chanasit J, Ries A, Ziegler U, Muller A, Stich A. Ross River virus infection in a traveller returning from northern Australia. Med Microbiol Immunol. 2009;198:271–3. 8. Moi ML, Takasaki T, Tochitani K, Shimizu T, Shinohara K, Tsuchido Y. The first case report of Ross River virus disease in a Japanese patient who returned from Australia. Kansenshogaku Zasshi. 2014;88:155–9. 9. Cramer JP, Kastenbauer U, Loscher T, Emmerich P, SchmidtChanasit J, Burchard GD, von Sonnenburg F. Polyarthritis in two travellers returning from Australia. J Clin Virol. 2011;52:1–3. 10. Harley D, Sleigh A, Ritchie S. Ross river virus transmission, infection, and disease: a cross-disciplinary review. Clin Microbiol Rev. 2001;14:909–32. 11. Rulli NE, Suhrbier A, Hueston L, Heise MT, Tupanceska D, Zaid A, Wilmes A, Gilmore K, Lidbury BA, Mahalingam S. Ross River virus: molecular and cellular aspects of disease pathogenesis. Pharmacol Ther. 2005;107:329–42.
