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Contents lists available at ScienceDirect

Journal of Clinical Virology journal homepage: www.elsevier.com/locate/jcv

Case report

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Zika virus infections imported to Italy: Clinical, immunological and virological findings, and public health implications Lorenzo Zammarchi a , Giulia Stella a , Antonia Mantella a , Dario Bartolozzi b , Dennis Tappe c , c,d ˜ Stephan Günther c , Lisa Oestereich c , Daniel Cadar c , César Munoz-Fontela , a,b,∗,1 c,e,1 Alessandro Bartoloni , Jonas Schmidt-Chanasit a

Clinica Malattie Infettive, Dipartimento di Medicina Sperimentale e Clinica, Università Degli Studi di Firenze, Largo Brambilla 3, 50134 Firenze, Italy SOD Malattie Infettive e Tropicali, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134 Firenze, Italy c Bernhard Nocht Institute for Tropical Medicine, WHO Collaborating Centre for Arbovirus and Haemorrhagic Fever Reference and Research, National Reference Centre for Tropical Infectious Diseases, Bernhard-Nocht-Strasse 74, 20359 Hamburg, Germany d Heinrich Pette Institute, Leibniz Institute for Experimental Virology, Martinistrasse 52, 20251 Hamburg, Germany e German Centre for Infection Research (DZIF), partner site Hamburg-Luebeck-Borstel, Hamburg, Germany

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Article history: Received 6 August 2014 Received in revised form 16 November 2014 Accepted 7 December 2014

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Keywords: Zika Dengue Immunity Italy Polynesia Travel

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1. Why this case is important?

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We report the first two cases of laboratory confirmed Zika virus (ZIKV) infections imported into Italy from French Polynesia. Both patients presented with low grade fever, malaise, conjunctivitis, myalgia, arthralgia, ankle oedema, and axillary and inguinal lymphadenopathy. One patient showed leukopenia with relative monocytosis and thrombocytopenia. The diagnosis was based on ZIKV seroconversion in both cases and on ZIKV RNA detection in one patient from acute serum sample. Sera from both patients exhibited cross-reactivity with dengue virus antigens. Our immunological analysis demonstrated that recovery from ZIKV infection is associated with restoration of normal numbers of immune cells in the periphery as well as with normal function of antigen-presenting cells. ZIKV is an emerging arbovirus, which has recently spread extensively in tourist destinations on several West Pacific islands. Returning viremic travelers may ignite autochthonous infections in countries like Italy, which are infested by Aedes albopictus, a suitable vector for ZIKV. The role of clinicians is crucial and includes early diagnosis and timely notification of public health authorities in order to quickly implement adequate focal vector control measurements. © 2014 Published by Elsevier B.V.

Zika virus (ZIKV) is an arbovirus belonging to the Flavivirus genus that was first isolated from a rhesus monkey in 1947 in Uganda [1]. Since its discovery, evidence of human infections has been reported from Egypt, several sub Saharan African countries, as well as Southern and South-Eastern Asian countries, and Oceania (Yap island in

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∗ Corresponding author at: Clinica Malattie Infettive, Dipartimento di Medicina Sperimentale e Clinica, Università Degli Studi di Firenze, Largo Brambilla 3, 50134 Firenze, Italy. Tel.: +39 55 7949431; fax: +39 55 7949431. E-mail addresses: lorenzo.zammarchi@unifi.it (L. Zammarchi), [email protected] (G. Stella), [email protected] (A. Mantella), [email protected] (D. Bartolozzi), [email protected] (D. Tappe), [email protected] (S. Günther), [email protected] (L. Oestereich), [email protected] (D. Cadar), [email protected] ˜ (C. Munoz-Fontela), alessandro.bartoloni@unifi.it (A. Bartoloni), [email protected] (J. Schmidt-Chanasit). 1 Both the authors contributed equally.

the Federated States of Micronesia) [2]. Beginning at the end of 2013, a large outbreak affected several islands of the West Pacific [3,4]. Imported cases have been described in several non-endemic countries including Japan, Germany, Canada, Australia and United States [5–9]. ZIKV is transmitted by different species of Aedes mosquitoes. Non-human primates and possibly rodents play a role as reservoir [10,11]. Direct interhuman transmission has been reported to occur perinatal [12] through blood transfusion [13], and sexually [9]. Occupational transmission in the laboratory setting has also been reported [14]. Returning travelers with ZIKV infection developed symptoms up to 6 days after leaving endemic areas [5–9], while symptoms in the patient with the presumed sexually transmitted infection began 10 days after the sexual intercourse with the index case [9]. Only about 18% of human infections results in clinical manifestations [15]. Most common clinical signs and symptoms are maculopapular rash, low grade fever, arthralgia, myalgia, headache and conjunctivitis, while oedema, sore throat, cough, vomiting, and

http://dx.doi.org/10.1016/j.jcv.2014.12.005 1386-6532/© 2014 Published by Elsevier B.V.

Please cite this article in press as: L. Zammarchi, et al., Zika virus infections imported to Italy: Clinical, immunological and virological findings, and public health implications, J Clin Virol (2014), http://dx.doi.org/10.1016/j.jcv.2014.12.005

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Table 1 Serological and virological data of two Italian travelers with acute Zika virus infection. Case 1 (female)

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Test used Anti-DENV-IgG Anti-DENV-IgM DENV–NS1 Ag Anti-ZIKV-IgG Anti-ZIKV-IgM ZIKV–RT-PCR

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Zika virus infections imported to Italy: clinical, immunological and virological findings, and public health implications.

We report the first two cases of laboratory confirmed Zika virus (ZIKV) infections imported into Italy from French Polynesia. Both patients presented ...
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