Imported Chikungunya infection, Italy.

To the Editor: Chikungunya virus (CHIKV) infection is a self-limiting illness characterized by fever, headache, weakness, rash, and arthralgia. Some patients have prolonged weakness or arthralgia lasting several months. In 2006, several Indian Ocean states and India had an outbreak of CHIKV infection (1,2). During the epidemic's peak, some European and American travelers returning from these areas were infected (3-6).

Because the foci of Aedes albopictus, 1 of the 2 main vectors of CHIKV, are now in Italy and many travelers visit CHIKV-epidemic areas, surveillance for imported cases is mandatory in Italy (7). From July to September 2006, a total of 17 confirmed cases of CHIKV infection were observed in travelers at 5 Gruppo di Interesse e Studio delle Patologie di Importazione (GISPI) centers (Italian network of Institutes of Infectious and Tropical Diseases). Serologic diagnosis was performed with a hemagglutination-inhibition test and confirmed by a plaque-reduction neutralization test (8). Demographic and epidemiologic characteristics of these patients are reported in the Table.

Cases were distributed throughout the year with a peak from March to May 2006 (n = 10). Nine patients (53%) were men. Median age was 43 years (range 31-66 years). Several reasons for travel were reported: tourism (64.6%), visits to relatives or friends (11.8%), business (11.8%), and missionary work (5.9%). One patient was a resident in the disease-epidemic area. The median exposure time in the CHIKV-endemic area for the 15 travelers was 15 days (range 9-93 days) (missionary and resident patients were excluded). The median delay before being seen at a clinic after return was 2 days (range 0-73 days). Only 7 patients (41.2%) were hospitalized. The remainder were outpatients.

All patients had fever; arthralgia (88.2%, n = 15), weakness (70.6%, n = 12), headache (11.8%, n = 2), diarrhea (11.8%, n = 2), and gum bleeding and epistaxis (5.9%, n = 1) were other reported symptoms. The median duration of fever was 5 days (range 2-12 days). Only 7 of 16 patients (43.8%) were still febrile when first seen. Physical examination showed diffuse macular erythematous rash in 13 patients (76.5%), a similar rate to that reported among French travelers (4). Hepatomegaly was found in 2 patients (11.8%), splenomegaly in 2 (11.8%), and peripheral lymphadenopathy in 2 (11.8%).

Twelve acute-phase patients were admitted to the hospital for blood testing within 3 days of the initial examination. In contrast with results of other studies, leukopenia and thrombocytopenia were uncommon in our study. Leukopenia (leukocyte count [greater than or equal to]4,000/[micro]L) was present in 4 patients (33.3%) and thrombocytopenia (platelet count [greater than or equal to]150,000/[micro]L) in 1 patient (8.3%). This finding may help distinguish CHIKV infection from dengue fever (4). Anemia (hemoglobin level [greater than or equal to]12 g/dL) was found in only 1 patient (8.3%). Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) determination were available for 12 patients. ALT and AST levels were elevated (>40 IU/L) in 5 (41.7%) and 2 (16.7%) patients, respectively. Seven (46.7%) of 15 patients fully recovered within 1 month; 8 patients (53.3%) reported persistent arthralgia.

Because the GISPI network provides regional coverage only, the number of imported CHIKV cases in all of Italy in 2006 was likely higher. Moreover, most patients probably did not seek medical care, and when they did, physicians may have failed to recognize the disease because of lack of familiarity with it or limited diagnostic facilities. Differential diagnosis with other arthropodborne viruses of the Alphavirus genus (Ross River, Barmah Forest, o'nyong nyong, Sindbis, and Mayaro viruses) is difficult, but these are comparatively rare. In contrast, dengue and CHIKV epidemics may overlap, and potential patients should be screened for both.

The potential risk for introduction and establishment of CHIKV reservoirs in areas with mosquito vectors was discussed in March 2006 by a multidisciplinary European expert panel (9). In Italy, A. albopictus was first recorded in 1990; it has since quickly spread across the country. Scattered foci are now reported in almost all regions, mainly along the coastal plains, from the sea to the inlands, up to an altitude of [approximately equal to]500-600 m (7).

The ability of A. albopictus to colonize new areas and its adaptability to the mild Italian climate allow vector populations to be active throughout the year (10). The patient is thought to be viremic for only 6-7 days (shortly before and during the febrile period) (6). We were unable to directly assess viremia levels; however, almost half the patients were still febrile on return to Italy, which suggests a potential risk.

Although the same mosquito is a potential vector of dengue, no autochthonous case has been reported as yet, despite annual reports of many imported dengue cases in Italy. On the other hand, the clinical manifestations of both conditions are nonspecific, and a hypothetical autochthonous case would most likely go undiagnosed unless a targeted surveillance system were established. Prompt reporting of imported CHIKV infections is essential for monitoring of potential risk. The possibility of introducing CHIKV into Italy cannot be ruled out on the basis of current evidence.

Acknowledgments

We thank Alberto Matteelli for important suggestions on the manuscript and for help in its preparation.

References

(1.) Bodenmann P, Genton B. Chikungunya: an epidemic in real time. Lancet. 2006;368:258.

(2.) Mudur G. Failure to control mosquitoes has led to two fever epidemics in India. BMJ. 2006;333:773.

(3.) Pfeffer M, Loescher T. Cases of chikungunya imported into Europe. Eurosurveillance [serial on the Internet]. 2006 Mar 16. [cited 2006 Mar 16]. Available from http://www.euro surveillance.org/ew/2006/060316.asp#2

(4.) Hochedez P, Jaureguiberry S, Debruyne M, Bossi P, Hausfater P, Brucker G, et al. Chikungunya infection in travelers. Emerg Infect Dis. 2006;12:1565-6.

(5.) Centers for Disease Control and Prevention. Chikungunya fever diagnosed among international travelers United States, 2005-2006. MMWR Morb Mortal Wkly Rep. 2006;55:1040-2.

(6.) Parola R de Lamballerie X, Jourdan J, Rovery C, Vaillant V, Minodier P, et al. Novel chikungunya virus variant in travelers returning from Indian Ocean islands. Emerg lnfect Dis. 2006;12:1493-9.

(7.) Romi R. Aedes albopictus in Italy: an underestimated health problem. Ann 1st Super Sanita. 2001;37:241-7.

(8.) Nicoletti L, Ciufolini MG, Verani R Sandfly fever viruses in Italy. Arch Virol Suppl. 1996;11:41-7.

(9.) Depoortere E, Coulombier D. ECDC Chikungunya risk assessment group. Chikungunya risk assessment for Europe: reconunendations for action. Eurosurveillance [serial on the Internet]. 2006 May 11. [cited 2006 May 11]. Available from http://www.eurosurveillance.org/ew/ 2006/060511.asp#2

(10.) Romi R, Severini F, Toma L. Cold acclimation and overwintering of female Aedes albopictus in Roma. J Am Mosq Control Assoc. 2006;22:149-51.

Address for correspondence: Anna Beltrame, Clinic of Infectious Diseases, Via Colugna no. 50-33100, Udine, Italy; email: anna.beltrame@ med.uniud.it

Anna Beltrame, * Andrea Angheben, ([dagger]) Zeno Bisoffi, ([dagger]) Geraldo Monteiro, ([dagger]) Stefania Marocco, ([dagger]) Guido Calleri, ([double dagger)] Filippo Lipani, ([double dagger]) Federico Gobbi, ([double dagger]) Francesca Canta, ([double dagger]) Francesco Castelli, ([section]) Maurizio Gulletta, ([section]) Sara Bigoni, ([section]) Veronica Del Punta, ([section]) Tiziana Iacovazzi, ([paragraph]) Roberto Romi, (#) Loredana Nicoletti, (#) Mara Grazia Ciufolini, (#) Giada Rotato, * Camilla Negri, * Pierluigi Viale, *

*Clinic of Infectious Diseases at University of Udine, Udine, Italy; ([dagger]) Sacro Cuore Hospital, Negrar, Italy; ([double dagger]) :Amedeo di Savoia Hospital, Torino, Italy; [section] University of Brescia, Brescia, Italy; [paragraph]F. Fallacara Hospital, Triggiano, Italy; and (#) Istituto Superiore di Sanita Roma, Italy.

Table. Demoqraphic and epidemioloqic data on 17 travelers
with chikunaunya infection diagnosed in 2006. Italy

Patient            Sex           Age, y      Reason for    Country of
no.                                            travel        origin

1                   M              32         Business      Reunion
2 [dagger]          F              39          Tourism     Mauritius
3 [double           M              46          Tourism     Mauritius
  dagger]
4 [double           M              32          Tourism     Madagascar
  dagger]
5 [section]         M              49          Tourism     Mauritius
6 [double           M              66          Tourism     Madagascar
  dagger]
7 [section]         M              36          Tourism     Mauritius
8 *                 F              43         Resident     Madagascar
9 [double           F              46          Tourism      Reunion
  dagger]
10 [para-           F              44        Visit rela-   Mauritius
   graph]                                       tives
11 [double          F              36          Tourism     Mauritius
  dagger]
12 [double          M              31          Tourism      Reunion
  dagger]
13 [double          M              44        Visit rela-    Cameroon
  dagger]                                       tives
14 *                M              35          Tourism     Seychelles
15 *                M              38          Tourism     Mauritius
16 [double          F              58        Missionary     Central
  dagger]                                       work        African
                                                            Republic
17 *                F              57         Business       India

Patient         Date of         Date of      Last date     Fever on
no.              return       first medi-     of fever      date of
               (length of     cal assess-    (length of     return?
                 stay,d)       ment after     fever, d)
                              return (de-
                                lay, d)

1              Feb 23 (93)     Feb 25 (2)    Feb 26 (4)       Yes
2 [dagger]     Feb 28 (10)     Feb 28 (0)    Feb 28 (4)       Yes
3 [double      Mar 7 (10)      Mar 7 (0)      Mar 6 (5)        No
  dagger]
4 [double      Mar 7 (15)      Mar 8 (1)      Mar 4 (4)        No
  dagger]
5 [section]    Mar 08 (16)     Mar 15 (7)     Mar 4 (5)        No
6 [double      Mar 24 (15)     Mar 24 (0)    Mar 27 (5)       Yes
  dagger]
7 [section]    Apr 4 (15)      Apr 5 (1)      Apr 1 (6)        No
8 *            Apr 10 (-)      Apr 11 (1)     Mar 2 (6)        No
9 [double      Jan 30 (16)    Apr 13 (73)      NA (2)          -
  dagger]
10 [para-      Apr 17 (33)     Apr 19 (2)    Apr 7 (12)        No
  graph]
11 [double     Apr 30 (11)     May 3 (3)      May 3 (3)       Yes
  dagger]
12 [double     Apr 21 (30)     May 4 (13)     Apr 5 (6)        No
  dagger]
13 [double     May 3 (24)     May 22 (19)     May 7 (6)       Yes
  dagger]
14 *           May 31 (9)      Jun 1 (1)      Jun 1 (2)       Yes
15 *           May 10 (11)     Jun 12 (2)     May 7 (4)        No
16 [double    Jun 24 (14 y)   Jul 10 (16)    Apr 26 (12)       No
  dagger]

17 *           Sep 8 (31)      Sep 9 (1)     Sep 10 (4)       Yes

* GISPI (Gruppo di Interesse e Studio delle Patologie di
Importazione) centers: Torino.

[dagger] GISPI center: Udine.

[double dagger] GISPI center: Negrar. NA, not available.

[section] GISPI center: Brescia.

[paragraph] (GISPI center: Triggiano.