Indigenous dengue fever, Buenos Aires, Argentina.

To the Editor: For 2 decades dengue has increased in the Americas, with epidemic peaks every 3 to 5 years (1). The disease has reemerged in 3 South American countries bordering Argentina, namely, Bolivia, Brazil, and Paraguay.

Argentina had remained free from dengue for >80 years before the disease was reintroduced in 1998 (2) as a consequence of insufficient mosquito control and importation of cases from disease-epidemic areas. Since then, indigenous dengue circulation has only been reported in the northern provinces of the country, which are close to endemoepidemic countries. However, the principal dengue vector, the Aedes aegypti mosquito,, has spread southward to latitude 35[degrees]S near Buenos Aires (3).

We describe what might be the southernmost indigenous case of dengue fever documented in South America; this case occurred in 2007, an epidemic peak year for the disease on this continent (1). The patient was a pneumonologist who worked part-time at Muniz Hospital, a referral infectious diseases treatment center in the Buenos Aires Federal District. She also provided healthcare at an outpatient clinic in Lanus, her town of residence, a suburb 6 km south of the Federal District. Febrile illness started suddenly in February 2007, midsummer season in Argentina. On day 5 of illness, fever was replaced by a short-lived rash and itching followed by asthenia and nausea that persisted for 2 days. The patient had not traveled or been accidentally exposed to patients' blood during the previous weeks. She had never been vaccinated against yellow fever. Dengue fever was only suspected retrospectively.

Serologic results provided supportive evidence of a recent dengue infection i.e., presence of immunoglobulin M, as determined by antibody-capture enzyme immunoassay, and immunoglobulin G seroconversion by 90% plaque reduction neutralization test on Vero cells (4). As shown in the Table, dengue virus serotype 3 was identified, and antibody results were negative for 3 other flaviviruses. Thus, this case fulfils Pan American Health Organization criteria for the diagnosis of dengue fever (5). Household contacts were seronegative.

For several years, conditions have been set for dengue virus circulation in Buenos Aires' urban and suburban areas because of the abundance of mosquitoes and disease in persons recently returning from neighboring countries. Risk for vector transmission is highest in the peripheral quarters of the city and towards late summer (6). Besides, Buenos Aires, like other Latin American metropolitan areas, is undergoing demographic changes that convey further risk for mosquito-borne disease transmission, namely, accelerated population growth mainly caused by informal settlements, deficient public health infrastructure and basic services, unregulated immigration from neighboring countries, and increased international mobility especially in or from neighboring countries (1).

Only imported dengue cases have been previously documented in Buenos Aires (2). According to official information, all 158 cases confirmed by antibody conversion in Buenos Aires Federal District and Province during 2007 were also imported (7). Of these, 50 occurred in the southern suburban district where our patient lives and works. In the summer of 2007, dengue infection was mainly introduced into the area by Paraguayan natives living in Buenos Aires who had recently visited their homeland. Dengue 3 serotype conversion was demonstrated in most of the cases investigated by plaque reduction neutralization assay, except for a few cases imported from Brazil, in which dengue 1 serotype was detected.

Most of the patients whose cases were diagnosed in Buenos Aires, including 5 who required hospitalization, were referred to Muniz Hospital. Built a century ago, Muniz Hospital comprises a number of independent pavilions surrounded by a spacious garden, where mosquitoes thrive, especially in summer. Thus, vector-borne infection in this case might have occurred either in Muniz Hospital, in the Federal District, or in the southern city suburb, where the patient lives and works.

Until recently, dengue had not been suspected in patients with a fever living in the Buenos Aires area in the absence of a recent history of travel to an endemoepidemic area. Confirmation of our case was evidence of local circulation of dengue virus. Thereafter, serum testing became recommended in Buenos Aires for acute febrile illness, among other dengue surveillance interventions in the area. More recently, epidemiologic surveillance of febrile illness has been strengthened countrywide upon the recent reporting of yellow fever cases in Argentina (8).

No circulation of dengue virus was reported in Buenos Aires during the first 10 epidemiologic weeks of 2008. However, vector control measures should be strengthened to minimize the risk of infective persons triggering an epidemic of dengue or other flavivirus disease.

Marcela Natiello, Viviana Ritacco, Maria Alejandra Morales, Bettina Deodato, Marisa Picollo, Edith Dinerstein, and Delia Enria

Author affiliations: Hospital "F. J. Muniz," Buenos Aires, Argentina (M. Natiello, B. Deodato, M. Picollo); Consejo Nacional de Investigaciones Cientificas y Tecnicas CONICET, Buenos Aires (V. Ritacco); Hospital Interzonal de Agudos "Evita," Lanes, Argentina (E. Dinerstein); and Instituto Nacional de Enfermedades Virales Humanas "Dr. Julio I. Maiztegui,", Pergamino, Argentina (M.A. Morales, D. Enria)

DOI: 10.3201/eid1409.080143

References

(1.) Pan American Health Organization. Dengue in the Americas: 2007 summary. EID updates: emerging and reemerging infectious diseases, region of the Americas. 2007 [cited 2008 Mar 13]. Available from http://www.paho.org/english/ad/dpc/cd/ eid-eer-2007-09-26.htm#sit

(2.) Seijo A, Cernigoi B, Deodato B. Dengue imported from Paraguay to Buenos Aires. Clinical and epidemiological report of 38 cases [in Spanish]. Medieina (B Aires). 2001;61:13741.

(3.) Avilds G, Paz MV, Rangeon G, Ranaivoarisoa MY, Verzeri N, Roginski S, et al. Laboratory surveillance of dengue in Argentina, 1995-2001. Emerg Infect Dis. 2003;9:73842.

(4.) Enria D, Morales MA, Fabbri C. Dengue. In: Cecchini E, Gonzfilez Ayala E, editors. Infectologla y Enfennedades Infecciosas. Buenos Aires: Ediciones Journal; 2007. p. 638-42.

(5.) Pan American Health Organization. Dengue and dengue hemorrhagic fever in the Americas: guidelines for prevention and control. PAHO scientific publication no. 548. Washington: The Organization; 1994. p. 1-21.

(6.) Carbajo AE, Gomez SM, Curto SI, Schweigmann NJ. Spatio-temporal variability in the transmission of dengue in Buenos Aires City [in Spanish]. Medicina (B Aires). 2004;64:2314.

(7.) Presidencia de la Nacion Argentina. Ministerio de Salud. Situacion Dengue en Argentina y el Mercosur (1-Junio-07) [cited 2008 Mar 13]. Available from http://www. msal.gov.ar/htm/Site/portada.htm

(8.) Desmecht D, Bergh RV, Sartelet A, Leclerc M, Mignot C, Misse F, et al. Evidence for transplacental transmission of the current wild-type strain of bluetongue virus serotype 8 in cattle. Vet Rec. 2008;163:50-2.

Address for correspondence: Viviana Ritaeco, Instituto Nacional de Enfermedades Infecciosas ANLIS "Carlos G. Malbrfin," Vdlez Sarsfield 563, (1281) Ciudad de Buenos Aires, Argentina; email: [e-mail]

Table. Serologic findings of an autochthonous case of dengue fever,
Buenos Aires, February 2007

                                          Plaque reduction
                                      neutralization test (90%)

                                  Saint Louis                 Yellow
Date                     MAC-     encephalitis   West Nile    fever
(days after onset)     ELISA *       virus         virus      virus

2007 Jul 7 (16)           +           <20           <20        <20
2007 Apr 13 (53)          ND          <20           <20        <20

                       Plaque reduction neutralization test (90%)

Date                   Dengue 1     Dengue 2     Dengue 3    Dengue 4
(days after onset)      virus        virus         virus      virus

2007 Jul 7 (16)           80          <20            80        <20
2007 Apr 13 (53)          40          <20           640        <20

* Immunoglobulin M antibody-capture enzyme immunoassay with suckling
mouse dengue virus antigen mixture of dengue 1, dengue 2, dengue 3, and
dengue 4 serotypes. ND, not determined.