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Venezuelan equine encephalitis and upper gastrointestinal bleeding in child.

Venezuelan equine encephalitis Venezuelan equine encephalitis An alphavirus infection first identified in a sick horse in Venezuela in 1938, which occurs as an epizootic infection in central and northern South America; most exposed humans develop flu-like Sx; ±4%, especially adolescents,  (VEE) is reemerging in Peru. VEE virus subtype ID in Peru has not been previously associated with severe disease manifestations. In 2006, VEE virus subtype ID was isolated from a boy with severe febrile disease and gastrointestinal bleeding; the strain contained 2 mutations within the PE2 region.

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Venezuelan equine encephalitis (VEE) is a reemerging disease in the Amazon region of Peru; subtype ID is the subtype most commonly isolated from humans (1-3). Although the typical clinical presentations of VEE are neurologic and febrile syndromes, in the Amazon region, the common presentation is a febrile syndrome with mild or no neurologic involvement (1-4). Human infections with VEE virus subtype IAB (1) See Internet Architecture Board.

(2) (Interactive Advertising Bureau, New York, www.iab.net) An industry association founded in 1996 to set standards and guidelines for interactive advertising and marketing.
 and IC produce more neurologic involvement and result in mortality rates as high as 0.5% during epidemics; however, epidemics with these viruses have not been reported in South America for more than a decade (5-7). During past epidemics, most neurologic disease and fatal cases were in children and elderly persons (8,9).

In 2006, an outbreak of febrile disease occurred in Jeberos, a rural Amazonian community in Loreto Peru, located 14 hours, by river, from Yurimaguas, Peru (Figure 1). Although VEE cases had been reported previously in Yurimaguas (T. Kochel, P.V. Aguilar, unpub. data), they had not been reported in Jeberos. We describe here the clinical manifestation of VEE subtype ID in a boy from Jeberos. The boy had severe disease; upper gastrointestinal bleeding Upper gastrointestinal (GI) bleeding refers to hemorrhage in the upper gastrointestinal tract. The anatomic cut-off for upper GI bleeding is the ligament of Treitz, which connects the fourth portion of the duodenum to the diaphragm near the splenic flexure of the colon. ; and neurologic, renal, and liver complications. He responded to supportive therapy.

The Case

On January 9, 2006, a 3-year-old boy from Jeberos was admitted to the Hospital Santa Gema in Yurimaguas. Three days before hospitalization, he had fever, chills, and malaise. Two days before hospitalization, the symptoms persisted and the boy was brought by his parents to the Health Center of Jeberos, where he received antipyretic antipyretic /an·ti·py·ret·ic/ (-pi-ret´ik)
1. relieving or reducing fever.

2. an agent that so acts.


an·ti·py·ret·ic
n.
An agent that reduces or prevents fever.
 medication (acetaminophen and the nonsteroidal anti-inflammatory drug nonsteroidal anti-inflammatory drug, a drug that suppresses inflammation in a manner similar to steroids, but without the side effects of steroids; commonly referred to by the acronym NSAID (ĕn`sĕd).  metamizole) for fever (40[degrees]C). One day before hospitalization, the boy became sleepy and irritable and had 2 episodes of vomiting followed by melena melena /me·le·na/ (me-le´nah) the passage of dark stools stained with altered blood.

me·le·na
n.
. The boy was then transferred by airplane to the Hospital Santa Gema in Yurimaguas. On the day of hospitalization, the boy was in poor general condition and had coffee-ground emesis emesis /em·e·sis/ (em´e-sis) vomiting.

em·e·sis
n. pl. em·e·ses
The act or process of vomiting.


Emesis
The medical term for vomiting.
 (with blood clots) and melena. His temperature was 37[degrees]C, blood pressure was 90/60 mm Hg, respiratory

rate was 45 breaths/min, and heart rate was 132 beats/min. He became somnolent som·no·lent
adj.
1. Drowsy; sleepy.

2. Inducing or tending to induce sleep; soporific.

3. In a condition of incomplete sleep; semicomatose.
, and marked paleness and scarce petechiae Petechiae
Tiny purple or red spots on the skin associated with endocarditis, resulting from hemorrhages under the skin's surface.

Mentioned in: Endocarditis, Hantavirus Infections, Hemorrhagic Fevers, Idiopathic Thrombocytopenic Purpura

 on both legs and severe dehydration were noted. No signs of jaundice, lymphadenopathy lymphadenopathy /lym·phad·e·nop·a·thy/ (-op´ah-the) disease of the lymph nodes.

angioimmunoblastic lymphadenopathy , angioimmunoblastic lymphadenopathy with dysproteinemia
, or conjunctival con·junc·ti·val
adj.
Relating to the conjunctiva.



conjunctival

pertaining to or emanating from conjunctiva.


congenital conjunctival membrane
 bleeding were observed. No other signs were found in the thorax or cardiovascular system. Focal or meningeal signs and joint inflammation were absent.

[FIGURE 1 OMITTED]

Laboratory test results were as follows: leukocytes 12,200/[mm.sup.3] (22% segmented cells, 0% bands, 75% lymphocytes, and 2% monocytes monocytes,
n.pl the largest of the white blood cells. They have one nucleus and a large amount of grayish-blue cytoplasm. Develop into macrophages and both consume foreign material and alert T cells to its presence.
); platelets 122,000/[mm.sup.3], hemoglobin 56 g/L, and hematocrit Hematocrit Definition

The hematocrit measures how much space in the blood is occupied by red blood cells. It is useful when evaluating a person for anemia.
Purpose

Blood is made up of red and white blood cells, and plasma.
 17%. Liver function was altered: alanine aminotransferase (ALT) 132 U/L, aspartate aminotransferase (AST (AST Computer, Irvine, CA) A PC manufacturer founded in 1980 by Albert Wong, Safi Quershey and Tom Yuen (A, S and T). It offered a complete line of PCs that sold through its dealer channel. ) 140 U/L, serum albumin 2.1 g/dL, and total bilirubin Bilirubin

The predominant orange pigment of bile. It is the major metabolic breakdown product of heme, the prosthetic group of hemoglobin in red blood cells, and other chromoproteins such as myoglobin, cytochrome, and catalase.
 2.4 mg/dL (direct bilirubin 1.4 mg/dL). Serum creatinine was 2.2 mg/dL and, because of the boy's age, was considered acute renal failure acute renal failure Acute kidney failure Nephrology An abrupt decline in renal function, triggered by various processes–eg, sepsis, shock, trauma, kidney stones, drug toxicity-aspirin, lithium, substances of abuse, toxins, iodinated radiocontrast. . Preliminary diagnoses were febrile and hemorrhagic Hemorrhagic
A condition resulting in massive, difficult-to-control bleeding.

Mentioned in: Hantavirus Infections


hemorrhagic

pertaining to or characterized by hemorrhage.
 syndrome with severe dehydration and anemia. On the day of admission, January 9, a blood sample was sent to the Naval Medical Research Center Detachment in Lima, Peru, and the National Institute of Health-Ministry of Health of Peru, for advanced analysis.

The boy was given supportive therapy, antimicrobial drugs, and blood replacement (200 mL). On January 10, his leukocyte count had dropped to 4,200/[mm.sup.3] (26% segmented, 14% bands, 56% lymphocytes, and 2% monocytes).

After the transfusion, his hematocrit was 25%; his platelet count was 108,000/[mm.sup.3] in the morning and decreased to 60,000/[mm.sup.3] by night (Table). Test results for malaria (blood smear), agglutinins for typhoid fever, and surface antigen of hepatitis B virus were negative. The boy was hydrated and afebrile afebrile /afe·brile/ (a-feb´ril) without fever.

a·feb·rile
adj.
Apyretic.



afebrile

without fever.

afebrile adjective Feverless
, but the melena and coffee-ground vomiting (with blood clots) persisted. On January 11, his hematocrit was 20% and platelet count was 91,000/[mm.sup.3]; he was still lethargic and the gastrointestinal bleeding persisted. On January 12, he received a transfusion of 150 mL whole blood; however, he still showed neurologic involvement (e.g., drowsiness, lethargy, confusion) and neck stiffness. On January 16, the boy's condition improved and the gastrointestinal bleeding stopped. Liver and renal functions returned to within normal limits: serum creatinine 1.6 mg/dL, ALT 40 U/L, AST 18 U/L, urine volume 535 mL/24 h, and urine protein 36 mg/24 h. The boy's mental status improved progressively, and he was discharged on January 20.

VEE virus was isolated from serum culture in Vero cells. No other viruses were isolated in Vero or C6/36 cells. A convalescent-phase sample obtained [approximately equal to] 2 weeks after symptom onset had a >4-fold higher titer than the acute-phase sample, according to a previously described immunoglobulin (Ig) M ELISA ELISA (e-li´sah) Enzyme-Linked Immuno-Sorbent Assay; any enzyme immunoassay using an enzyme-labeled immunoreactant and an immunosorbent.

ELISA
n.
 specific for VEE (2). The sample was IgM negative for other local arthropod-borne viruses such as dengue dengue
 or breakbone fever or dandy fever

Infectious, disabling mosquito-borne fever. Other symptoms include extreme joint pain and stiffness, intense pain behind the eyes, a return of fever after brief pause, and a characteristic rash.
, yellow fever, Mayaro, Oropouche, and members of the group C complex. Genetic analyses using previously described methods further identified the VEE strain as subtype ID, genotype Panama-Peru (1,4) (Figure 2). The strain was genetically similar to other strains isolated previously in Peru; however, 2 amino acid changes were observed within the envelope glycoprotein precursor (PE2) region (H [right arrow] Q, V [right arrow] I). The National Institute of Health-Ministry of Health reported negative results for leptospirosis leptospirosis (lĕp'təspīrō`sĭs), febrile disease caused by bacteria of the genus Leptospirae. The disease occurs in dogs, cattle, pigs, sheep, goats, and horses and is transmissible to humans.  and rickettsial diseases, according to IgM ELISA and indirect immunofluorescent assay, respectively.

In February 2006, another case of VEE in a child was reported. A 10-year-old boy with similar clinical signs, including headache, vomiting, melena, and altered mental status (somnolence somnolence /som·no·lence/ (som´no-lens) drowsiness or sleepiness, particularly in excess.

som·no·lence
n.
1. A state of drowsiness; sleepiness.

2.
 and confusion) was admitted to the hospital in Yurimaguas. The boy, a resident of Esperanza village, Lagunas district, had visited the Aypena River near Jeberos. The acute-phase serum sample was positive for VEE virus by PCR PCR polymerase chain reaction.

PCR
abbr.
polymerase chain reaction


Polymerase chain reaction (PCR) 
; however, no virus was isolated in cell culture. A convalescent-phase sample, taken a week after onset of signs, was negative by VEE IgM ELISA; no additional convalescent-phase sample was obtained from the patient. No epizootics were reported.

Conclusions

VEE virus subtype ID was isolated from a child with neurologic and severe hemorrhagic manifestations in the northern Peruvian jungle. During this episode, local health workers in Jeberos reported that they had evaluated at least 5 cases with some hemorrhagic manifestations; however, no samples were obtained from those cases, and thus there is no definitive proof that the patients were infected with VEE virus.

[FIGURE 2 OMITTED]

The VEE strain isolated from the boy with confirmed VEE contained 2 mutations within the PE2 region, which differed from other subtype ID strains from Peru. Nevertheless, the contribution of these or any other possible mutations in the viral genome to the hemorrhagic manifestation observed in the patient remains unknown. Many questions remain about the effect of VEE virus in the Jeberos community.

Acknowledgments

We thank Carolina Guevara, Roxana Caceda, Vidal Felices, and Cristhopher Cruz for invaluable support in the execution of the study. We also thank Brett Forshey, Joan Neyra, and Ernesto Ortiz for critically reading the manuscript.

This study was funded by the US Department of Defense Global Emerging Infections Systems Research Program, Work Unit No. 847705.82000.25GB.B0016.The study protocol "Surveillance and Etiology of Acute Febrile Illnesses in Peru" was approved by the Naval Medical Research Center Detachment Institutional Review Board (Protocol NMRCD NMRCD Naval Medical Research Center Detachment .2000.0006) in compliance with all applicable federal regulations governing the protection of human subjects.

References

(1.) Aguilar PV, Greene IP, Coffey LL, Medina G, Moncayo AC, Anishchenko M, et al. Endemic Venezuelan equine encephalitis in northern Peru. Emerg Infect Dis. 2004;10:880-8.

(2.) Watts DM, Callahan J, Rossi C, Oberste MS, Roehrig JT, Wooster MT, et al. Venezuelan equine encephalitis febrile cases among humans in the Peruvian Amazon River region. Am J Trop Med Hyg. 1998;58:35-40.

(3.) Watts DM, Lavera V, Callahan J, Rossi C, Oberste MS, Roehrig JT, et al. Venezuelan equine encephalitis and Oropouche virus infections among Peruvian army troops in the Amazon region of Peru. Am J Trop Med Hyg. 1997;56:661-7.

(4.) Oberste MS, Weaver SC, Watts DM, Smith JF. Identification and genetic analysis of Panama-genotype Venezuelan equine encephalitis virus Venezuelan equine encephalitis virus is a mosquito-borne viral pathogen that causes Venezuelan equine encephalitis or encephalomyelitis (VEE). VEE can affect all equine species, such as horses, asses, and zebras.  subtype ID in Peru. Am J Trop Med Hyg. 1998;58:41-6.

(5.) Rivas F, Diaz LA, Cardenas VM, Daza E, Bruzon L, Alcala A, et al. Epidemic Venezuelan equine encephalitis in La Guajira, Colombia, 1995. J Infect Dis. 1997;175:828-32. DOI: 10.1086/513978

(6.) Weaver SC, Salas R, Rico-Hesse R, Ludwig GV, Oberste MS, Boshell J, et al. Re-emergence of epidemic Venezuelan equine encephalomyelitis Venezuelan equine encephalomyelitis

an encephalomyelitis with clinical signs similar to those of western and eastern encephalomyelitis; abbreviated VEE. See also equine viral encephalomyelitis.
 in South America. VEE Study Group. Lancet. 1996;348:436-40. DOI: 10.1016/S0140-6736(96)02275-1

(7.) Bowen GS, Fashinell TR, Dean PB, Gregg MB. Clinical aspects of human Venezuelan equine encephalitis in Texas. Bull Pan Am Health Organ. 1976;10:46-57.

(8.) Johnson KM, Martin DH. Venezuelan equine encephalitis. Adv Vet Sci Comp Med. 1974;18:79-116.

(9.) Rossi AL. Rural epidemic encephalitis in Venezuela caused by a group A arbovirus arbovirus

Any of a large group of viruses that develop in arthropods (chiefly mosquitoes and ticks). The name derives from “arthropod-borne virus.” The spheroidal virus particle is encased in a fatty membrane and contains RNA; it causes no apparent harm to the
 (VEE). Prog Med Virol. 1967;9:176-203.

Author affiliations: Naval Medical Research Center Detachment, Lima, Peru (S. Vilcarromero, V.A. Laguna-Torres, P.V. Aguilar, T.J. Kochel); Hospital of Yurimaguas, Loreto, Peru (C. Fernandez); Cayetano Heredia University, Lima (S. Vilcarromero, E. Gotuzzo); General Directorate of Epidemiology, Lima (L. Suarez); and National Institute of Health-Ministry of Health, Lima (M. Cespedes)

DOI: 10.3201/eid 1502.081018

Address for correspondence: Patricia V. Aguilar, US Naval Medical Research Center Detachment, 3230 Lima P1, Washington, DC 20521-3230, USA; email: patricia.aguilar@med.navy.mil

Dr Vilcarromero is a physician who responds to outbreaks and individual cases in Yurimaguas, Peru, and provides healthcare in the Hospital Santa Gema. He participates in the "Surveillance and Etiology of Acute Febrile Illnesses in Peru" project, carried out by the Naval Medical Research Center Detachment, Ministry of Health, and the Cayetano Heredia and San Marcos universities in Peru This is a list of officially recognized public and private universities in Peru, sorted by region. City of Lima
  • Universidad Nacional Mayor de San Marcos, http://www.unmsm.edu.pe/
  • Universidad Nacional Agraria La Molina, http://www.lamolina.edu.
.
Table. Blood cell counts and hemoglobin values in a 3-year-old boy
with Venezuelan equine encephalitis, Jeberos, Peru, January 2006 *

                                                       Leukocytes, %

Date/time                                 Leukoc         Neutrophils
of sample    Platelets/   Hematocrit,     ytes/
collection   [mm.sup.3]        %        [mm.sup.3]   Bands   Segmented

Jan 9         122,000         17          12,900       0        22

Jan 10
  4 h         108,000         25          4,200       14        26
  10 h        120,000         23            NM        NM        NM
  16 h         87,000         22            NM        NM        NM
  22 h         60,000         21            NM        NM        NM

Jan 11         91,000         20            NM        NM        NM

Jan 16        230.000         35          8.900        2        70

Date/time                Leukocytes, %
of sample                                            Hemoglobin,
collection   Eosinophils   Monocytes   Lymphocytes       g/L

Jan 9             2            2           76            56

Jan 10
  4 h             2            2           56
  10 h           NM           NM           NM            NM
  16 h           NM           NM           NM            NM
  22 h           NM           NM           NM            NM

Jan 11           NM           NM           NM            NM

Jan 16           NM           NM           28            NM

* NM, not measured.
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Title Annotation:DISPATCHES
Author:Vilcarromero, Stalin; Laguna-Torres, V. Alberto; Fernandez, Connie; Gotuzzo, Eduardo; Suarez, Luis;
Publication:Emerging Infectious Diseases
Date:Feb 1, 2009
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