Martinique: Two cases of Zika-encephalopathy
April 22nd, 2016
Case 1
At the end of February 2016, two months after the detection of the first Zika virus-positive cases on Martinique, a previously healthy young adult was admitted to the University Hospital of Martinique, after having experienced an episode of convulsive seizures that occurred six hours after the onset of a dengue-like syndrome (fever, arthralgia, asthenia and headache). Upon initial clinical evaluation, the patient was febrile, with a low level of consciousness (Glasgow coma scale (GCS) 9) and no neurological focal signs. After direct intravenous injection of clonazepam (one milligram), the patient recovered to a normal level of consciousness (GCS 15). The patient was hospitalised for three days, then returned back home with symptomatic treatment of acetaminophen and codeine against headache and arthralgia. One week later, clinical assessment found no new neurological symptoms, but headache and arthralgia persisted for 45 days.
Brain magnetic resonance imaging (MRI) and video-electroencephalogram (EEG) performed on day 5 after onset of neurological symptoms, were normal.
Laboratory findings at onset of neurological symptoms showed normal blood count and a sterile CSF with no white blood cells (norm: < 10/ml), and 0.20 g/L protein (norm: 0.15–0.40). The glycorachia/glycaemia ratio was normal (norm: >0.5).
The patient was screened for the common aetiologies of viral encephalitis: test results for herpes simplex virus, varicella zoster virus and cytomegalovirus (CMV) by PCR were negative in CSF. Direct detection in CSF of enterovirus, dengue virus (DENV) and chikungunya virus by real-time RT-PCR were negative. Serological tests for HIV, CMV and venereal research disease laboratory (VDRL) were negative. Serology for toxoplasmosis was positive in IgG. Direct detection of Leptospira sp. in plasma by PCR was negative. Cryptococcus sp. antigenemia in serum was negative. Detection of Zika virus by real-time RT-PCR in plasma, cerebrospinal fluid and urine were positive.
Case 2
In the last week of February 2016, a patient in their late 70s was brought to the University Hospital of Martinique by their family who reported symptoms including acute mental confusion, speech disorder, and right facial palsy, which had started three hours before hospital admission. Upon initial clinical evaluation the patient was afebrile and aphasic; conjunctivitis, bilateral hands oedema, and peripheral arthritis were present. Facial palsy was not noticed upon clinical examination. Aphasia resolved spontaneously 45 minutes after the first clinical evaluation.
Upon initial clinical evaluation, brain MRI was only consistent with leukoaraiosis, and EEG revealed an unequivocal asymmetry with abnormal left fronto-temporal slow waves. These waves were consistent with the presence of a pathological process, but had no specific pattern. The EEG performed one week later showed almost complete regression of the slow waves.
The analysis of CSF showed a protein count of 0.40 g/L and a white blood cell count of 2/mL. The glycorachia/glycaemia ratio was normal. PCR for common aetiologies of encephalitis was negative. Detection of Zika virus by real-time RT-PCR in plasma, CSF and urine gave a positive result.”