title: Viremia and Clinical Presentation in Nicaraguan Patients Infected With Zika Virus, Chikungunya Virus, and Dengue Virus.
abstract: BACKGROUND
  Zika virus (ZIKV), chikungunya virus (CHIKV), and dengue virus (DENV) cocirculate in Nicaragua. In this study, we sought to compare the quantified viremia and clinical presentation of patients infected with 1 or more of these viruses.
  
  
  METHODS
  Acute-phase serum samples from 346 patients with a suspected arboviral illness were tested using a multiplex real-time reverse-transcription polymerase chain reaction for ZIKV, CHIKV, and DENV. Viremia was quantitated for each detected virus, and clinical information from request forms submitted with each sample was recorded.
  
  
  RESULTS
  A total of 263 patients tested positive for 1 or more viruses: 192 patients tested positive for a single virus (monoinfections) and 71 patients tested positive for 2 or all 3 viruses (coinfections). Quantifiable viremia was lower in ZIKV infections compared with CHIKV or DENV (mean 4.70 vs 6.42 and 5.84 log10copies/mL serum, respectively; P < .001 for both comparisons), and for each virus, mean viremia was significantly lower in coinfections than in monoinfections. Compared with patients with CHIKV or DENV, ZIKV patients were more likely to have a rash (P < .001) and less likely to be febrile (P < .05) or require hospitalization (P < .001). Among all patients, hospitalized cases had higher viremia than those who did not require hospitalization (7.1 vs 4.1 log10 copies/mL serum, respectively; P < .001).
  
  
  CONCLUSIONS
  ZIKV, CHIKV, and DENV result in similar clinical presentations, and coinfections may be relatively common. Our findings illustrate the need for accurate, multiplex diagnostics for patient care and epidemiologic surveillance.
authors: Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, California.
authors: Jesse J
authors: JJ
authors: Waggoner
authors: Sustainable Sciences Institute.
authors: Lionel
authors: L
authors: Gresh
authors: National Virology Laboratory, Centro Nacional de Diagnóstico y Referencia, Ministry of Health, Managua, Nicaragua.
authors: Maria Jose
authors: MJ
authors: Vargas
authors: National Virology Laboratory, Centro Nacional de Diagnóstico y Referencia, Ministry of Health, Managua, Nicaragua.
authors: Gabriela
authors: G
authors: Ballesteros
authors: National Virology Laboratory, Centro Nacional de Diagnóstico y Referencia, Ministry of Health, Managua, Nicaragua.
authors: Yolanda
authors: Y
authors: Tellez
authors: Department of Scientific Computing, Florida State University, Tallahassee.
authors: K James
authors: KJ
authors: Soda
authors: Department of Pathology, Stanford University School of Medicine.
authors: Malaya K
authors: MK
authors: Sahoo
authors: National Virology Laboratory, Centro Nacional de Diagnóstico y Referencia, Ministry of Health, Managua, Nicaragua.
authors: Andrea
authors: A
authors: Nuñez
authors: National Virology Laboratory, Centro Nacional de Diagnóstico y Referencia, Ministry of Health, Managua, Nicaragua.
authors: Angel
authors: A
authors: Balmaseda
authors: Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley.
authors: Eva
authors: E
authors: Harris
authors: Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, California.|Department of Pathology, Stanford University School of Medicine.
authors: Benjamin A
authors: BA
authors: Pinsky
mesh_terms: D000328:Adult; D065632:Chikungunya Fever / Q000150:complications / Q000503:physiopathology / Q000821:virology*; D060085:Coinfection; D003715:Dengue / Q000150:complications / Q000503:physiopathology / Q000821:virology*; D005260:Female; D006801:Humans; D008297:Male; D009527:Nicaragua; D014766:Viremia / Q000503:physiopathology / Q000821:virology; D055815:Young Adult; D000071243:Zika Virus Infection / Q000150:complications / Q000503:physiopathology / Q000821:virology*
keywords: Zika virus; chikungunya virus; coinfection; dengue virus; viremia