Zika virus epidemic in Brazil. I. Fatal disease in adults: Clinical and laboratorial aspects.
Zika virus (ZIKV) was first detected in Brazil in May 2015 and the country experienced an explosive epidemic. However, recent studies indicate that the introduction of ZIKV occurred in late 2013. Cases of microcephaly and deaths associated with ZIKV infection were identified in Brazil in November, 2015.



To determine the etiology of three fatal adult cases.



Here we report three fatal adult cases of ZIKV disease. ZIKV infection in these patients was confirmed by cells culture and/or real-time reverse transcriptase polymerase chain reaction (RT-qPCR) and by antigen detection using immunohistochemical assay. Samples of brain and other selected organs taken at autopsy from three patients were also analyzed by histopathological and immunohistological examination.



The first patient, a 36-year-old man with lupus and receiving prednisone therapy, developed a fulminant ZIKV infection. At autopsy, RT-qPCR of blood and tissues was positive for ZIKV RNA, and the virus was cultured from an organ homogenate. The second patient, a previously healthy female, 16 years of age, presented classic symptoms of Zika fever, but later developed severe thrombocytopenia, anemia and hemorrhagic manifestations and died. A blood sample taken on the seventh day of her illness was positive RT-PCR for ZIKV RNA and research in the serum was positive for antinuclear factor fine speckled (1/640), suggesting Evans syndrome (hemolytic anemia an autoimmune disorder with immune thrombocytopenic purpura) secondary to ZIKV infection. The third patient was a 20-year-old woman hospitalized with fever, pneumonia and hemorrhages, who died on 13days after admission. Histopathological changes were observed in all viscera examined. ZIKV antigens were detected by immunohistochemistry in viscera specimens of patients 1 and 3. These three cases demonstrate other potential complications of ZIKV infection, in addition to microcephaly and Guillain-Barre syndrome (GBS), and they suggest that individuals with immune suppression and/or autoimmune disorders may be at higher risk of developing severe disease, if infected with ZIKV.
Seção de Arbovirologia e Febres Hemorrágicas, Instituto Evandro Chagas, Ministério da Saúde, Ananindeua, Pará, Brazil; Programa de Pós-graduação em Virologia (PPGV) do Instituto Evandro Chagas, Ananindeua, Pará, Brazil. Electronic address: raimundaazevedo@iec.pa.gov.br.
Raimunda S S
RS
Azevedo
Seção de Patologia, Instituto Evandro Chagas, Ministério da Saúde, Ananindeua, Pará, Brazil. Electronic address: marialvaaraujo@iec.pa.gov.br.
Marialva T
MT
Araujo
Seção de Patologia, Instituto Evandro Chagas, Ministério da Saúde, Ananindeua, Pará, Brazil. Electronic address: arnaldofilho@iec.pa.gov.br.
Arnaldo J
AJ
Martins Filho
Seção de Arbovirologia e Febres Hemorrágicas, Instituto Evandro Chagas, Ministério da Saúde, Ananindeua, Pará, Brazil. Electronic address: consuelooliveira@iec.pa.gov.br.
Consuelo S
CS
Oliveira
Seção de Arbovirologia e Febres Hemorrágicas, Instituto Evandro Chagas, Ministério da Saúde, Ananindeua, Pará, Brazil. Electronic address: brunonunes@iec.pa.gov.br.
Bruno T D
BT
Nunes
Seção de Arbovirologia e Febres Hemorrágicas, Instituto Evandro Chagas, Ministério da Saúde, Ananindeua, Pará, Brazil; Departamento de Patologia, Universidade do Estado do Pará, Belém, Pará, Brazil. Electronic address: anacecilia@iec.pa.gov.br.
Ana C R
AC
Cruz
Universidade Federal do Maranhão, São Luiz, Maranhão, Brazil. Electronic address: ana.giselia@globo.com.
Ana G P A C
AG
Nascimento
Hospital Universitário João de Barros Barreto, Universidade Federal do Pará, Belém, Pará, Brazil. Electronic address: ritaclosset@uol.com.br.
Rita C
RC
Medeiros
Hospital Universitário João de Barros Barreto, Universidade Federal do Pará, Belém, Pará, Brazil. Electronic address: cezar_caldas@yahoo.com.br.
Cezar A M
CA
Caldas
Hospital Universitário João de Barros Barreto, Universidade Federal do Pará, Belém, Pará, Brazil. Electronic address: fernando.stm@hotmail.com.
Fernando C
FC
Araujo
Departamento de Patologia, Universidade do Estado do Pará, Belém, Pará, Brazil. Electronic address: juarez.quaresma@gmail.com.
Juarez A S
JA
Quaresma
Departamento de Patologia, Universidade do Estado do Pará, Belém, Pará, Brazil. Electronic address: barbaravasconcelos@globo.com.
Barbara C B
BC
Vasconcelos
Laboratório Central, Secretaria de Saúde Pública do Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil. Electronic address: lacenrn@yahoo.com.br.
Maria G L
MG
Queiroz
Seção de Arbovirologia e Febres Hemorrágicas, Instituto Evandro Chagas, Ministério da Saúde, Ananindeua, Pará, Brazil. Electronic address: elizabethsalbe@iec.pa.gov.br.
Elizabeth S Travassos
ES
da Rosa
Seção de Arbovirologia e Febres Hemorrágicas, Instituto Evandro Chagas, Ministério da Saúde, Ananindeua, Pará, Brazil. Electronic address: danielehenriques@iec.pa.gov.br.
Daniele F
DF
Henriques
Seção de Arbovirologia e Febres Hemorrágicas, Instituto Evandro Chagas, Ministério da Saúde, Ananindeua, Pará, Brazil. Electronic address: elianapinto@iec.pa.gov.br.
Eliana V P
EV
Silva
Seção de Arbovirologia e Febres Hemorrágicas, Instituto Evandro Chagas, Ministério da Saúde, Ananindeua, Pará, Brazil. Electronic address: anniferchiang@iec.pa.gov.br.
Jannifer O
JO
Chiang
Seção de Arbovirologia e Febres Hemorrágicas, Instituto Evandro Chagas, Ministério da Saúde, Ananindeua, Pará, Brazil. Electronic address: liviamartins@iec.pa.gov.br.
Lívia C
LC
Martins
Seção de Arbovirologia e Febres Hemorrágicas, Instituto Evandro Chagas, Ministério da Saúde, Ananindeua, Pará, Brazil. Electronic address: danielemedeiros@iec.pa.gov.br.
Daniele B A
DB
Medeiros
Seção de Arbovirologia e Febres Hemorrágicas, Instituto Evandro Chagas, Ministério da Saúde, Ananindeua, Pará, Brazil. Electronic address: julianaabreulima@hotmail.com.
Juliana A
JA
Lima
Seção de Arbovirologia e Febres Hemorrágicas, Instituto Evandro Chagas, Ministério da Saúde, Ananindeua, Pará, Brazil. Electronic address: marcionunesbrasil@yahoo.com.br.
Márcio R T
MR
Nunes
Seção de Arbovirologia e Febres Hemorrágicas, Instituto Evandro Chagas, Ministério da Saúde, Ananindeua, Pará, Brazil; Programa de Pós-graduação em Virologia (PPGV) do Instituto Evandro Chagas, Ananindeua, Pará, Brazil. Electronic address: jedson.cardoso@gmail.com.
Jedson F
JF
Cardoso
Seção de Arbovirologia e Febres Hemorrágicas, Instituto Evandro Chagas, Ministério da Saúde, Ananindeua, Pará, Brazil. Electronic address: spatroca@gmail.com.
Sandro P
SP
Silva
Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA. Electronic address: peshi@utmb.edu.
Pei-Yong
PY
Shi
Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA. Electronic address: rtesh@utmb.edu.
Robert B
RB
Tesh
Seção de Arbovirologia e Febres Hemorrágicas, Instituto Evandro Chagas, Ministério da Saúde, Ananindeua, Pará, Brazil. Electronic address: suelirodrigues@iec.pa.gov.br.
Sueli G
SG
Rodrigues
Seção de Arbovirologia e Febres Hemorrágicas, Instituto Evandro Chagas, Ministério da Saúde, Ananindeua, Pará, Brazil; Departamento de Patologia, Universidade do Estado do Pará, Belém, Pará, Brazil. Electronic address: pedrovasconcelos@iec.pa.gov.br.
Pedro F C
PF
Vasconcelos
D000293:Adolescent; D000328:Adult; D000956:Antigens, Viral / Q000032:analysis; D001344:Autopsy; D001921:Brain / Q000821:virology; D001938:Brazil; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D007150:Immunohistochemistry; D008297:Male; D012367:RNA, Viral / Q000097:blood; D060888:Real-Time Polymerase Chain Reaction; D014776:Virus Cultivation; D014781:Viscera / Q000821:virology; D055815:Young Adult; D000071244:Zika Virus / Q000302:isolation & purification*; D000071243:Zika Virus Infection / Q000175:diagnosis* / Q000473:pathology*
D000956:Antigens, Viral; D012367:RNA, Viral
Autoimmune disorders; Erythematous lupus; Evans syndrome; Histopathology; Immunohistochemistry; Zika virus