Month: November 2023

A 39-year-old male was hospitalized for one month at an outside hospital with acute respiratory failure which required high flow oxygen supplementation. He was diagnosed with HIV with a CD4 cell count of 36 cells/µL. His risk factors included sex with men and women. Patient was not vaccinated for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). He was also diagnosed with CMV DNAemia of 200,000 copies/mL in plasma and presumed Pneumocystis jirovecii (PJP) pneumonia given consistent imaging findings and a positive beta-D-glucan result. Sputum Pneumocystis Calcofluor white smear was negative, and the patient deferred bronchoscopy. He was treated for CMV DNAemia with intravenous ganciclovir for 3–4 weeks before transitioning to oral valganciclovir. He was also treated for PJP pneumonia with steroids and trimethoprim-sulfamethoxazole until developing hyperkalemia and transitioned to pentamidine to complete treatment. He was started on antiretroviral therapy (ART) with bictegravir/emtricitabine/tenofovir alafenamide. He was discharged on ART, valganciclovir, and prophylactic dapsone for PJP pneumonia prevention. Fig. 1 Coronal CT image shows bilateral peri-broncho-vascular nodules and ground glass opacities Full size image Four months after discharge from the outside hospital, the patient presented to the emergency department in the summer of 2022 with a dry cough for 3 weeks accompanied by intermittent fever, chills, night sweats, dysphagia, and diarrhea. He also had unintentional weight loss of 15 pounds over the last month. He had not been taking his medications for the last month and had been lost to follow up. Patient was raised in Mexico, but had no other recent travel, animal exposures, or current partners. On physical examination, his temperature was 37.8 C°, heart rate of 128 beats per minute, and a respiration rate of 26 breaths per minute with pulse oxygenation of 94%. The patient was diaphoretic but in no acute distress. Other findings were notable for oropharyngeal white patches, bilateral coarse breath sounds, and multiple flesh colored umbilicated papules on the left thorax. The exam was negative for hepatosplenomegaly or lymphadenopathy. On admission, chest x-ray revealed an ill-defined focal hazy opacity of the right lateral middle lung with a computerized tomography (CT) scan subsequently showing extensive areas of bilateral tree-in-bud infiltrate with scattered ground glass and consolidative opacities (Figs. 1, 2 and 3). Labs confirmed advanced HIV with CD4 of 6 cells/µL and a HIV viral load of > 800,000 copies/mL. He was found to be positive for SARS-CoV-2 by polymerase chain reaction (PCR). Plasma CMV PCR was elevated at 3.9 million copies/mL. Fig. 2 Axial CT image demonstrates nodules in peripheral aspects of right upper and left upper lobes Full size image Coronavirus disease 2019 (COVID-19) treatment was deferred as the patient presented with subacute symptoms for several weeks prior to arrival without initial hypoxemia. The patient was started on empiric typical and atypical bacterial pneumonia treatment with vancomycin, cefepime, and doxycycline. He also started PJP treatment with trimethoprim-sulfamethoxazole. Additionally, the patient was started on fluconazole for presumed Candida esophagitis. However, during his admission, the patient developed worsening oxygen requirements and persistent fevers. CT angiogram did not show evidence of pulmonary embolism. C-reactive protein was elevated at 1.7 mg/dL and ferritin was 4,003 ng/mL. Bronchoalveolar lavage (BAL) was performed including viral culture which was positive for CMV. SARS-CoV-2 specific testing was not performed on the BAL fluid, and it is not routinely recovered from the cell lines used for viral culture at the reference laboratory. AFB culture was also performed on the BAL which later grew Mycobacterium avium complex (MAC). Transbronchial biopsies taken demonstrated pneumonitis with numerous enlarged, virally infected cells with both cytoplasmic and large nuclear inclusions. These findings were diagnostic of CMV pneumonitis (Fig. 4). Immunostaining confirmed numerous, scattered positive cells for CMV (Fig. 4B and D) whereas stains for acid fast bacilli and fungi were negative. The patient was initiated on intravenous ganciclovir for CMV pneumonitis. Dilated ophthalmologic exam did not reveal retinitis. The patient’s fevers, dyspnea, and cough resolved over the next seven days, and he was transitioned to oral valganciclovir. Of note, the MAC isolated on BAL was not treated due to patient’s improvement on other therapy. Fig. 3 Axial CT image demonstrates nodules and consolidative opacities in right middle lobe and posterior left lung base Full size image Fig. 4 Histopathologic and immunohistochemical evaluation of transbronchial biopsy. A) Fragment of lung tissue with scattered enlarged cells (small arrowheads) with cytologic features diagnostic for CMV infection in a background of pneumonitis (100x magnification, H&E). B) Immunohistochemical confirmation using antibodies to CMV that are binding to enlarged cells (strong nuclear staining) scattered throughout the biopsy (100x magnification, CMV IHC). C) Multiple enlarged cells (arrowheads), some with characteristic nuclear inclusions in a background of reactive and inflamed lung parenchyma (400x magnification, H&E). D) CMV immunohistochemical staining with strong positivity in the nuclei and scattered positivity in the cytoplasm of the same cells (400x magnification, CMV IHC) Full size image The patient was prescribed a 21-day course of valganciclovir. At outpatient follow up, he reported doing well and was finishing his CMV therapy. On that visit, he was reinitiated on ART with abacavir/dolutegravir/lamivudine. He presented again 2 months after initial presentation with dyspnea and fevers, requiring readmission to the hospital. A repeat CT revealed resolution of the majority of nodular opacities and residual ground glass opacities (Fig. 5), but his CMV PCR showed a plasma level of 5 million copies/mL. Patient’s SARS-CoV-2 by PCR testing was persistently positive, which seemed to indicate inability to clear the virus versus a continued active infection. He was briefly treated with intravenous foscarnet given initial concern for ganciclovir resistance; however, the mutational analysis for ganciclovir, cidofovir, and foscarnet resistance was negative with codons 457–630 of UL97 gene and codons 393–1000 of UL54 gene sequencing. Repeat CD4 was < 10 cells/µL and HIV viral load was 6 million copies/mL concerning for non-adherence to ART. The patient was switched back to intravenous ganciclovir and then to oral valganciclovir with symptomatic improvement. Fig. 5 Coronal CT image obtained 3 months later with resolution of majority of the nodular opacities with

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Abstract To investigate the clinical and molecular characteristics and evolution of the Zika virus (ZIKV) in Thailand from March 2020 to March 2023. In all, 751 serum samples from hospitalized patients in Bangkok and the surrounding areas were screened for ZIKV using real-time RT-PCR. Demographic data and clinical variables were evaluated. Phylogenetic and molecular clock analysis determined the genetic relationships among the ZIKV strains, emergence timing, and their molecular characteristics. Among the 90 confirmed ZIKV cases, there were no significant differences in infection prevalence when comparing age groups and sexes. Rash was strongly associated with ZIKV infection. Our ZIKV Thai isolates were categorized into two distinct clades: one was related to strains from Myanmar, Vietnam, Oceania, and various countries in the Americas, and the other was closely related to previously circulating strains in Thailand, one of which shared a close relation to a neurovirulent ZIKV strain from Cambodia. Moreover, ZIKV Thai strains could be further classified into multiple sub-clades, each exhibiting specific mutations suggesting the genetic diversity among the circulating strains of ZIKV in Thailand. Understanding ZIKV epidemiology and genetic diversity is crucial for tracking the virus’s evolution and adapting prevention and control strategies. Introduction Zika virus (ZIKV) is a single-stranded RNA flavivirus primarily transmitted by the Aedes mosquitoes. It was first discovered in Uganda in 1947 and identified in Asia in 19661,2. Prior to 2007, only sporadic ZIKV infection cases with self-limiting or mild symptoms were documented in Africa and Asia3. In 2007, the first ZIKV outbreak occurred in Yap Islands, Micronesia, affecting 73% residents4. Subsequent outbreaks occurred in French Polynesia in 2013–2014, during which the association between ZIKV infection and Guillain–Barré syndrome was noted5,6. ZIKV was first identified in Brazil in 20157 and rapidly spread throughout the Americas8. Brazil experienced a dramatic rise in ZIKV-linked neonatal microcephaly cases, resulting in the declaration of a public health emergency of international concern by the WHO in early 2016 to establish a causal connection between ZIKV and congenital disabilities9. Since then, many countries have increased their focus on monitoring ZIKV infections. Before 2016, multiple lines of evidence indicated that ZIKV circulated at low levels, and sporadic cases were reported in Southeast Asian countries including Thailand for decades10. From 2016 to 2017, the number of ZIKV infection cases in Thailand dramatically increased by over 1500 cases; however, it remains unclear whether this rise was because of higher infection rates or increased awareness11. According to the Bureau of Epidemiology, Ministry of Public Health, Thailand, the morbidity rate in 2016 was 1.69 per 100,000 population. From 2019 to 2022, the morbidity rates of ZIKV in Thailand were < 0.5 yearly; the rates were 0.41, 0.36, 0.10, and 0.29 per 100,000 population, respectively12. From 2016 to 2022, the Bureau reported 234 confirmed cases of ZIKV in pregnant women. Among them, 11 patients experienced miscarriages, of which four were related to ZIKV infection. Furthermore, clinical surveillance of 2217 neonates with microcephaly revealed 15 cases of congenital Zika syndrome. While the ZIKV epidemic and its genetic characterization in the Americas are well documented, its presence and molecular epidemiology in Southeast Asia, particularly in Thailand, are areas of concern and ongoing investigation. Few studies have explored the molecular epidemiology of the Thai ZIKV strains. Hence, more research is required on the current genetic characterization and diversity of ZIKV strains in Thailand since the COVID-19 pandemic. This research aimed to comprehensively evaluate the ZIKV prevalence, clinical presentation, and genetic characteristics in Thailand from 2020 to 2023. Investigating the genetic diversity of the current ZIKV circulating in Thailand can help assess the risk of outbreaks and guide public health strategies and preparedness efforts. Results Demographic characteristics and clinical features Out of the 751 samples (Table 1), 12.0% (90/751; 56.7% female and 43.3% male) tested positive for ZIKV infection based on Zika viral RNA presence. There was no significant sex-related difference in ZIKV prevalence (p = 0.507). The median age of patients with confirmed ZIKV was 37 (IQR: 29–46) years (range: 1–71 years). Most patients were in the 36–45 years age group (32.2%), followed by 26–35 years (22.2%) and 46–55 years (13.3%). Prevalence was lower among participants aged ≤ 15 years (10%) and 16–25 years (10%). Age was not significantly associated with increased ZIKV infection (p = 0.187). The median duration from illness onset to Zika RNA diagnosis was 3.5 days (IQR: 3–5 days). Table 1 Demographic characteristics and clinical presentation of individuals according to ZIKV infection, Thailand (2020–2023) (N = 751).Full size table The common clinical symptoms among ZIKV patients included rash (83.1%), fever (71.2%), arthralgia (54.2%), myalgia (39%), and conjunctivitis (22%). Skin rash was strongly associated with ZIKV infection (odds ratio [OR] 19.89, p < 0.001), as were arthralgia (OR 2.63, p < 0.001), and conjunctivitis (OR 11.73, p < 0.001). There was no evidence of ZIKV-associated neurological complications. Next, we examined the correlation between age groups and clinical characteristics and found that only arthralgia or joint pain (p = 0.022) showed a significant association with age groups (Table 2). In addition, the percentage of ZIKV-positive samples in each study year was analyzed and showed that there were 4.67% (12/257) tested positive for ZIKV infection in March 2020-December 2020, 7.54% (8/109) in 2021, 17.5% (47/269) in 2022. Interestingly, 19.8% (23/116) tested positive for ZIKV in the first three months of 2023. Table 2 Clinical characteristics in different age groups of ZIKV-infected participants (N = 59).Full size table Genome sequence and phylogenetic analysis of ZIKV detected in Thailand during 2020–2023 We constructed a maximum likelihood phylogenetic tree and examined the nucleotide identity using complete coding sequences of ZIKV Thai strains of 2020–2023 from this study (n = 17) and additional sequences representing various strains sourced from the GenBank database. Our ZIKV Thai isolates belonged to the Asian lineage and could be classified into two clades: Southeast Asian (SEA) and Asian-American (AA). Out of the 17 ZIKV Thai isolates from 2020 to 2023 (Figs. 1 and 2), 11 were in the SEA clade, which includes strains from Thailand in 2016–2017 (98.5–99.4% sequence identity), Singapore in 2016 (99.0–99.4% sequence identity), and Cambodia in 2019 (98.8–99.5% sequence identity). Most of our SEA ZIKV strains

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