+1 Recommend
1 collections
      • Record: found
      • Abstract: found
      • Article: not found

      Neurological disease in adults with Zika and chikungunya virus infection in Northeast Brazil: a prospective observational study

      , MD a , , PhD b , , Prof, PhD d , , PhD c , , MD a , , MD a , a , , PhD f , , PhD a , , PhD b , , MRCP f , , MD a , , MD g , , MRCP f , i , , MSc j , , PhD j , , PhD f , k , , DPhil f , l , , Prof, PhD g , h , , FRCR i , , Prof, FRCP m , , PhD c , , MD n , , Prof, PhD e , , Prof, PhD b , , Prof, MRCPath o , p , , PhD c , , MBChB f , , Prof, FRCP f , i , k , *

      The Lancet. Neurology

      Elsevier Ltd.

      Read this article at

          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.



          Since 2015, the arthropod-borne viruses (arboviruses) Zika and chikungunya have spread across the Americas causing outbreaks, accompanied by increases in immune-mediated and infectious neurological disease. The spectrum of neurological manifestations linked to these viruses, and the importance of dual infection, are not known fully. We aimed to investigate whether neurological presentations differed according to the infecting arbovirus, and whether patients with dual infection had a different disease spectrum or severity.


          We report a prospective observational study done during epidemics of Zika and chikungunya viruses in Recife, Pernambuco, a dengue-endemic area of Brazil. We recruited adults aged 18 years or older referred to Hospital da Restauração, a secondary-level and tertiary-level hospital, with suspected acute neurological disease and a history of suspected arboviral infection. We looked for evidence of Zika, chikungunya, or dengue infection by viral RNA or specific IgM antibodies in serum or CSF. We grouped patients according to their arbovirus laboratory diagnosis and then compared demographic and clinical characteristics.


          Between Dec 4, 2014, and Dec 4, 2016, 1410 patients were admitted to the hospital neurology service; 201 (14%) had symptoms consistent with arbovirus infection and sufficient samples for diagnostic testing and were included in the study. The median age was 48 years (IQR 34–60), and 106 (53%) were women. 148 (74%) of 201 patients had laboratory evidence of arboviral infection. 98 (49%) of them had a single viral infection (41 [20%] had Zika, 55 [27%] had chikungunya, and two [1%] had dengue infection), whereas 50 (25%) had evidence of dual infection, mostly with Zika and chikungunya viruses (46 [23%] patients). Patients positive for arbovirus infection presented with a broad range of CNS and peripheral nervous system (PNS) disease. Chikungunya infection was more often associated with CNS disease (26 [47%] of 55 patients with chikungunya infection vs six [15%] of 41 with Zika infection; p=0·0008), especially myelitis (12 [22%] patients). Zika infection was more often associated with PNS disease (26 [63%] of 41 patients with Zika infection vs nine [16%] of 55 with chikungunya infection; p≤0·0001), particularly Guillain-Barré syndrome (25 [61%] patients). Patients with Guillain-Barré syndrome who had Zika and chikungunya dual infection had more aggressive disease, requiring intensive care support and longer hospital stays, than those with mono-infection (median 24 days [IQR 20–30] vs 17 days [10–20]; p=0·0028). Eight (17%) of 46 patients with Zika and chikungunya dual infection had a stroke or transient ischaemic attack, compared with five (6%) of 96 patients with Zika or chikungunya mono-infection (p=0·047).


          There is a wide and overlapping spectrum of neurological manifestations caused by Zika or chikungunya mono-infection and by dual infections. The possible increased risk of acute cerebrovascular disease in patients with dual infection merits further investigation.


          Fundação do Amparo a Ciência e Tecnologia de Pernambuco (FACEPE), EU's Horizon 2020 research and innovation programme, National Institute for Health Research.


          For the Portuguese and Spanish translations of the abstract see Supplementary Materials section.

          Related collections

          Most cited references 18

          • Record: found
          • Abstract: not found
          • Article: not found


            • Record: found
            • Abstract: found
            • Article: not found

            Dengue Virus-Specific Antibodies Enhance Brazilian Zika Virus Infection.

            Anti-Flavivirus antibodies are highly cross-reactive and may facilitate Zika virus (ZIKV) infection through the antibody-dependent enhancement (ADE) mechanism. We demonstrate that dengue-specific antibodies enhance the infection of a primary Brazilian ZIKV isolate in a FcγRII-expressing K562 cell line. In addition, we demonstrate that serum samples from dengue-immune pregnant women enhanced ZIKV infection. These findings highlight the need for epidemiological studies and animal models to further confirm the role of ADE in the development of congenital and neurological complications associated with ZIKV infections.
              • Record: found
              • Abstract: found
              • Article: found
              Is Open Access

              Epidemiology of Chikungunya Virus in Bahia, Brazil, 2014-2015

              Chikungunya is an emerging arbovirus that is characterized into four lineages. One of these, the Asian genotype, has spread rapidly in the Americas after its introduction in the Saint Martin island in October 2013. Unexpectedly, a new lineage, the East-Central-South African genotype, was introduced from Angola in the end of May 2014 in Feira de Santana (FSA), the second largest city in Bahia state, Brazil, where over 5,500 cases have now been reported. Number weekly cases of clinically confirmed CHIKV in FSA were analysed alongside with urban district of residence of CHIKV cases reported between June 2014 and October collected from the municipality’s surveillance network. The number of cases per week from June 2014 until September 2015 reveals two distinct transmission waves. The first wave ignited in June and transmission ceased by December 2014. However, a second transmission wave started in January and peaked in May 2015, 8 months after the first wave peak, and this time in phase with Dengue virus and Zika virus transmission, which ceased when minimum temperature dropped to approximately 15°C. We find that shorter travelling times from the district where the outbreak first emerged to other urban districts of FSA were strongly associated with incidence in each district in 2014 (R2).

                Author and article information

                Lancet Neurol
                Lancet Neurol
                The Lancet. Neurology
                Elsevier Ltd.
                16 September 2020
                October 2020
                16 September 2020
                : 19
                : 10
                : 826-839
                [a ]Department of Neurology, Hospital da Restauração, Recife, Brazil
                [b ]Department of Collective Health, Institute Aggeu Magalhães, Oswaldo Cruz Foundation, Recife, Brazil
                [c ]Department of Virology, Institute Aggeu Magalhães, Oswaldo Cruz Foundation, Recife, Brazil
                [d ]Department of Clinical Medicine, Federal University of Pernambuco, Recife, Brazil
                [e ]Department of Tropical Medicine, Federal University of Pernambuco, Recife, Brazil
                [f ]National Institute for Health Research Health Protection Research Unit on Emerging and Zoonotic Infections, Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool, Liverpool, UK
                [g ]Department of Neurology, Erasmus University Medical Center, Rotterdam, Netherlands
                [h ]Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands
                [i ]The Walton Centre NHS Foundation Trust, Liverpool, UK
                [j ]Department of Biostatistics, University of Liverpool, Liverpool, UK
                [k ]Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
                [l ]Alder Hey Children's NHS Foundation Trust, Liverpool, UK
                [m ]Department of Neurology and Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
                [n ]Department of Neurology, Division of Neuroimmunology and Neuroinfectious Disorders, Johns Hopkins University School of Medicine, Baltimore, MD, USA
                [o ]Blood Borne Virus Unit, Virus Reference Department, Public Health England, London, England
                [p ]Flavivirus Reference Laboratory, Evandro Chagas National Infectious Disease Institute, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
                Author notes
                [* ]Correspondence to: Prof Tom Solomon, NIHR Protection Research Unit on Emerging and Zoonotic Infections, Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool, Liverpool L69 7BE, UK
                © 2020 Elsevier Ltd. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.




                Comment on this article