UNDIAGNOSED RESPIRATORY DISEASE - BRAZIL: (PARA) REQUEST FOR INFORMATION

Published Date: 2012-12-04 11:18:09
Subject: PRO/AH/EDR> Undiagnosed respiratory disease - Brazil: (PA) RFI 
Archive Number: 20121204.1436678

UNDIAGNOSED RESPIRATORY DISEASE - BRAZIL: (PARA) REQUEST FOR INFORMATION
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Date: Sun 2 Dec 2012

Source: Para Government press release [in Portuguese, trans. Mod.MPP, edited]

http://www.pa.gov.br/noticia_interna.asp?id_ver=113000





Patients with respiratory syndrome are transferred from Curuca to Belem


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The State Department of Public Health (Sespa) decided to transfer 5 patients in serious clinical condition from Curuca Municipal Hospital to Belem, with symptoms of an acute respiratory syndrome with as yet undiagnosed etiology. The purpose of the transfer is to assure better care of the patients, cases which are still under investigation by the Sespa Epidemiologic Surveillance unit in conjunction with the 3rd Regional Center for Health in Castanhal, the Curuca Municipal Health Secretariat, the State Central Laboratory (Lacen), the Renato Chaves Center of Scientific Expertise (CPC), and the Evandro Chagas Institute.



The patients that were transferred to the capital [Belem is the capital of Para State] will be admitted to the Meningitis Diagnostic Unit (UDM), of the Joao de Barros Barreto University Hospital, under the care [monitoring] of the Infectious Disease physicians. In addition to these 5 people, another 14 [individuals] showed symptoms of the disease since the beginning of the outbreak in the Municipal Hospital of Curuca, where a 17 year old female died in the ICU of Santa Casa, on the evening of Sat 1 Dec 2012.


The case of the young woman [the 17 year old] is being investigated because she was a resident of Curuca and a cousin of a nursing technician in the Municipal Hospital, who also presented with symptoms of this disease. The young woman was pregnant and lost the baby after being infected. Although the body was released for burial and taken to Curuca, the Sespa team contacted the family and asked permission for an autopsy, which will be performed at the Center for Scientific Expertise in Belem.



The initial suspicion was that the patients had been victims of radioactive contamination and then by a chemical product used in developing the radiographs. [This hypothesis] was discarded as a function of the presenting symptoms -- low fever, shortness of breath, oliguria (reduced urine volume), hypotension, hypoglycemia, bradycardia (slow heart rate), and hemorrhagic manifestations in the digestive system, among others. The working hypothesis of Sespa is now a viral, bacterial, or fungal infection.



To discover the causative agent of the disease nasopharyngeal secretions of the patients were collected, as well as blood for a series of laboratory tests that are underway in Lacen [State Laboratory] and the Evandro Chagas Institute, including, blood cultures and studies for various viruses, including H1N1 and hantavirus. The patients were [empirically] treated with ciprofloxacin and Tamiflu even in the absence of test results, but they did not show any improvement.



The State Laboratory also collected samples of the water supply of Curuca City Hospital because of a suspicion that the causative agent might me found there. According to the director of the Sespa Health Surveillance Unit, Rosiana Nobre, in addition to the investigation and medical attention of the patients, it was necessary to provide assistance to the families and professionals supposedly exposed [to the source of the infection], as well as to disinfect the Municipal Hospital in order to eliminate the possible sources of infection and provide the Municipal Hospital of Curuca with medicines, supplies, and personal protective equipment (PPE).



Nobre also said they were developing an orientation guide for the Curuca population, hospital workers, and family members on preventive measures to avoid the emergence of new cases pending laboratory results and the identification of more specific measures for disease prevention.



[Byline: Roberta Vilanova, Sespa]



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Communicated by:

ProMED-mail



[An initial reaction one has upon reading the introductory paragraphs describing the outbreak of an acute severe respiratory illness associated with reduced urinary output was to wonder if this might be another new location for a nosocomial outbreak of the novel coronavirus described in the Eastern Mediterranean countries of Saudi Arabia, Jordan, and Qatar. As one reads more of the official announcement, this seems to be less and less a possible explanation for this outbreak.



A curious symptom described in the clinical presentations above is the relative bradycardia. Usually when there is respiratory distress (due to hypoxia -- low blood oxygen concentrations) or when there is a fever, it is often accompanied by a tachycardia (fast heart beat). Diseases that are known to present with a relative bradycardia (slow heart beat in the face of other symptoms) include typhoid fever, legionnaires' disease, psittacosis, typhus, leptospirosis, malaria, babesiosis, dengue fever, and viral hemorrhagic fevers (see refs 1,2,3 below). With respect to the presentation of hypoglycemia, Mod. ML mentioned that hyperglycemia is the most common blood glucose abnormality seen early in the course of bacterial sepsis. Profound hypoglycemia may occur late in the course of sepsis. Hypoglycemia with cardiovascular collapse is seen in patients with adrenal insufficiency.



In another newswire, there is mention there had been 19 cases with respiratory symptoms reported from the Hospital in Curuca during the period 23-24 Nov 2012. Further investigation revealed a predominance of hypoglycemia, bradycardia, and gastrointestinal hemorrhagic symptoms (see http://g1.globo.com/pa/para/noticia/2012/12/tecnicos-de-hospital-de-curuca-sao-transferidos-para-belem.html in Portuguese).



When one reads the paragraphs towards the end of the press release discussing the concerns that there was exposure to the etiologic agent through a water source of the hospital, this moderator wondered about legionellosis as one of the diseases under suspicion.



There is clearly much room for speculation, with many questions -- what is the apparent transmission? Is a common source exposure suspected? (while the newswire mentions that 19 cases were reported during a 24-48 hour period, it doesn't mention if that reflected the dates of onset of the illnesses, but does seem to suggest there may have been a common source exposure, as did the initial working hypothesis of a possible radiation exposure). What is the suspected incubation period? Is there evidence for person-to-person transmission? What does the epidemic curve look like? (number of cases by date of onset of illness). What is the distribution of the symptom complex (what is the frequency of the symptoms in the affected group of individuals)?



More information on the results of the investigations to date as well as laboratory results when available would be greatly appreciated.



For a map of the state of Para in Brazil, see http://www.v-brazil.com/graphics/para.gif. Belem is to the northeast of the state, with Castanhal to the northeast of Belem.

For a map of Brazil showing the location of Curuca, seehttp://www.maplandia.com/brazil/para/curuca/. It is further northeast of both Castanhal and Belem.

For the HealthMap/ProMED-mail interactive map of Brazil see http://healthmap.org/r/4oYc.