Toscana Virus Infection in American Traveler Returning from Sicily, 2009 | CDC EID

EID Journal Home > Volume 16, Number 9–September 2010

Volume 16, Number 9–September 2010
Letter
Toscana Virus Infection in American Traveler Returning from Sicily, 2009
Meagan K. Kay, Katherine B. Gibney, Francis X. Riedo, Olga L. Kosoy, Robert S. Lanciotti, and Amy J. Lambert

Author affiliations: Centers for Disease Control and Prevention, Atlanta, Georgia, USA (M.K. Kay); Centers for Disease Control and Prevention, Fort Collins, Colorado, USA (K.B. Gibney, O.L. Kosoy, R.S. Lanciotti, A.J. Lambert); and Evergreen Hospital Medical Center, Kirkland, Washington, USA (F.X. Riedo)

To the Editor: Since the discovery of Toscana virus (TOSV) in 1971 in Tuscany (1), sandfly-borne TOSV has become recognized as a leading cause of acute meningitis in central Italy during the summer (2). France, Spain, Portugal, Greece, and Cyprus have also reported cases of TOSV infection (2). Although TOSV has been detected in sandflies in Sicily (3), we are not aware of any historically documented human infection with TOSV in this southernmost region of Italy.

We report TOSV infection of an American male physician, 65 years of age, who traveled to Sicily for 3 weeks and returned to the United States in October 2009. Two days after his return, he awoke with a headache, and hours later he noticed difficulty finding words. His headache progressed, and during the next few hours, he experienced severe expressive dysphasia. At admission to the hospital, he denied having fever, nuchal rigidity, photophobia, nausea, vomiting, or diarrhea.

Other than changing planes in Milan, the patient had remained in Sicily during the entire 3 weeks of his visit. He had sustained both mosquito and what he thought were flea bites while in Sicily. He had no known exposure to bats, rabid animals, or ticks.

Computed tomographic scan and magnetic resonance imaging of the brain showed no mass lesions or abnormality of the cerebral vessels. A sample of cerebrospinal fluid (CSF) obtained at admission showed 14 leukocytes/mm3 (reference range 0–5 leukocyte/mm3) with 100% lymphocytes, a protein level of 126 mg/dL (reference range 15–45 mg/dL), and a glucose level of 63 mg/dL (reference range 50–80 mg/dL). A nasopharyngeal swab specimen was negative for influenza A and B virus antigens. Other than a decreased thrombocyte count and an elevated serum glucose level, the results of complete blood count, comprehensive chemical panel, and coagulation studies were within normal limits. PCR results for CSF were negative for herpes simplex virus, enterovirus, and parechovirus. Test results for acute-phase and convalescent-phase serum specimens performed at the Washington State Department of Health Laboratory were negative for West Nile virus and St. Louis encephalitis virus immunoglobulin M.

Serum and CSF were sent to the Centers for Disease Control and Prevention in Fort Collins, Colorado. TOSV RNA was detected in a CSF sample collected on day 1 of illness by using reverse transcription–PCR (4). Plaque-reduction neutralization assays demonstrated a >4-fold rise in TOSV neutralizing antibodies between paired serum specimens collected on days 1 (titer <1:10) and 21 (titer 1:320) of illness. No similar rise in neutralizing antibodies to serologically related phleboviruses (e.g., sandfly fever Naples virus and sandfly fever Sicilian virus) was detected. The patient received supportive care only. He had a complete neurologic recovery in 10 days and was able to return to work.

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Toscana Virus Infection in American Traveler Returning from Sicily, 2009 | CDC EID