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Viremia and Clinical Presentation in Nicaraguan Patients Infected with Zika Virus, Chikungunya Virus, and Dengue Virus

  1. Benjamin A. Pinsky1,5,#
  1. 1Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
  2. 2Sustainable Sciences Institute, Managua, Nicaragua
  3. 3National Virology Laboratory, Centro Nacional de Diagnóstico y Referencia, Ministry of Health, Managua, Nicaragua
  4. 4Department of Scientific Computing, Florida State University, Tallahassee, FL, USA
  5. 5Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
  6. 6Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, Berkeley, CA, USA
  1. #Corresponding Author: Benjamin A. Pinsky, 3375 Hillview Ave, Room 2913, Palo Alto, CA 94304. Phone: +001 (650) 721-1896, Fax: +001 (650) 723-6918, E-mail: bpinsky{at}


Background. Zika virus (ZIKV), chikungunya virus (CHIKV), and dengue virus (DENV) co-circulate in Nicaragua. In this study, we sought to compare the quantified viremia and clinical presentation of patients infected with one or more of these viruses.

Methods. Acute-phase serum samples from 346 patients with a suspected arboviral illness were tested using a multiplex real-time RT-PCR for ZIKV, CHIKV, and DENV. Viremia was quantitated for each detected virus, and clinical information was recorded from request forms submitted with each sample.

Results. Two hundred sixty-three patients tested positive for one or more viruses: 192 patients tested positive for a single virus (mono-infections) and 71 patients tested positive for two or all three viruses (co-infections). Quantifiable viremia was lower in ZIKV infections compared to CHIKV or DENV (mean 4.70 vs 6.42 and 5.84 log10 copies/mL serum, respectively; p<0.001 for both comparisons), and for each virus, mean viremia was significantly lower in co-infections than in mono-infections. Compared to patients with CHIKV or DENV, ZIKV patients were more likely to have a rash (p<0.001) and less likely to be febrile (p<0.05) or require hospitalization (p<0.001). Among all patients, hospitalized cases had higher viremia than those who did not require hospitalization (7.1 vs 4.1 log10 copies/mL serum, respectively; p<0.001).

Conclusions. ZIKV, CHIKV, and DENV result in similar clinical presentations, and co-infections may be relatively common. Our findings illustrate the need for accurate, multiplex diagnostics for patient care and epidemiologic surveillance.

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