Mucocutaneous Findings and Course in an Adult With Zika Virus Infection

Importance  The Zika virus epidemic has been declared a public health emergency of international concern by the World Health Organization. We describe the mucocutaneous features and histologic correlation in a patient with the acute Zika virus infection.

Observations  We observed the presence of a diffuse papular descending eruption, petechiae on the palate, and hyperemic sclerae in a 44-year-old man returning from Puerto Rico with confirmatory testing for the Zika virus.

Conclusions and Relevance  A detailed awareness of mucocutaneous findings associated with Zika virus infection will support its early recognition and will facilitate elimination of Zika infection from consideration for concerned patients who present with other, more common erythematous eruptions.

Zika virus (ZIKV) is an enveloped, single-stranded RNA flavivirus transmitted by the mosquito vector Aedes aegypti. ZIKV was incidentally discovered in a febrile Rhesus monkey at a Ugandan yellow fever surveillance center in 1947.¹ In 2007, human ZIKV infection was reported in other parts of Africa, Asia, and the Pacific Islands.² In early 2015, the virus was observed in Brazil and later in the 25 countries of the Americas.² Based on the interim case definition by the World Health Organization, a person suspected of being infected with ZIKV has an erythematous eruption and/or fever with at least 1 of the following: arthralgia, arthritis, and/or conjunctivitis. Herein, we describe the mucocutaneous morphologic findings and histologic correlation in ZIKV infection.

In February 2016, a 44-year-old man returned from a 6-day vacation in Puerto Rico. Within 3 days of his return, the patient experienced headache and lethargy. This was followed 1 day later by the appearance of an erythematous eruption on the arms, dorsal side of the hands, and the palms. Over the course of the next 24 hours, the eruption became more apparent and had also spread to the trunk. Itching was not a major feature. The patient also noted that his eyes appeared “bloodshot.” As the eruption faded on the upper body, it became more apparent on the lower body. On day 3, the patient noted the eruption to be most pronounced on the knees and feet, and he described burning pain of the feet. He developed joint pains involving the wrists, knees, and ankles on day 4. The erythematous eruption, arthralgias, and constitutional symptoms improved by day 5 and were resolved by day 8. The patient remained afebrile throughout the course of illness. He did not experience cough, coryza, sore throat, diarrhea, nausea, or vomiting and stated that he had not taken new prescriptions or over-the-counter medications in the 6 weeks prior to onset of the eruption.

On physical examination, there were numerous tiny pink and red erythematous papules scattered diffusely over the head, neck, trunk, and extremities, including the palms and soles (Figure 1A). Many papules were partially nonblanching, particularly in acral regions (Figure 1B). There were petechiae on the hard palate, and sclerae were injected and nonpurulent (Figure 2). Lymph nodes were not palpable.

Biopsy specimens of lesional skin showed mild and focally moderate perivascular lymphocytic infiltrate in the upper dermis (Figure 3A). The deep dermis and subcutis (not shown) were unremarkable. A high-power view showed the focal moderate perivascular lymphocytic infiltrate in the upper dermis (Figure 3B). There were no cytologic abnormalities of the lymphocytes. The infiltrate was not composed of eosinophils or neutrophils. No viral cytopathic changes were noted in the tissue.

Real-time polymerase chain reaction (RT-PCR) for ZIKV RNA was detected in the urine but not in the serum from samples taken 3 days after the eruption was noted. Enzyme-linked immunosorbent assay on serum was reactive for IgM.

The incubation period of ZIKV ranges from 3 to 12 days.³ Signs and symptoms include an exanthem (in 90% of patients), arthralgias (in 65%), nonpurulent conjunctivitis (in 55%), and headache.⁴ The exanthem has been described in the nondermatology literature as “maculopapular” or morbilliform. However, we have noted it to be distinctly comprised of small papules. The exanthema has also been described to descend—to start on the trunk and eventually involve the lower body.⁵ This was indeed the case for the patient described herein. We have also observed the presence of petechiae on the palate. Fever is not a prominent feature and is low grade when present. ZIKV is detectable by RT-PCR in the urine at a higher load and for a longer duration than in serum.⁵ Serum levels of ZIKV may not be detectable via RT-PCR for up 20 days after onset of symptoms.⁶ Treatment of ZIKV infection is supportive.

We have detailed the morphologic mucocutaneous findings and histologic characteristics of lesional skin that may support the health care community in recognizing exanthems suspected to be related to ZIKV infection and perhaps in eliminating it from consideration for concerned patients who present with other, more common eruptions.

Corresponding Author: Amit Garg, MD, Department of Dermatology, Hofstra Northwell School of Medicine, 1991 Marcus Ave, Ste 300, New Hyde Park, NY 11042 (amgarg@northwell.edu).

Accepted for Publication: April 11, 2016.

Published Online: May 11, 2016. doi:10.1001/jamadermatol.2016.1433.

Author Contributions: Dr Garg had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Cellura, Garg.

Acquisition, analysis, or interpretation of data: Derrington, Cellura, McDermott, Gubitosi, Sonstegard, Chen, Garg.

Drafting of the manuscript: Derrington, Cellura, Gubitosi, Sonstegard, Chen, Garg.

Critical revision of the manuscript for important intellectual content: Cellura, McDermott, Garg.

Administrative, technical, or material support: Derrington, Cellura, McDermott, Gubitosi.

Study supervision: Cellura, Garg.

Pathologic analysis: Chen.

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.