Skip directly to site content Skip directly to page options Skip directly to A-Z link Skip directly to A-Z link Skip directly to A-Z link
Volume 22, Number 5—May 2016

Fatal Sickle Cell Disease and Zika Virus Infection in Girl from Colombia

Cite This Article

To the Editor: Zika virus, a mosquito-borne flavivirus, causes, a usually self-limiting febrile and exanthematic arthralgia syndrome that resembles dengue and chikungunya (1). This arboviral disease has emerged in tropical areas of Latin America, particularly in Brazil and Colombia (2), as a public health threat in 2015 and has spread into areas to which dengue virus (DENV) and chikungunya virus (CHIKV) are endemic (14).

Cases of severe and fatal Zika virus infection have not been described (5), and the spectrum of clinical disease remains uncertain in the setting of rapidly evolving epidemics of this arbovirus in Latin America (1). We report a person with sickle cell disease who acquired a Zika virus infection and died.

The patient was a 15-year-old girl who in October 2015 came to the outpatient clinic of the Hospital of Malambo (a primary-level public hospital) in Malambo (Atlántico Department) in northern Colombia. In this region, during September 22, 2015–January 2, 2016, a total of 468 suspected cases of Zika virus infection and 4 reverse transcription PCR (RT-PCR)–confirmed cases have been reported. This patient had a high fever (temperature >40°C), arthralgias, retro-ocular pain, abdominal pain, myalgias, and jaundice for the previous 4 days. She had sickle cell disease for 5 years (hemoglobin genotype SC identified by DNA analysis), but no previous hospitalizations or episodes of vaso-occlusive crises. She had never had dengue, chikungunya, or acute chest syndrome.

At admission to the hospital, the patient had a pulse rate of 112 beats/min, a respiratory rate of 24 breaths/min, a blood pressure of 110/70 mm Hg, and a temperature of 39.0°C. She had abdominal pain, no petechiae, and no lymphadenopathy. The patient was given acetaminophen. Results of a neurologic assessment were unremarkable. Clinical laboratory findings are shown in the Table.

Given these manifestations, she was given a diagnosis of a DENV infection and referred to Barranquilla Hospital Metropolitano (Barranquilla, Colombia) where she was admitted 1 day later. Physical examination showed a pulse rate of 122 beats/min, a respiratory rate of 34/min (peripheral capillary oxygen saturation 93%), a blood pressure of 112/58 mm, and a temperature of 37.5°C. She had generalized jaundice, respiratory distress, severe abdominal pain, hepatomegaly, and splenomegaly, but no lymphadenopathy. The patient was conscious (stuporous) and had a Glasgow Coma Scale score of 13. Cardiovascular assessment showed tachycardia and a holosystolic murmur (grade II) but no other findings.

The patient was then transferred to the pediatric intensive care unit, where she was intubated and mechanical ventilation was initiated. Her condition was considered life threatening; the patient had severe acute respiratory distress syndrome and progressive hypoxemia despite ventilator treatment, and laboratory findings worsened (Table).

The patient was given transfusions of blood products for treatment of anemia and thrombocytopenia. Chest radiograph and ultrasound showed an extensive right-side hemothorax. The result of a Zika virus–specific real-time RT-PCR was positive (Table). Her clinical condition deteriorated. Despite intensive treatment, the patient did not recover and died 37 hours later. An autopsy showed hepatic panacinar necrosis, erythrophagocytosis of Kupffer cells, and severe decrease of splenic lymphoid tissue (functional asplenia) with multiple drepanocytes and splenic sequestration, but no signs of yellow fever or malaria (Technical Appendix Figure).

Although sickle cell disorders are not common in Colombia, their frequency is higher along the Caribbean coast (including Atlántico Department) and 2 times that of the rest of Colombia) (6). Although chronic diseases, such as sickle cell disorders, are considered to be a risk factor for development of severe dengue and chikungunya (7,8), no cases have been reported in association with Zika. Reports of patients co-infected with DENV and CHIKV are rare, few details are available, and mostly restricted to few fatal cases of dengue (9). In patients with dengue, deaths might be higher among those who have a hemoglobin SC genotype, as recently reported (10). Onset of vaso-occlusion in persons with sickle cell disorders is often triggered by inflammation, as has been reported in DENV infections and which probably occurred in our patient (8). This complication and severe splenic sequestration, detected by autopsy, probably caused her death.

In summary, this case indicates that patients with sickle cell disorders and suspected arboviral infections should be closely monitored. Given current epidemics of Zika virus infection in Colombia (746 RT-PCR–confirmed cases and 11,712 suspected cases during September 22, 2015–January 2, 2016), atypical and severe manifestations and concurrent conditions in patients should be assessed to prevent additional deaths (2).


Laura Arzuza-Ortega, Arnulfo Polo, Giamina Pérez-Tatis, Humberto López-García, Edgar Parra, Lissethe C. Pardo-Herrera, Angélica M. Rico-Turca, Wilmer Villamil-Gómez, and Alfonso J. Rodríguez-Morales
Author affiliations: Entidades Promotoras de Salud Barrios Unido Mutual, Quibdó, Colombia (L. Arzuza-Ortega); Empresa Social del Estado Hospital de Malambo, Malambo, Colombia (A. Polo); Hospital Metropolitano, Barranquilla, Colombia (G. Pérez-Tatis, H. López-García); Instituto Nacional de Salud, Bogotá, Colombia (E. Parra, L.C. Pardo-Herrera, A.M. Rico-Turca); Hospital Universitario de Sincelejo, Sincelejo, Colombia, (W. Villamil-Gómez); Universidad del Atlántico, Barranquilla (W. Villamil-Gómez); Universidad de Cartagena, Cartagena, Colombia (W. Villamil-Gómez); Universidad Tecnológica de Pereira, Pereira, Colombia (A.J. Rodriguez-Morales)



  1. Rodriguez-Morales  AJ. Zika: the new arbovirus threat for Latin America. J Infect Dev Ctries. 2015;9:6845. DOIPubMedGoogle Scholar
  2. Pan American Health Organization. Neurological syndrome, congenital malformations, and Zika virus infection. Implications for public health in the Americas—epidemiological alert 2015 [cited 2016 Jan 1].
  3. Alfaro-Toloza  P, Clouet-Huerta  DE, Rodriguez-Morales  AJ. Chikungunya, the emerging migratory rheumatism. Lancet Infect Dis. 2015;15:5102. DOIPubMedGoogle Scholar
  4. Campos  GS, Bandeira  AC, Sardi  SI. Zika Virus Outbreak, Bahia, Brazil. Emerg Infect Dis. 2015;21:18856. DOIPubMedGoogle Scholar
  5. Kwong  JC, Druce  JD, Leder  K. Zika virus infection acquired during brief travel to Indonesia. Am J Trop Med Hyg. 2013;89:5167. DOIPubMedGoogle Scholar
  6. Fong  C, Lizarralde-Iragorri  MA, Rojas-Gallardo  D, Barreto  G. Frequency and origin of haplotypes associated with the beta-globin gene cluster in individuals with trait and sickle cell anemia in the Atlantic and Pacific coastal regions of Colombia. Genet Mol Biol. 2013;36:4947. DOIPubMedGoogle Scholar
  7. Economopoulou  A, Dominguez  M, Helynck  B, Sissoko  D, Wichmann  O, Quenel  P, Atypical chikungunya virus infections: clinical manifestations, mortality and risk factors for severe disease during the 2005–2006 outbreak on Reunion. Epidemiol Infect. 2009;137:53441. DOIPubMedGoogle Scholar
  8. Moesker  FM, Muskiet  FD, Koeijers  JJ, Fraaij  PL, Gerstenbluth  I, van Gorp  EC, Fatal dengue in patients with sickle cell disease or sickle cell anemia in Curacao: two case reports. PLoS Negl Trop Dis. 2013;7:e2203. DOIPubMedGoogle Scholar
  9. Bravo  JR, Guzman  MG, Kouri  GP. Why dengue haemorrhagic fever in Cuba? 1. Individual risk factors for dengue haemorrhagic fever/dengue shock syndrome (DHF/DSS). Trans R Soc Trop Med Hyg. 1987;81:81620 and. DOIPubMedGoogle Scholar
  10. Rankine-Mullings  A, Reid  ME, Moo Sang  M, Richards-Dawson  MA, Knight-Madden  JM. A retrospective analysis of the significance of haemoglobin SS and SC in disease outcome in patients with sickle cell disease and dengue fever. EBioMedicine. 2015;2:935–9.




Cite This Article

DOI: 10.3201/eid2205.151934

Related Links


Table of Contents – Volume 22, Number 5—May 2016

EID Search Options
presentation_01 Advanced Article Search – Search articles by author and/or keyword.
presentation_01 Articles by Country Search – Search articles by the topic country.
presentation_01 Article Type Search – Search articles by article type and issue.


Page created: April 14, 2016
Page updated: April 14, 2016
Page reviewed: April 14, 2016
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.