MAJOR ARTICLE 152 • CID 2020:71 (1 July) • Radhakrishnan et al Clinical Infectious Diseases Received 17 April 2019; editorial decision 7 August 2019; accepted 17 August 2019; published online October 18, 2019. Correspondence: C. Radhakrishnan, Professor of Medicine, Government Medical College, Kozhikode, Kerala, India (chandnisajeevan@gmail.com). Clinical Infectious Diseases ® 2020;71(1):152–7 © The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com. DOI: 10.1093/cid/ciz789 Clinical Manifestations of Nipah Virus–Infected Patients Who Presented to the Emergency Department During an Outbreak in Kerala State in India, May 2018 Radhakrishnan Chandni, 1, T. P. Renjith, 1 Arshad Fazal, 1 Noufel Yoosef, 1 C. Ashhar, 1 N. K. Thulaseedharan, 1 K. P. Suraj, 1 M. K Sreejith, 1 K. G. Sajeeth Kumar, 1 V. R. Rajendran, 1 A. Remla Beevi, 2 R. L. Sarita, 3 Attayur P. Sugunan, 4 Govindakarnavar Arunkumar, 5, D. T. Mourya, 6 and Manoj Murhekar 7, 1 Government Medical College, Kozhikode, Kerala, India; 2 Directorate of Medical Education, Thiruvananthapuram, Kerala, India; 3 Directorate of Health Services, Thiruvananthapuram, Kerala, India; 4 Indian Council of Medical Research (ICMR)-Regional Medical Research Centre, Port Blair, Andaman & Nicobar Islands, India; 5 Manipal Institute of Virology, Manipal Academy of Higher Education (Institute of Eminence Deemed to be University), Manipal, Karnataka, India; 6 ICMR-National Institute of Virology, Pune, Maharashtra, India; and 7 ICMR-National Institute of Epidemiology, Chennai, Tamil Nadu, India Background. An outbreak of Nipah virus (NiV) disease occurred in the Kozhikode district of Kerala State in India in May 2018. Several cases were treated at the emergency medicine department (ED) of the Government Medical College, Kozhikode (GMCK). Te clinical manifestations and outcome of these cases are described. Methods. Te study included 12 cases treated in the ED of GMCK. Detailed clinical examination, laboratory investigations, and molecular testing for etiological diagnosis were performed. Results. Te median age of the patients was 30 years and the male to female ratio was 1.4:1.0. All the cases except the index case contracted the infection from hospitals. Te median incubation period was 10 days, and the case fatality ratio was 83.3%. Ten (83.3%) patients had encephalitis and 9 out of 11 patients whose chest X-rays were obtained had bilateral infltrates. Tree patients had bradycardia and intractable hypotension requiring inotropes. Encephalitis, acute respiratory distress syndrome, and myocarditis were the clinical prototypes, but there were large overlaps between these. Ribavirin therapy was given to a subset of the patients. Although there was a 20% reduction in NiV encephalitis cases treated with the drug, the diference was not statistically signifcant. Te outbreak ended soon afer the introduction of total isolation of patients and barrier nursing. Conclusion. Te outbreak of NiV disease in Kozhikode in May 2018 presented as encephalitis, acute respiratory distress and my- ocarditis or combinations of these. Te CFR was high. Ribavirin therapy was tried but no evidence for its beneft could be obtained. Keywords. Nipah virus; encephalitis; Nipah epidemic; Nipah clinical manifestations Kozhikode; Kerala-India. Nipah virus (NiV) infection is a newly emerging viral zoonosis that has the potential to cause severe disease in both animals and humans [1]. NiV, a member of the Henipavirus genus of the Paramyxoviridae family [2], is a highly infectious pathogen [3]. The natural host of the virus is the fruit bat of the Pteropus genus belonging to the Pteropodidae family [4]. NiV was implicated as the causative agent of outbreaks in humans and pigs in Malaysia in 1998 [5, 6], where pigs acted as intermediate amplifying hosts [7]. Te disease re-emerged in Bangladesh in 2001 and again in 2003 [8]. An epidemiological link to the consumption of raw date palm juice was identifed during an outbreak in 2005 [9]. Twenty-three introductions of NiV from animal carriers to hu- mans resulting in 10 outbreaks and 122 cases were identifed in Bangladesh between 2001 and 2007 [10]. Drinking raw date palm juice and contact with patients with NiV disease, including caring for such patients, were the most common risk factors [11]. In India, NiV infection was frst detected when clinical spe- cimens of patients afected during an outbreak of febrile illness with altered sensorium, which occurred in Siliguri, West Bengal, in 2001, were tested retrospectively [12, 13]. Forty-fve (75%) of the 60 cases were hospital workers who cared for NiV cases or who had exposure to a patient with NiV disease in a hospital. Te outbreak ended 5 days afer the introduction of barrier nursing in the hospitals [12]. Another cluster of 5 cases of NiV encepha- litis occurred in a village on the Bangladesh border in 2007 [14]. On 5 May 2018, a young male patient died of encephalitis of unknown etiology at Government Medical College, Kozhikode (GMCK), in the state of Kerala, India. Within 2 weeks of his death, 3 of his family members developed similar illness and all of them died. Blood samples of these patients tested positive for NiV RNA at the Manipal Institute of Virology (MIV), formerly the Manipal Centre for Virus Research, and this was confrmed by the Indian Council of Medical Research (ICMR)-National Institute of Virology, Pune, India. Te NiV etiology of the di- sease was known just before the death of the second case [15]. Downloaded from https://academic.oup.com/cid/article/71/1/152/5598918 by EVES-Escola Valenciana dÉstudis de la Salut user on 08 June 2022