PLOS Neglected Tropical Diseases, February 12, 2018

Ravi Mehta, Cristiane Nascimento Soares, Raquel Medialdea-Carrera, Mark Ellul, Marcus Tulius Texeira da Silva, Anna Rosala-Hallas, Marcia Rodrigues Jardim, Girvan Burnside, Luciana Pamplona, Maneesh Bhojak, Radhika Manohar, Gabriel Amorelli Medeiros da Silva, Marcus Vinicius Adriano, Patricia Brasil, Rita Maria Ribeiro Nogueira, Carolina Cardoso Dos Santos, Lance Turtle, Patricia Carvalho de Sequeira, David W. Brown, Michael J. Griffiths, Ana Maria Bispo de Filippis, Tom Solomon



During 2015–16 Brazil experienced the largest epidemic of Zika virus ever reported. This arthropod-borne virus (arbovirus) has been linked to Guillain-Barré syndrome (GBS) in adults but other neurological associations are uncertain. Chikungunya virus has caused outbreaks in Brazil since 2014 but associated neurological disease has rarely been reported here. We investigated adults with acute neurological disorders for Zika, chikungunya and dengue, another arbovirus circulating in Brazil.


We studied adults who had developed a new neurological condition following suspected Zika virus infection between 1st November 2015 and 1st June 2016. Cerebrospinal fluid (CSF), serum, and urine were tested for evidence of Zika, chikungunya, and dengue viruses.


Of 35 patients studied, 22 had evidence of recent arboviral infection. Twelve had positive PCR or IgM for Zika, five of whom also had evidence for chikungunya, three for dengue, and one for all three viruses. Five of them presented with GBS; seven had presentations other than GBS, including meningoencephalitis, myelitis, radiculitis or combinations of these syndromes. Additionally, ten patients positive for chikungunya virus, two of whom also had evidence for dengue virus, presented with a similar range of neurological conditions.


Zika virus is associated with a wide range of neurological manifestations, including central nervous system disease. Chikungunya virus appears to have an equally important association with neurological disease in Brazil, and many patients had dual infection. To understand fully the burden of Zika we must look beyond GBS, and also investigate for other co-circulating arboviruses, particularly chikungunya.

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