International Notes Brazilian Purpuric Fever -- Mato Grosso, Brazil

Brazilian purpuric fever (BPF) is a life-threatening pediatric infection that is preceded by conjunctivitis and caused by a specific strain of Haemophilus influenzae biogroup aegyptius (BPF clone*) (1-4). BPF was recognized during 1984 in the state of Sao Paulo, Brazil, when 10 children in a town of 20,000 persons died of an acute febrile illness associated with purpura and vascular collapse (5,6). Until December 1989, no cases of BPF had been reported outside of Sao Paulo and the neighboring state of Parana. This report summarizes the recognition and investigation of BPF in the state of Mato Grosso.

In December 1989, two definite** cases of BPF were identified in persons in two cities in Mato Grosso (Figure 1). In the first case, H. influenzae biogroup aegyptius was isolated by blood culture from a clinically ill child; in the second, a definite case of BPF was clinically diagnosed. In addition, from August through October 1989, three possible*** BPF cases occurred in Mato Grosso.

In January 1990, the Mato Grosso State Department of Health (MGSDH) distributed information about BPF to all hospitals and clinics in the state and conducted an educational seminar on BPF for physicians and public health workers. Health professionals were encouraged to report all suspected BPF cases to the MGSDH.

By April 1990, 26 cases (including the two definite and three possible cases identified in December) that were believed to be either definite or possible BPF had been reported. Of these, 10 cases (from six widely separated cities) were confirmed: three as definite and seven as possible BPF. The overall attack rate for the combined population of the six cities was six per 100,000 children less than 10 years of age. Six of the 10 children classified as definite or possible cases died; another suffered autoamputation of portions of distal toes and fingers following septic shock.

The 16 other cases could not be confirmed as either definite or possible; however, at least some of these cases are believed to have been BPF because 1) no other cause of illness was identified and 2) the BPF clone was isolated on conjunctival culture from two of the children who could not be classified as having either definite or possible BPF but who were hospitalized with an acute febrile illness. Reported by: IM Bortolotto, Div of Epidemiologic Surveillance, Mato Grosso State Dept of Health; OA Takano, Federal Univ of Mato Grosso, Brazil. GA Silva, JCM Alves, Center for Epidemiologic Surveillance, MLC Tondella, B Mezzacapa Neto, K Irino, MCC Brandileone, VSD Vieira, EA Waldman, CEA Melles, Adolfo Lutz Insititute, MG Semeghini, ERSA-48 Epidemiologic Surveillance, Sao Paulo State Dept of Health, Brazil. LH Harrison, Dept of International Health, Johns Hopkins Univ, Baltimore, Maryland. Meningitis and Special Pathogens Br, Div of Bacterial and Mycotic Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: The recognition of BPF cases in six cities in Mato Grosso suggests that the BPF clone has a wider geographic distribution than previously considered and/or may be capable of gradual geographic spread. The epidemiology of BPF in Mato Grosso was similar to previously described BPF cases in Sao Paulo and Parana (7).

During the epidemiologic investigation of BPF in Mato Grosso, a randomized study was conducted to compare the efficacy of topical chloramphenicol with that of oral rifampin for conjunctival eradication of the BPF clone among children with BPF clone conjunctivitis. The results of this study suggest that oral rifampin is substantially more effective (8). Because the development of BPF may be related to conjunctival carriage of the BPF clone, oral rifampin may be useful for prevention of BPF among children with BPF clone conjunctivitis. In Sao Paulo and Mato Grosso, some children with conjunctivitis who have been exposed to a suspected case of BPF are being treated with oral rifampin (20 mg/kg divided by ay for 4 days).

During April 1990, a hospital-based system of active surveillance for BPF was established in Mato Grosso to identify additional BPF cases, better define the clinical spectrum of disease, and establish a population-based incidence for BPF. Additional cases of BPF in Mato Grosso have been identified through this system. Moreover, recent definite and possible BPF cases have been reported in Sao Paulo. The occurrence of BPF in Mato Grosso and the continued occurrence of BPF in Sao Paulo emphasize the need for improved understanding of the epidemiology and pathogenesis of BPF to enable the development of effective methods for its control and prevention.

References

1. CDC. Brazilian purpuric fever: Haemophilus aegyptius bacteremia complicating purulent conjunctivitis. MMWR 1986;35:553-4.

2. Irino K, Lee IML, Kaku M, et al. Febre purpurica brasileira: resultados preliminares da investigacao etiologica. Rev Inst Med Trop Sao Paulo 1987;29:174-7.

3. Brazilian Purpuric Fever Study Group. Haemophilus aegyptius bacteremia in Brazilian purpuric fever. Lancet 1987;2:761-3.

4. Brenner DJ, Mayer LW, Carlone GM, et al. Biochemical, genetic, and epidemiolgic characterization of Haemophilus influenzae biogroup aegyptius (Haemophilus aegyptius) strains associated with Brazilian purpuric fever. J Clin Microbiol 1988;26:1524-34.

5. CDC. Preliminary report: epidemic fatal purpuric fever among children--Brazil. MMWR 1985;34:217-9.

6. Brazilian Purpuric Fever Study Group. Brazilian purpuric fever: epidemic purpura fulminans associated with antecedent purulent conjunctivitis. Lancet 1987;2:757-61.

7. Harrison LH, Silva GA, Pittman M, et al. Epidemiology and clinical spectrum of Brazilian purpuric fever. J Clin Microbiol 1989;27:599-604.

8. Perkins BA, Silva GA, Tondella MLC, et al. Confirmation of Brazilian purpuric fever in a new region of Brazil and evaluation of oral rifampin to eradicate conjunctival carriage of Haemophilus aegyptius (Abstract). In: Proceedings of the 30th Interscience Conference on Antimicrobial Agents and Chemotherapy. Washington, DC: American Society for Microbiology, 1990:277.

• BPF clones are defined as H. influenzae biogroup aegyptius strains that have the characteristics of strains that have caused BPF. These strains probably descended from a single clone with unique invasive potential.

** A definite BPF case is defined as isolation of H. influenzae biogroup aegyptius from a normally sterile body site or, in a child aged 3 months to 10 years, acute febrile illness, abdominal pain or vomiting, hemorrhagic skin lesions, a history of conjunctivitis in the 30 days preceding fever, no evidence of meningitis, and exclusion of meningococcal disease by specific tests. If other tests are obtained, results must be negative for other known pathogenic bacteria, and cerebrospinal fluid must contain less than 100 leukocytes/uL (1).

*** A possible BPF case is defined as fever, recent conjunctivitis, and acute hemorrhagic skin lesions in a child aged 3 months to 10 years (7).

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