Epidemiologic Notes and Reports B-Virus Infection in Humans -- Pensacola, Florida

Between March 28 and April 7, 1987, four persons were admitted to hospitals in Pensacola and Gulf Breeze, Florida, with illnesses that were later confirmed to be caused by infection with B-virus (cercopithecid herpesvirus 1, Herpesvirus simiae (1)). Three were monkey handlers with the Naval Aerospace Medical Research Laboratory (NAMRL) at the Pensacola Naval Air Station; the fourth was the wife of one of the three handlers.

Patient 1: On about March 4, a 31-year-old male who had been employed as an animal caretaker for 8 years was bitten on the left thumb by a 3-year-old Rhesus monkey that was suffering from severe bilateral conjunctivitis and diarrhea. The employee had occasionally handled smaller monkeys without protective leather gloves, and it is not certain whether he was wearing gloves when he was bitten. Five days later, he developed numbness in his left arm. Eighteen days after being bitten, he developed lethargy, fever, chills, dizziness, and myalgia. At no time did he have skin lesions suggestive of herpesvirus infection. Over the next 4 days, he developed numbness and paresthesia in the left side of his body, diplopia, and leg weakness. On March 28, he was admitted to the hospital. Two days later, he was placed on intravenous acyclovir. Subsequently, B-virus antibodies were detected in his serum by enzyme immunoassay (titer = 32). Spinal fluid that was collected before the initiation of acyclovir therapy was positive for B-virus. The patient continued to deteriorate and was put on a respirator. His therapy was changed to 9-(1,3-dihydroxy-2-propoxymethyl)guanine (DHPG) on a compassionate Investigational New Drug protocol granted by the Food and Drug Administration. He is currently semi-comatose.

Patient 2: On about March 10, a 37-year-old male who had been employed as a biological technician for 13 years suffered a penetrating wound which may have been a monkey bite or scratch on the left forearm. Patient 2 had had frequent contact with the monkey that injured Patient 1, and his wound may have been inflicted by this animal. Patient 2 had also handled smaller animals without leather gloves, but it is uncertain whether he was wearing them at the time he was exposed. Five days after his injury, he developed herpetiform vesicles at the site of the wound. On March 26, after the lesions had become crusted, he was seen by a dermatologist who detected giant cells in scrapings from the lesions (Tzanck preparation) but no distinct viral inclusions. A presumptive diagnosis of herpes zoster versus herpes simplex was made. Topical acyclovir was prescribed, but the patient treated himself only with topical hydrocortisone cream. Over the next several days, he developed numbness in his left arm, chest pain, dyspnea, fever, confusion, lethargy, diplopia, and dysphagia. He made several visits to emergency rooms before being hospitalized on March 28. Later that day, he suffered a respiratory arrest and was placed on mechanical ventilation. A lumbar puncture was consistent with aseptic meningitis. He was placed on intravenous acyclovir. A skin biopsy specimen obtained the day after admission was positive for B-virus. Treatment was subsequently changed to intravenous DHPG. However, the patient's condition deteriorated, and he died on April 28.

Patient 3: On March 11, a 53-year-old male laboratory supervisor who had been employed at NAMRL for 12 years handled a clinically healthy monkey. He wore leather gloves to catch the animal but wore only surgical gloves while holding it afterward. He reported no bites, scratches, or contact with monkey body fluids. On March 27, he noted pruritic vesicles on the third finger of his right hand. Three days later the lesions were dry and crusted. A physician at the laboratory referred him to a dermatologist who performed a biopsy and later placed him on oral acyclovir. The tissue obtained during the biopsy was positive for a herpesvirus, and, on April 6, the patient was hospitalized. Intravenous acyclovir was begun on April 10, and the tissue was confirmed positive for B-virus on April 13. The lesions continued to heal, and the disease did not progress further. On April 21, the patient was discharged from the hospital and instructed to continue treatment with oral acyclovir. However, he greatly reduced his dosage a few days later. Routine follow-up cultures of conjunctiva and buccal mucosa obtained on April 28 were positive for B-virus the following day. He was readmitted to the hospital and again placed on intravenous acyclovir. He has remained asymptomatic. All other follow-up cultures except a rectal culture obtained May 8 have been negative.

Patient 4: The 29-year-old wife of Patient 2 applied hydrocortisone cream to her husband's skin lesions beginning about March 18. During this time, she also applied this cream to an area of contact dermatitis under a ring on her finger. The dermatitis was highly pruritic, and she scratched it to the point of bleeding. On April 1, she was seen by a dermatologist who performed a culture of samples taken from the lesion and prescribed oral acyclovir. On April 7, the culture was reported positive for B-virus, and the patient was hospitalized and placed on intravenous acyclovir. Her dermatitis cleared, and the disease did not progress further. Cultures of oral and conjunctival specimens were performed every 3 to 4 days. The conjunctival cultures became positive for B-virus beginning with the specimen of April 10 and remained positive through April 28. She had no clinical evidence of conjunctivitis, and subsequent cultures have been negative.

Forty-nine persons who had direct (skin-to-skin or body-fluid-to-skin) contact with the patients before diagnosis are under clinical and laboratory surveillance for B-virus infection. No cases of infection or illness suggestive of B-virus have been detected among this group. The ill monkey that bit Patient 1 and that may have bitten Patient 2 and the clinically healthy monkey that was handled by Patient 3 have positive saliva cultures for B-virus. Reported by: DG Griffin, MD, Escambia County Public Health Unit, Pensacola; EW Sutton, MD, Santa Rosa County Public Health Unit, Milton; PL Goodman, MD, WA Zimmern, MD, ND Bernstein, MD, Pensacola; TW Bean, MC, USN, MR Ball, MS, CM Schindler, DO, Naval Hospital, Pensacola; CPT JO Houghton, MC, USN, CDR JA Brady, MSC, USN, LCDR AH Rupert, MC, USN, LTC GS Ward, VC, USA, Naval Aerospace Medical Research Laboratory, Naval Air Station, Pensacola; MH Wilder, Acting State Epidemiologist, Florida Dept of Health and Rehabilitative Svcs, Tallahassee, Florida. JK Hilliard, PhD, Southwest Foundation for Biomedical Research, San Antonio, Texas. RL Buck, MC, USN, DH Trump, MC, USN, Navy Environmental and Preventive Medicine Unit No. 2, Norfolk, Virginia. Div of Viral Diseases, Center for Infectious Diseases; Div of Field Svcs, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: B-virus, a close relative of the herpes simplex viruses of man, is enzootic in macaques and possibly other Old World monkeys. It is most frequently associated with Rhesus monkeys (Macaca mulatta). Like herpes simplex virus infections in man, B-virus infection in monkeys is characterized by intermittent reactivation and shedding, particularly during periods of stress and/or immunosuppression. Fortunately, symptomatic infection in monkey handlers and in persons handling monkey tissue appears to be rare--since the discovery of the virus in the 1930s, only 23 cases of symptomatic human infection have been described in the literature (2). However, the consequences of symptomatic infection are severe--of the 23 patients, 18 have died from encephalitis. The frequency of asymptomatic human infection is unknown.

In at least one instance, Patient 1 and Patient 2 had handled an ill monkey that had not been anesthetized. It appears that at least one of them had not worn the recommended protective clothing. One was bitten, and the other was either bitten, scratched, or infected through contamination of a preexisting wound. It is, therefore, likely that the use of appropriate protective clothing could have prevented illness in at least one of the men. Patient 3, however, was appropriately protected when he handled the second culture-positive monkey, and he was not aware of any skin contact with the monkey or its body fluids. However, he may have had unrecognized contact with contaminated material.

Patient 4 has the first documented case of human-to-human transmission of B-virus. Infectious fluid from her husband's skin lesions was apparently inoculated directly into macerated skin, similar to the inoculation produced by a monkey bite. Since her infection does not appear to have spread systemically, she may have spread the infection to her eyes when she inserted her contact lenses. Transmission of the virus by less direct contact, such as inoculation of infectious fluid on intact skin or transmission by fomites, although theoretically possible, has not been documented. The lack of detectable infection thus far in persons with such exposures to any of the four patients suggests that transmission from casual contact is unlikely. This information will be important as

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