Clinical Studies

Arthropod-Borne Virus Disease in Florida*

Report of a 1958 Outbreak in Miami and a Serologic S’ul-u~~~
qf
Miami Residents

T
ifk. small outbreak in man of arthropocl- tients hospitalized \vith \+us meningitis or
t)ornc virus meningitis and encephalitis vllcephalitis betwecu February and September
th.:~t occurred in Miami during the last four lO.i8 were tested for hemag$utination-inhibi-
irwnths of 1958 is noteworthy since it is the first tion antibodies to \-arious group R arl )o viruses,
su~:h outbreak to bc recognized in Florida. Prior and serum samples collected in 1957 and 1958
to this only occasional cases of arthropod-borne from sixty-four Miami residents \\ithout signs of
(ariw) virus infection in man had bcrn detected central nervous system infection \\‘err trs ted for
in the state: only t\vo cases of St. Louis cncepha- iiwtraliziny antihotlics to se\ eraI group .-A and
litis \vcre reported before 1958, and cases of R arho viruses.
Eastern equine encephalomyelitis ancl \l-estern
rquinc enccp halomyclitis \vcrc equalI!! rare
[I:,?]. Similar arbo virus infection occurrccl in L’lit~ictrlC&r irr ‘l’he diagnosis of’ virlus cnccpha-
1958 ill ac\-vral (:aribbean Islancls and on the litis ~vas made in patients with acute OIXCI ol a f’ehrilc
Spanish Main: in Fctxuar)-, St. Louis cncepha- disease associated with impaired intellectual function
or altered consciousness or other objcctikc widenct
litis infection \vas seen in Panama: in August, it
of neurologic abnormality above the filth I:cwical
occurred in Jamaica; and in Scptembrr, it was
segment of the spinal cord. In these t)atit.nts. leuko-
prcscnt in Trinidad and reappeared in Panama. cytes \wre almost alxvays prcsrnt in thr- spillal lluid.
St. T.ouis encephalitis virus was isolatccl from \Yrus mrningitis was considerc.d to 1)~ ;I*, acute’
tllv ))lood of three patients in Trinidad and leebrilc disease characterized l+ the findings of ar
Panama whose onI!- s)-mptoms \vcrc severe lcast 30 \vhitc blood cells per cu. mm. in the spinal
h~aclache and fr\.er; the o\wt encephalitis of fluid, normal sugar levels in the spinal fluid and none
thus Jamaican patients was found to tx St. Louis of the signs of rncephalitis. In both illnesses, headache
ellccphalitis t))- serologic test L&5]. Thus the \vas usually a prominent syin~)torn. Patients with
fwain tumors or abscesses. bacterial or liingal menin-
cases in Miami that year may well liave been
gitis, syphilis, cerebral vascular accidtnts. bacterial
part of the outbreak of arbo virus infection that
cndocarditis and ljoisoning overt’ cuclud~l from the
ws tlwn occurring iii the Caribbean area.
rtudv.
III ;I search for othrr overt and for inapparent In addition to the studies l’or arbo viruses 10 bc
art)0 1 irus infections in South Florida. serologic listed. serologic studies for leptospirosis and lympho-
stuclics were carried out on specimens collected cytic choriomeningitis, influenza .2. aclcnc~~iruses and
from Miami residents prior to October 1’958. C:oxsackie B viruses were performed on IIIOS~ of tllesc~
Serum specimens obtained from eighteen pa- patients at rcfcwnce laboratories.

* l’roin the Department of Medicine, Liniversity of Miami School of Medicine and ‘l‘he Jackson Rl~morial HOS-
pital, htiami, Florida, and the Laboratory of Tropical Virology, National Institute of Allergy and Infectious Diseases,
National Institutes of Isealth, U. S. Public 1Health Service, Bethesda, Maryland. This study was supportctl in part by
U. S. Public Health Service Research Grant No. E-4084 from thr National Institutes of r\llergy and lnfrctiow ‘I)iseases,
Public I Iealth Service, Bethesda, Maryland.
t Markle Scholar in Medical Scienrr.

VOL. 35, NOVEMBER 1963 673

674 Arthropod-Borne Virus Disease-E~renkranz et al.
inhibition tests performed according to Clarke and
Casals 1.91. In general, the hemagglutinating antigens

-r I&stern
employed those contained
from high speed centrifugation
in the supernatant fluid
of a borate-saline
Equine (pH 9.0) suspension of infected brains from suckling
it. Louis Enceph- Ilheus
Enceph- mice. Naturally occurring hemagglutination in-
alitis Virus Virus
alitis hibitors were removed from the serum by acetone
Virus extraction [ 701. Erythrocytes were obtained from
Day
Case Of chickens less than four days of age.
NO. Dis- All serum specimens were stored at minus 20’~.
case * Lo,g IHemag- -femag- 14 until tested.
Jeutral- Iclutina- Tlutina- VlWral-
ization tion tion ization
CASE REPORTS
Index Inhibi- Inhibi- Index
(log- tion tion ilog- Details of the arbo virus serology in Cases I,
.rithms) Titer 1 Titer t 3rithms) II, III and v are given in Table I.

CASE: I. A seventy year old white woman, who

121 2,560
had been ill for six days with fever, myalgia and
139 1,280 0:; severe headache, together with dysuria and frequency
3 0
100 1,280 of urination, was admitted to the Mercy Hospital of
116 2:; u:4 Miami on September 29, 1958. Her past history was
23$ yr. 0.5 80 ‘40 noncontributory. She had been a resident of Miami
9 1.5 5,120 320 for fifteen years.
31 1.8 10,240 640 Physical examination revealed a drowsy patient
42 1.8 2,560 640 i: ; with moderate nuchal rigidity. The blood pressure
111 29 1,280 80 was 1701’90 mm. Hg and the temperature 101’~. On
3 0.1 1,280 1,280
neurologic examination the patient was confused and
10 1,280 2,560
0:4 unable to remember recent events. No weakness,
36 ;:4 1,280 2,560
68 1 .8 2,560 2,560 involuntary movements or sensory changes were
found and the reflexes were physiologic and equal.
- -
Examination of the spinal fluid revealed 76 white
* Calculated from the day on which fever and/or
blood cells per cu. mm. which were predominantly
headache first occurred.
t Reciprocal of dilution. polymorphonuclear leukocytes, sugar 36 mg. per cent
and protein 103 mg. per cent. ‘The results of the blood
Neutralization 7‘ests. Virus neutralization tests count, urinalysis and blood cultures were within
were carried out according to the method described normal limits. A chest roentgenogram revealed
by Paul [6], with minor modifications. Undiluted moderate cardiomegaly.
serum from four patients (Cases I, II, III and v) and For the first three days of hospitalization the patient
other selected persons was tested with four successive was febrile, with temperatures ranging between 101”
tenfold dilutions of virus. On specimens from persons and 103%. Thereafter improvement occurred, her
without signs of central nervous system disease, a headache slowly decreasing in intensity and her con-
screening virus neutralization test \zas carried out by fusion gradually disappearing. ‘Treatment was
inoculation into mice of a mixture of undiluted serum entirely supportive. The patient made a complete
and a single virus dilution calculated to contain 50 recovery and no neurologic residua were observed on
LDs0 of virus. Each virus-serum mixture was inocu- repeated examinations through 1961.
lated intracerebrally into each of five mice. ‘l‘he
methods and interpretation of screening virus CASE II. 4 seventy-seven year old white man was
neutralization tests were those described by Smith- admitted to the Mercy Hospital of Miami on October
burn [7]. 8, 1958, because of the persistence of severe headache,
For the purpose of this investigation neutralizing dizziness, fever, chills, vomiting and frequency of
indices were calculated in the following manner: The urination. These symptoms had begun suddenly two
LDbo titer (Reed-Muench [a]) of the mixture of virus days earlier. Prior to this he had been in good health
and the test serum was subtracted from the LDSo and had been a resident of Miami for at least three
titer of the mixture of virus and the control serum (a years.
calf serum devoid of neutralizing antibodies); this Physical examination revealed a drowsy white man
difference, expressed in logarithms, is the log neu- with a temperature of 100.8”~. General physical
tralizing index. examination did not reveal any abnormalities except
Hemagylutination Inhibition ‘I’est. Hemagglutinat- nuchal rigidity. On neurologic examination the
ing antigens were prepared and the hemagglutination patient did not respond to questions intelligibly but

AMERICAN JOURNAL OF MEDICINE

 Arthropod-Borne Virus Disease-Efzrenkranz et al. 675
he did seem to recognize his wife and daughter. The decreased 10 101”~. by the third hospital day and
reflexrs were hyperactive but symmetrical; no shortly thereafter became normal. On awakening,
abnormal refexes were noted. There was no muscular she was unable to recall the events immediately
weakness. The optic fundi appeared normal. On preceding her hospitalization. Neurologic examina-
examination of the spinal fluid 33 white blood cells tion at this tim? revealed tremulousness and past
prr cu. mm. were found. the majority werr poly- pointing; these findings persisted for several months.
morphonucl~:ar leukocytes; the spinal fluid sugar was When the patient was examined one and two years
90 rng. per cent. protein 66 mg. prr cent. Blood later, no ncurologic abnormalities were clrtectedi.
cultures were negative. ‘I he initial blood count,
urinalysis and chest roentgenogram did not reveal Cornmen/: ‘Thrse three patients (Chases I, 11 and
any abnormalities. hn electroencephalogram revealed III) had the tvpical clinical findings and course
dysrhythmic slow recording with 5--7 per second
of epidemic encephalitis. Serolo,qic studies
acti>;ity throughout. This was described as sleep
demonstrated recent St. Louis encephalitis virus
dysrhythmia without focus.
infection in all three.
The patient had daily temperature elevations to
104”k. for the first t\vo days of hospitalization; there-
CASE IV. A thirty-two year old white housewife
after. thr temperature dropped to 101’ or 102’F. and
was admitted to the .Jackson Memorial Hospital on
remained there for the next three days. after which he
November 7, 1958> because of intractable headache
became afebrile. Occasional episodes of spasms of the
of five days’ duration. One day after the onset of the
fact and of thr extremities were noted; it was also
headache, she experienced nausea and vomitccl; she
observed that the patient “picked” at the bed sheets.
noted stiffness of the neck \vith forlvard flexion ‘of the
An increase in the whit? blood cell count to 14,000
head. She was given antibiotics orally and b> injection
per cu. mm. occurred after the first clay of hospital-
but there was nc, improvement in her condition. She
ization and then rapidly returned to normal.
was hospitalized then because of the persistence of
‘l‘he patient was treated supportively and recovery
headache. Prior to the onset of the hcadarhe the
was complete. He was examined at the National
patient had enjoyed good health. Sht- had bet-n a
Insl.itutes of Health in 1961; no neurologic abnor-
Miami resident for twenty years.
maiitics were evident.
No abnormalities were found on general physical
(:X1. III. A forty-seven year old white housewife examination except for herpes labialis. ‘l‘hc tcmpcra-
\vas admitted to the Jackson Memorial Hospital on ture was 97.6%. .l‘he only neurologic abnormalities
October 2. 1958, in an irrational state. On October detected were moderate nuchal rigidity and hypcr-
17 she experienced severe headache, backache, chills. active deep tendon reflexes; there was no ataxi.l.
stiffness of the neck, fever and a nonproductive cough. 1,umbar puncture revealed an initial ljressurc of
Although she was givrn tetracycline by her family 134 mm. ‘l’he spinal fluid revealrd 150 white I)lood
doctor her syrnptoms persisted. On the morning of cells per cu. mm. which were primarily polymorpho-
admission she was found to behave abnormally and nuclear, non-reactive serologic test for s)-philis, sugar
to speak inl:oherently. Prior to the onset of this illness 68 mg. pt’r cent and protein 79 mg. per cent. Spinal
she had been perfectly well. She had been a resident fluid and blood cultures were negative. ‘[‘he white
of I he Miami arra for three years. blood cell count was 17,300 per cu. mm. with 92. per
On admission to the hospital her temperature was cent polymorphonuclcar leukocytes. For the first four
104%. Physical examination revealed that the patient days of hospitalization the patient‘s tcmpcrature
was irrational and had agitated, purposeless motions. ranged between 101” and 103%. Shr thtn became
‘fhrrr were no signs of muscle wtlakness and the afebrile, her headache disappeared and she was
sensation of pain appeared to be intact; nonsustained discharged.
clonus was noted in the left ankle. Shortly aftrr ‘The patient \vas found dead in brd on November
enl.t,ring the hospital, the patient became comatose -70 ? 1958. approximatelv two weeks after her dis-
and incontinent of urine and feces. charge from the hospital and t\venty-five days after
‘l’he white blood cell count was 14:OOO prr cu. mm. the onset of her symptoms. ‘The patient‘s headache
\vith 91 per cent polymorphonuclear leukocytes. \vas said to have recurrrd at home and convulsive
I,umbar puncture revealed an initial pressure of 1 SO episodes were noted by members of the farnil>- just
mm. Examination of the spinal fluid sugar was 54 mg. prior to her death.
per cent, protein 116 mg. per cent; there were 00 :\t auropsy, the brain weighed I.335 gnn. and
white blood cells per cu. mm. of which 46 were poly- showed no gross abnormalities. Microscopic examina-
morphonuclear. Rorntgenograms of the chest and tion of the cerebral hemispheres, brain stem and
skull did not disclose any abnormalities. An electro- cerebellum revtbaled prominent perivascular lympho-
encrphalogram did not show an)- gross asymmetry? cytic cuffing in the leptomeninges, cortex, white
focal or paroxysmal abnormalities. matter and nuclei. Swelling or necrosis and disap-
‘l’he patient remained unconscious for three days pearance of nerve cell bodies were noted in various
and then awakened gradually. Her temperature parts of the brain, but these changes were more

“‘)L. 35, NOVEMBER 1963

 676 Arthropod-Borne Virus Disease-Ehrenkranz et nl.
Obstetric Clinic of the Jackson Memorial Hospital.
She was known to have been hypertensive for the past
four years, with blood pressures ranging up to 200/l 00
mm. Hg; she had been treated with chlorothiazide
and a rauwolfia preparation. The patient was born
in Puerto Rico but had lived in Miami for twelve
years prior to this illness.
Physical examination revealed an acutely ill
pregnant woman with a blood pressure of 110/70
mm. Hg and a temperature of 104%. A grade 2 harsh
systolic murmur was heard over the precordiurn.
Slight cardiomegaly was present. ‘l‘he abdomen was
protuberant and the fundus of the uterus was palpable
at 2 fingerbreadths above the umbilicus. Neurologic
examination disclosed no abnormalities except for
resistance of the neck to full flexion.
The hemoglobin was 11 gm. per cent; the white
blood cells numbered 10,000 per cu. mm., with a
normal differential count. ‘l’here was a moderate
number of white blood cells in the sediment of the
urine and a quantitative urine culture yielded more
FIG. 1. Case Iv. Section of ccrehellum showinq a dc- than 100~000 Escherichia coli per ml. of urine. On
generating segment of the Purkinjc ccl1 layer with a glial lumbar puncture the initial pressure of spinal fluid was
node in the adjacent molecular layer and prri\,ascular
230 mm. Examination of the spinal fluid revealed 450
lymphocytic cuffing in the leptomcningvs. An artifact
red blood cells per cu. mm., 264 white blood cells per
is present in the centrr of the lield. Original ma!qGfica-
tion X 73. cu. mm. with 90 per cent being polymorphonuclear,
sugar 59 mg. per cent and protein 26 mg. per cent.
pronounced in the Purkinje cell layer of the cerebellar After the first day of hospitalization the patient’s
cortex. In the cerebellum, and to a lesser extent temperature ranged between 99.4’ and 102%. for the
elsewhere, the degeneration or loss of nerve ~11s was next three days; thereafter, she became afebrile.
frequently associated with proliferation of mic.roglial Blood and spinal fluid cultures were negative. No
cells and formation of glial nodes. (Fig. 1.) Scattered neurologic abnormalities were observed on repeated
small foci of demyelinization of the white mattc’r were examinations. Lumbar punctures revealed a decrease
also noted in these sections. Inclusion bodies or in white blood cells to 127 per cu. mm. by the tenth
changes in the vessel walls could not be found. An hospital day, lvithout elevation of the spinal fluid
incidental autopsy finding was the presence of sar- protein. The urinary tract infection was treated with
coid-like granulomas in the lungs and liver. tetracycline.
Serum was not available for arbo virus studies. On April 15, 1759, four and a half months after the
onset of her illness, the patient was delivered of an
Comment: The severity and extent of this apparently normal 7 pound male infant. The patient
was seen through 1961; no neurologic abnormalities
patient’s illness was not evident until her termi-
were noted up to that time.
nal convulsions and death. The autopsy findings
are those of widespread virus encephalitis.
Comment: This patient lvith virus meningitis
CASE v. A thirty-eight year old Negro \voman has serologic findirlgs of recent group R arbo
became ill on December 29, 1958, with severe throb- virus infection.
bing generalized headache. She came to the Jackson
SEKOI.OGIC INVESTIGATION 01’ CASES I, 11, III
Memorial Hospital on January I, 1959, because of
the persistence of headache which had awakened her AND V
from sleep on several occasions and was not relieved by The serologic findings listed in Table I
simple remedies. On each of the two days immedi- establish that group R arbo virus infection did
ately preceding admission she had vomited three or
occur in these cases and in all likelihood was the
four times, and on the day prior to admission she
cause of the encephalitis and meningitis. Al-
experienced shaking chills followed by profuse
sweating. Between December 29 and January 1 the though no serum was obtained during the acute
patient also experienced urinary frequency, mild phase of illness in Case I, the high titers of both
soreness in the right flank and nocturia. neutralizing and hemagglutinating inhibition
At the time of admission the patient was five antibodies to St. Louis encephalitis virus in
months pregnant and was under the care of the serum obtained on the 121st and 139th day of

AMERICAN JOURNAL OF MEDICINE

 Arthropod-Borne Virus Disease-Hzrenkranz et al.
TABL.E II
.4RBO VIRUS NEUTRALIZING ANTIBODIES Ih MlAhlI RESIDENTS

Viruses Used in Neutralization Tests

Number logarithms 1,11:,0 used*

I
’ 13,l.h 1 .o, 1 .3 1 .l, 2.3 1.6, 2.5 1 .O, 2.’ ~ I .o
Number of serum samples tpstcd 45 62 01 45 36 40
Number of serum samples positive I 0 1 0 3 I 3
Proportion positive (5,) 2 I 0 3 0 8 j 8
-___ --
* Two figures are civen in most instanrcs sinw two neutralization tests wew usually required to t(xt the numl~~ of
srrum spwimens indicated.

tliscase point to the recent occurrence of infec- guished in the absence of recovery of the virus.
tioii with this or a closely related agent. In This serologic pattern of high antibocl) titers to
C:ai;c II the marked rise in titer of hemagglutina- antigenically related viruses is similar to that
tion inhibition antibody to St. Louis cncepha- seen in residents of known endemic areas of
litis virus between day 3 and da)- 100 of disease group B arbo virus infection [ 7 jr, I_‘].
clearly associates the time of St. 120uis cncepha- ‘T’herc was no serologic eviclence of infection
litis virus infection with the signs of encephalitis; with Eastern cquinc encephalitis, lvmphocvtic
the low titers of hema gglutination inhibition choriomcningitis, mumps, influenza A, adeno-
and neutralizing antibodies in the specimen viruses, C:ossackie B or leptospirosis in these
taken two years and eight months later are in patients. Attempts to isolate viruses from spinal
keeping with infection by St. Louis encephalitis fluid anct blood in Casr III were unsuccessful.
virus in 1058.
In Chase<III and v a significant rise in the level
of St. I,ouis encephalitis virus neutralizing So hemagglutination inhibition antibody to
anti body was demonstrated at three and one St. Louis cnccphatitis, Ilheus or .Japanesc B
months, respectively, after the beginning of the encephalitis viruses was found in the serum
illrlrsses. The high St. T,ouis encephalitis virus specimens obtained during the acute and con-
hemagglutination inhibition antibody titers in \.alescent phases of disease from fourteen pa-
both confirm the recent occurrence of group B ticnts II-it11 \ irus meningitis and four with
arbo virus infection. In case III, as in Chases I and cnccphalitis accluired in Miami bet~~rcn Frh-
II, the infection was likely due to St. Louis ruary and September 1958.
enccplialitis virus. as the lo\v Ilheus virus In order to investigate inapparent arlx) virus
hemagglutination inhibition antibody titers are infection in h4iami residents, single serum
beet attributed to a response to antigens common specimens obtainect from sixty-one adults and
to I)otli viruses. BJ- contrast, the serologic find- three children in 1937 and early 1058 tvere
ing< in Cast v \rere distinctly different from examined for neutralizing antibodies to group
thc)se in the other casts since this patient’s A and group B viruses. (Table II.) At the time
hrmagglutination inhibition antibod>- titers to of bleeding, the adults had been rcsidcnts of the
Ilheus and St. Louis encephalitis viruses were .Uiami area from three to forty-three years and
equally high. Prior to this illness this patient were under treatment at the Jackson Memorial
(C:asc v) had been a resident of XZiami for Jlospital or Clinics for a variety nf illnesses
t\<‘elve !.ears: ho\Vcver, she was born in Puerto unrelated to those known to be caused by arbo
Rico and earlier infection mitll arl)o viruses viruses. Of serum tested for antibodies to group
ma” ha\v: occurred there. The serologic results A agents (Eastern and LYestern equine cncepha-
in this instance can be attributed to infection litis), one of forty-five neutralized Eastern cquinc
wi.th either Ilheus or St. I,ouis encephalitis encephalitis virus and none of sixty-two neu-
virtls. The infecting agent cannot be. distin- tralized Western equine encephalitis virus. B\
“r,l.. 15, NOVEMRER 1963
 678 Arthropod-Borne Virus Disease--Ehrenkranz et al.

TABLE III

BIRTHPLACE AND DURATION OF FLORIDA RESIDENCE OF PERSONS

WITH ARTHROPOD-BORNE VIRUS NEUTRALIZING ANTIBODIES

T
-

I Neutralizing Antibodies to*

Florida Group A Virus Group B Virus

Miami
Resident Birthplace
Resident
(no. of yr.)
I- Eastern Western
7

St. Louis Yellow West

Equine Equine Ilheus
Encephalitis Fever Nile
Encephalitis Encephalitis
~~-

A 27 3 Georgia + - - - -
B 24 3 Bahamas _ - + - T +
C 35 35 Florida - _ _ _ + NT
D 58 8 Tennessee - -
_
-
_
- +
_ NT
E 72 43 Bahamas NT NT +
F 20 20 Florida _ _ _ _ _ +
- - - -I - !-
* f Designates antibody present; - designates antibody not detected; NT designates not tested.

contrast, neutralizing antibodies to four group B litis infection, ncurologic manifestations similarly
agents (St. Louis encephalitis, yellow fever, varied from severe headache alone to frank
Ilheus and West Nile viruses) were detected in encephalitis.
five of sixty-two serum samples. Xeutralizing The concurrence of eight and perhaps ten
antibodies to more than one arbo virus were cases of St. Louis encephalitis in Panama,
found in the serum of only one person, Miami Jamaica, Trinidad and Miami in 1958 points
resident B (Table III); in this instance anti- to trans-Caribbean spread of St. Louis encepha-
bodies to St. Louis encephalitis, Ilheus and litis virus. (Fig. 2.) Since large epidemics of St.
West Nile viruses were all present. The amounts Louis encephalitis are infrequent and the ratio
of serum available from two persons with Ilheus of inapparent to apparent infection in such
antibody were insufficient to test for presence outbreaks ranges from 16: 1 to 500: 1 ]13], it is
of West Nile virus neutralizing antibodies. The likely that undetected cases of St. Louis encepha-
three serum specimens reactive with Ilheus litis virus infection occurred elsewhere in South
virus in the screening virus neutralization test Florida and Caribbean Islands in 1958 and
were tested further and log neutralization that this outbreak may have been considcrabl)
indices of Ilheus virus were 1.8, 2.0 and 1.2. more extensive than these cases suggest. Indeed,
a major factor making possible the intensive
COMMENTS
study of these cases in Panama, Jamaica,
St. Louis encephalitis in three Miami patients Trinidad and Miami was their occurrence in
(Cases I, II and III) was characterized by severe relative proximity to laboratories engaged in
headache, fever and impaired intellectual func- arbo virus research.
tion or coma. Two additional patients may have Above and beyond these cases of St. Louis
had St. Louis encephalitis virus infection as encephalitis, the serologic survey of specimens
well: in Case IV the diagnosis of virus encepha- obtained prior to the autumn of 1958 reveals
litis was made solely on the pathologic findings, that South Florida, together with various
and in Case v serologic studies did not distin- Caribbean areas, is a region of considerable
guish between St. Louis encephalitis and Ilheus arbo virus activity. Six of sixty-four serum
virus infection. In the latter two patients, samples from Miami residents neutralized arbo
encephalitis was not clinically apparent and viruses and five of the six had antibodies to
their illnesses consisted of headache, fever and group B arbo viruses (St. Louis encephalitis,
meningitis. In the patients from Jamaica, Ilheus and !Vest Nile viruses). This proportion
Trinidad and Panama with St. Louis encepha- is similar to that of another 1957-1958 study of
AMERICAN JOURNAL OF MEDICINE
 Arthropod-Borne Virus Disease-Ehrenkranz et al. 679

1958 TRANS-CARIBBEAN
OUTBREAK OF
ARTHROPOD- BORNE VIRUS
INFECTION

REPUBLIC
OF

FIG. 2. Sites of group B arbo virus casvs occurring in Ck~ribbean Islands and adjacent arras in 19Sb.

serum samples from Miami residents in which
9 per cent of the adults were found to have
group B arbo virus antibodies as manifested by
the results of an hemagglutination inhibition
test with a. dengue virus [ 741. Serologic reactions
to arbo virus infection are not limited to the
infecting agent but are apt to occur bvith anti-
genitally related viruses as well [ 7 1,751; thus the
occurrence of antibodies to St. Louis enccpha-
litis, Ilheus, \2:est Nile and dengur viruses in
South Florida’:residrnts does not imply, neces-
sarily, infection with each iof thcw viruses.
However, the presence in Florida of a group B
arbo virus other than St. Louis encephalitis is
suspect due to the absence of antibody to St.
Louis encephalitis virus in some serum samples
from Miami residents neutralizing Ilheus or
\Vest Nile viruses. (Tahlc III.) Since 1Vest Nile
virus has not yet been encountered in the Yew
World, it is unlikely that infection with this
virus has been occurring in Miami.* ‘IVest Nile
virus neutralizing antibodies have also been
detected in the serum of Trinidad residents but
only in association with neutralizing antibodies
* Because of the mig-ration of cattle rgrets from .4frica
to South and North America [7ril thrrc is a remote
possibility t.hat IVest Nile virus map have bwn recently
introduced into the Ll’estern Hemisphere.
vol.. 35, NOVEMBER 1963
to Ilheus and other group B arbo viruses j 171.
“Dengue-like” disease has occurred in Miami,
hut attempts to isolate an infecting agent have
not been successful [74,78]. Dengue virus has
I xen present in Jamaica, Trinidad and British
(Guiana in recent years [77,77,7Q]. Ilheus virus
infection may well occur in Florida as Ilheus
virus infwtion of birds, mosquitos and man does
occur on both sides of the (:aribhean Sea in
Honduras, Guatemala, Trinidad and British
Guiana [_)1)_-221;too little is currently known of
the natural clisease to recognize it clinically
[Xl. While antibodies to St. I.ouis encephalitis,
Ilheus, IVest Nile and dengue viruses are found
in populaces of South Florida as well as of some
Caribbean Islands, serologic cvidencc of infec-
tion with yellow fever (another group II arbo
virus) is confined to residents of the more
southern Caribbean areas [ 7 7,771. Ar bo l;irusrs
thus far isolated in the Caribbean Islands and
North America are listed in Table IV.
The possible relation of bird migration to
trans-Carihbcan arbo virus infection is at
present a sub.ject for further investigation since
insufficient data arc at hand to support or reject
this hypothesis. Suffice it to say that birds using
the Mississippi and Atlantic fly-ways of North
-America traverse the Florida peninsula on their
680 Arthropod-Borne Virus Disease-E/zrenkranz et al.
TABLE IV presented. These findings suggest that Florida,
ARTHROPOD-BORNE VIRUSES OF NOR?‘H AMERICA
together with the Caribbean Islands and the
AND TIIE CARIBBEAN ISLANDS [75]
Spanish Main, is an endemic area of arthropod-
borne virus disease.
Grouf
A
Eastern equine encephalomyelitis (EEE)
\Yestern equine encephalomyelitis (WEE) dcknowlea&ment: F2:e are grateful to I)r. Joseph
Venezuelan equine encephalornyelitis (VEE) E. Smadel of the National Institutes of Health
Mayaro
and to Dr. Wilbur G. Downs of the Rockefeller
Groufi R
Foundation for their critical and constructive
Bat salivary gland (Rio Bravo)
Ilhcus
reviews of the manuscript. LVe are also grateful
Modoc to Dr. Peritz Scheinberg, Professor of Neurology,
St. Louis encephalitis (SLE) University of Miami, for bringing Cases I and II
Yellow fever to our attention.
Powassan
Dengue viruses
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VQL. 35, NOVEMBER 1963