A-Z Index × Submit A-Z Index × Submit A-Z Index Search Dropdown × Submit Facebook Twitter LinkedIn Syndicate Emerging Infectious Disease journal ISSN: 1080-6059 Disclaimer: Early release articles are not considered as final versions. Any changes will be reflected in the online version in the month the article is officially released.
A previously healthy 26-year-old man died of hemorrhagic fever with fulminant hepatitis and shock 36 hours after returning to France from Mecca, Saudi Arabia. Postmortem analyses detected low-level dengue virus RNA and positive NS1 antigen along with unexpected extremely high-titer disseminated velogenic avian orthoavulavirus 1 infection with elevated systemic cytokine responses.
A previously healthy 26-year-old man sought care in Paris, France, immediately after returning from Mecca, Saudi Arabia, in January 2025. He was experiencing fever, myalgia, headache, abdominal pain, and diarrhea that began 4 days earlier. He reported no specific exposure during his trip, including no contact with animals, contaminated food or water, or insect bites. He had no history of immunosuppression or repeated infection. No family members traveling with him experienced similar symptoms. We report the patient’s clinical course and laboratory findings.
At admission to the intensive care unit in Saint-Antoine hospital (Paris, France), the patient had fever (40°C), tachypnoea (45 breaths/min, SpO 2 95% on room air), poor tissue perfusion, and oliguria. Results of cardiopulmonary, abdominal, and neurologic examination were unremarkable. Conjunctival hemorrhage and hematuria were present at hospital admission. Despite early fluid resuscitation and empirical antimicrobial treatment, his condition rapidly deteriorated. He experienced multiple organ dysfunction syndrome including hypotension, purpuric livedo, anuria, and acute kidney failure (creatinine 600 μmol/L), elevated level of lactate (4.4 mmol/L), major hepatic dysfunction (alanine aminotransferase and aspartate aminotransferase levels were >100 times the upper limit of normal and factor V was at 51%), thrombocythemia (29 × 10 9 /L), decreased hematocrit (39%), decreased prothrombin time (52%), and disseminated intravascular coagulation. Inflammatory markers were elevated (C-reactive protein 320 mg/L; procalcitonine 136 µg/L). We could not perform bacterial analysis because the patient was isolated for initial suspicion of highly infectious pathogens. Body computed tomography results were unremarkable. We applied resuscitation measures and escalated antimicrobial therapy.
Etiologic assessment included PCR testing for malaria, SARS-CoV-2, influenza, cytomegalovirus, Ebola virus, Zika virus, chikungunya virus, and serology for HIV and for hepatitis A, B, C, and E; all results were negative. At that time, the patient’s blood tested negative by PCR and IgM and IgG serology for dengue virus (DENV). The patient’s condition continued to deteriorate; he experienced refractory shock, fulminant hepatitis, and disseminated intravascular coagulation. He died 36 hours after hospital admission.
Figure 1 . Liver biopsy images from study of a fatal infection with dengue virus and avian orthoavulavirus 1 in traveler from Saudi Arabia, 2025. A) Sirius red stain showing normal architecture without...
Postmortem laboratory results revealed a low dengue viral load in urine with quantitative reverse transcription PCR results at a cycle threshold (Ct) of 39 from a pan-dengue duo test and Ct of…