Zika Virus Infection with Fatal Secondary Hemophagocytic Lymphohistiocytosis Syndrome as an Atypical Presentation

Rationale: Zika virus (ZIKV) is an uncommon tropical viral illness caused by a flavivirus transmitted by mosquitoes such as dengue virus, West Nile virus and yellow fever virus. Clinical manifestations of Zika virus infection are usually milder in nature. It usually presents with a self-resolving triad of fever, rash and polyarthralgia. There are very few case reports of severe or lethal cases. Patients concern: 66 years male patient was admitted with an acute febrile illness for 5 days and underwent evaluation for multiple organ dysfunction. He was diagnosed with Zika virus infection which was confirmed by polymerase chain reaction. He had rapid clinical deterioration with coagulopathy, resistant hypotension, multi- organ dysfunction with secondary Hemophagocytic Lymphohistiocytosis Syndrome (sHLH). He died within 72 hours of presentation. Diagnosis: Zika virus infection with secondary HLH syndrome. Interventions: The patient was admitted to the intensive care unit (ICU). He had multi-organ dysfunction and required mechanical ventilation, sustained low efficiency dialysis (SLED), vasopressors, steroids, intravenous immunoglobulin, antibiotics and supportive treatment. Outcomes: The patient succumbed to his illness within 72 hours of admission. Lessons: Zika infection though considered a mild illness, can rapidly evolve into a severe form of disease and can be lethal. There is a need for increased clinical awareness and watchfulness for such atypical presentations of ZIKV infection.