Table 4.

Summary of case reports reporting on signs and symptoms of qRT-PCR-confirmed ZIKV coinfections (n=21 reports)

Author (year)	Location	Study year	Sex	Age (years)	Coinfecting agent(s)	Other pathogens tested (negative)	WHO ZIKV signs or symptoms						Other reported signs or symptoms		Additional information	Level of evidence*
							Rash	Fever	Arthralgia	Conjunctivitis	Myalgia	Headache	URT symptoms	GI symptoms
Brito et al24 (2017)	Brazil	2016	M	74	CHIKV	DENV, HIV, CMV, HTLV, Schisto, HSVI/2 cystcercosis	NR	†	†	NR	NR	NR	NR	†	Complications: Meningoencephalitis associated with Guillain-Barré syndrome (EMG confirmed)	5
Silva et al (2018)	Brazil	2016	M	30	CHIKV	DENV, bacterial/fungal and MTB infections	NR	†	†	NR	†	NR	NR	NR	Comorbidities: Systemic lupus erythematosus Complications: Persistent fever for 5 weeks and renal dysfunction. 2 months postinfection severe arthralgia, requiring arthroplasty. 10 months postinfection acute deterioration in renal function, respiratory insufficiency and sepsis. Outcome: Death	5
Cherabuddi et al26 (2016)	Colombia	2016	F	40	CHIKV	DENV	†	†	†	†	NR	NR	NR	NR	Back pain, retro-ocular pain Complications: Persistent severe arthralgia after 2 months Outcome: Sequelae	5
Zambrano et al27 (2016)	Ecuador	2016	M	43	CHIKV	DENV	†	†	†	†	NR	NR	†	NR	Outcome: Full recovery	5
Zambrano et al27 (2016)	Ecuador	2016	F	43	CHIKV	NR	‡	†	‡	†	†	†	NR	NR	Outcome: Full recovery	5
Zambrano et al27 (2016)	Ecuador	2016	F	57	CHIKV	DENV	NR	†	NR	NR	NR	†	NR	NR	Lumbar back pain Complications: Guillain-Barré syndrome (EMG confirmed) Outcome: Full recovery	5
Azeredo et al19 (2018)	Brazil	2016	F	NR	DENV	CHIKV	†	†	NR	NR	NR	†	NR	†	Retro-orbital pain Complications: Suspected vertical transmission, pregnancy outcome alive newborn with functional plagiocephaly a flat spot on the back or side of newborn’s skull Gestational age at infection: 9 weeks	5
Azeredo et al19 (2018)	Brazil	2016	F	NR	DENV	CHIKV	†	†	NR	†	NR	NR	NR	NR	Retro-orbital pain Complications: Suspected vertical transmission to deceased newborn with respiratory insuf-ficiency Gestational age at infection: 20 weeks	5
Dupont-Rouzeyrol et al32 (2015)	New Caledonia	NR	F	38	DENV 1	NR	†	†	†	†	†	†	NR	†	Asthenia, retro-ocular pain Outcome: Full recovery	5
Dupont-Rouzeyrol et al32 (2015)	New Caledonia	NR	M	14	DENV 3	NR	NR	†	†	NR	†	†	NR	NR	Asthenia Outcome: Full recovery	5
Iovine et al 33 (2017)	United States§	2016	F	26	DENV 2	CHIKV	†	†	NR	†	NR	NR	†	†	Retro-orbital pain, fatigue, malaise, facial flushing Outcome: Full recovery	5
Villamil-Gomez et al35 (2016)	Colombia	NR	F	33	CHIKV, DENV	Plasmodium spp	†	NR	†	†	‡	†	NR	‡	Physical examination revealed cervical lymphadenopathy, bipalpebral oedema, and painful oedema in the lower limbs Outcome: Weekly obstetric ultrasounds from 14.6 to 29 weeks of gestation were normal	5
Gunturiz et al36 (2018)	Colombia	2016	F	18	CHIKV, Toxo	NR	NR	NR	NR	NR	NR	NR	NR	NR	Complications: Suspected vertical transmission of ZIKV infections to the fetus with outcome of fetus diagnosed with CZS at 20 weeks of gestation, termination at 29 weeks of gestation	5
Villamil-Gomez et al34 (2018)	Colombia	2015/2016	M	28	HIV	NR	†	†	NR	†	NR	NR	NR	NR	Recently diagnosed with HIV (<1 year), Lymphocytes T CD4 count (cells/mm3): 450, HIV viral load (RNA copies/mL): 100 Complication: Demyelination was found (EMG findings)	5
Villamil-Gomez et al34 (2018)	Colombia	2015/2016	F	49	HIV	NR	NR	NR	NR	NR	NR	NR	NR	†	Recently diagnosed with HIV (<1 year) Lymphocytes T CD4 count (cells/mm3): 98 HIV viral load (RNA copies/mL): 1800 Hypotension, dysarthria, decreased muscle strength, relaxation of sphincters, areflexia and basal bilateral crackles in the lungs Complications: Sepsis	5
Villamil-Gomez et al34 (2018)	Colombia	2015/2016	F	45	HIV	NR	†	†	NR	†	NR	NR	NR	†	Recently diagnosed with HIV (1 year ago) Lymphocytes T CD4 count (cells/mm3): 380 HIV viral load (RNA copies/mL): 800 Complication: Demyelination was found (EMG findings)	5
Valdespino- Vazquez et al37 (2018)	Mexico	2016	F	22	EBV, HHV6	DENV, CHIKV, WNV, VZ, HSV-I/2, HHV7, HHV8, CMV	†	†	NR	NR	NR	†	NR	NR	Infection of pregnant women at 14 weeks of gestation Complications: Suspected vertical transmission of ZIKV infections to the foetus with outcome of diagnosed CZS and fetal death at 30 weeks of gestational age, 4 hours after birth	5
Araujo et al38 (2018)	Brazil	2016	M	26	HSV-1	DENV, HSV, VZ, EBV, Toxo, HepC/B, Syphilis spp.	NR	†	NR	NR	NR	†	NR	†	Complications: Meningoencephalitis Outcome: Full recovery	5
Biron et al 39 (2016)	New Caledonia	NR	M	19	Leptospira spp	CHIKV, DENV	NR	†	NR	NR	†	NR	†	NR	Complications: Haemodynamic condition was unstable, sceptic shock Outcome: Full recovery	5
Neaterour et al (2017)	Puerto Rico	2016	M	48	Leptospira spp	DENV, CHIKV	NR	†	NR	NR	†	†	NR	†	Complications: Severe thrombocytopenia, persistent hypotension (BP=60/40), and onset of haematochezia suggestive of an acute gastrointestinal bleed. Haemodynamic instability and haemorrhagic manifestations. Cardiac arrest. Outcome: Death.	5
Alves et al41 (2017)	Brazil	NR	M	NR, a boy	Schistosoma mansoni	NR	†	†	NR	NR	NR	NR	NR	NR	Complications: Inflammation of the right testicle and epididymis. The microscopic examination of the testis ruled out the possibility of cancer but confirmed the diagnosis of extensive loss of testicular structure and schistosome egg-induced granulomas. Outcome: Full recovery	5

URT symptoms: pharyngitis, sore throat, cough, pharyngeal congestion, adenopathy. GI symptoms: nausea, diarrhoea, vomiting, constipation, stomach ache.

*All articles were rated according to level of evidence using the Oxford Centre for Evidence-based Medicine’s Levels of Evidence, March 2009.¹¹

†Reported to be present.

‡Reported not to be present.

§Travel associated diagnosed from Haiti.

CHIKV, chikungunya virus; CMV, cytomegalovirus; CZS, congenital Zika syndrome; DENV, dengue virus; EMG, electromyography testing; GI, gastrointestinal; Hep, hepatitis virus; HHV, human herpes virus; HSV, herpes simplex virus; HTLV, human T-lymphotropic virus; MTB, Mycobacterium tuberculosis; NR, not reported; Toxo, Toxoplasma gondii; URT, upper respiratory tract; VZ, varicella zoster; WNV, West Nile virus.