Original ArticleUnexpected Hazard of Illegal Immigration Outbreak of Viral Myocarditis Exacerbated by Confinement and Deprivation in a Shipboard Cargo ContainerLi, Melissa K. MD; Beck, Melinda A. PhD; Shi, Qing MS; Harruff, Richard C. MD, PhDAuthor Information From the University of Florida, Gainesville, Florida (M.K.L.); Departments of Pediatrics and Nutrition, University of North Carolina, Chapel Hill, North Carolina (M.A.B., Q.S.); and King County Medical Examiner's Office, Seattle, Washington (R.C.H.). Manuscript received May 24, 2003; accepted November 18, 2003. Reprints: Richard C. Harruff, MD, PhD, King County Medical Examiner's Office, 325 Ninth Avenue, HMC Box 359792, Seattle, WA 98104-2499. E-mail: [email protected]. The American Journal of Forensic Medicine and Pathology: June 2004 - Volume 25 - Issue 2 - p 117-124 doi: 10.1097/01.paf.0000127394.74705.7e Buy Metrics Abstract We present a group of 18 illegal immigrant stowaways who arrived in a shipboard cargo container suffering from gastroenteritis, dehydration, and malnutrition and showing evidence of viral myocarditis in 3 of 4 fatalities. Our investigation included an evaluation of the 2-week ocean voyage, analysis of medical records and laboratory results of the survivors, autopsies on the decedents, and viral studies on their heart tissue. Of 3 stowaways who died shipboard, 2 showed lymphocytic myocarditis and 1 could not be evaluated histologically due to decomposition. A fourth stowaway died 4 months after arrival with dilated cardiomyopathy and lymphocytic myocarditis. Reverse-transcriptase polymerase chain reaction and nucleotide sequencing of viral isolates from the decedents’ heart tissues demonstrated Coxsackie virus B3 genome. We believe that these cases represent an outbreak of viral myocarditis, exacerbated by acute dehydration and malnutrition, due to confinement within the shipping container. Our evidence indicates that close confinement promoted the spread of the virus, and nutritional deprivation increased the stowaways’ vulnerability. Furthermore, our observations support the conclusion, based on experimental studies, that nutritionally induced oxidative stress increased the virulence of the etiologic viral agent. In summary, these cases represent a potential infectious disease hazard of illegal immigration. © 2004 Lippincott Williams & Wilkins, Inc.