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Influenza, not Ebola, More Likely the Cause of 430 BCE Athenian Outbreak TO THE EDITOR—Kazanjian [1] offers an interesting argument that the Athenian outbreak during the Peloponnesian war in 430 BCE, described by Thucydides [2], was caused by Ebola. However, as hypothesized by Langmuir et al [3, 4], the Athenian outbreak is far more likely to have resulted from an influenza pandemic, possibly associated with toxic shock syndrome. Contemporaneous and subsequent observers of the 1918 pandemic observed signs and symptoms similar to those noted by Thucydides [5–7]. The Athenian pandemic caused deaths among animals as well as humans, including, notably, “birds of prey,” which reportedly “disappeared” [2]. Although Ebola may infect such animals as bats, primates, and rodents, it has not thus far been linked to large numbers of bird or other animal deaths. Influenza, by contrast, is harbored by and affects many animal species [8, 9]. The Athenian outbreak varied in severity over a period of 4 or 5 years [1, 3]. Influenza pandemics may likewise occur in waves [9]. Kazanjian suggests that a multiyear Ebola outbreak is plausible, but to date this does not seem to have occurred. Although Ebola is associated with labored breathing, it does not, in contrast 1492 • CID 2015:61 (1 November) • CORRESPONDENCE to the disease described by Thucydides, seem to be typically associated with “hard cough,” chest pain, sneezing, or hoarseness, which seem more characteristic of respiratory infections [2, 10, 11]. Thucydides also commented that the year of the Athenian outbreak was “unprecedentedly free from sickness” [2]. So too did some during the 1918 pandemic remark on “the almost entire absence of any other disease” [5]. “Everything was influenza,” one physician wrote [5]. Clinical manifestations and sequelae of recent influenza pandemics, such as the 2009 H1N1 (swine) flu [12, 13], further strengthen the hypothesis of Langmuir et al [3, 4]. Finally, just as those afflicted by Ebola [10] and the 1918 influenza [14, 15] also suffered from such comorbid conditions as malaria and tuberculosis, so too was the Athenian outbreak possibly aggravated by unrecognized chronic and acute conditions affecting ancient Greece [16]. Many deaths were also probably attributable to poor sanitation, malnutrition, poverty, and overcrowding, problems only exacerbated by the war that was Thucydides’ primary focus. Note Potential conflict of interest. Author certifies no potential conflicts of interest. The author has submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed. Mitchell Berger Public Health Advisor, Exton, Pennsylvania References 1. Kazanjian P. Ebola in antiquity? Clin Infect Dis 2015; 61:963–8. 2. Thucydides. The history of the Peloponnesian War. Translated by Richard Crawley. Project Gutenberg. Available at: http://www.gutenberg. org/files/7142/7142-h/7142-h.htm. Accessed 31 July 2015. 3. Langmuir AD, Worthen TD, Solomon J, Ray GC, Petersen E. The Thucydides syndrome: a new hypothesis for the cause of the plague in Athens. NEJM 1985; 313:1027–30. 4. Langmuir AD, Ray CG. The Thucydides syndrome. JAMA 1987; 257:3071. 5. Myers SW. Clinical observations in a recent epidemic of influenza. Boston Med Surg J 1919; 180:98–101. 6. Locke EA, Ronne GE, Lande H. The clinical aspects of the recent influenza epidemic. Boston Med Surg J 1919; 180:124–35. 7. Ordway MD. Report of neurological sequelae of influenza in the Boston city hospital neurological outpatient department from July, 1918 to July, 1919. Boston Med Surg J 1920; 182:194–200. 8. H1N1 Flu in Animals - Information, California Department of Public Health. Available at: http://www.cdph.ca.gov/HEALTHINFO/ DISCOND/Pages/H1N1Animals.aspx. Accessed 31 July 2015. 9. Taubenberger J, Morens D. 1918 influenza: the mother of all pandemics. Emerg Infect Dis 2006; 12:15–22. 10. Barry M, Toure A, Traore FA, et al. Clinical predictors of mortality in patients with Ebola virus disease. Clin Infect Dis 2015; 60: 1821–4. 11. Clark DV, Kibuuka H, Millard M, et al. Long-term sequelae after Ebola virus disease in Bundibugyo, Uganda: a retrospective cohort study. Lancet Infect Dis 2015; 15:905–12. 12. Ekstrand JJ, Herbener A, Rawlings J, et al. Heightened neurologic complications in children with pandemic H1N1 influenza. Ann Neurol 2010; 68:762–6. 13. Writing Committee of the WHO Consultation on Clinical Aspects of Pandemic (H1N1) 2009 Influenza. Clinical aspects of pandemic 2009 influenza A (H1N1) virus infection. N Engl J Med 2010; 362:1708–19. 14. Brabin BJ. Malaria’s contribution to World War One—the unexpected adversary. Malar J 2014; 13:497. 15. Oei W, Nishiura H. The relationship between tuberculosis and influenza death during the influenza (H1N1) Pandemic from 1918–19. Comput Math Methods Med 2012; doi:10. 1155/2012/124861. 16. Kousoulis AA, Chatzigeorgiou KS, Danis K, et al. Malaria in Laconia, Greece, then and now: a 2500-year-old pattern. Int J Infect Dis 2013; 17:e8–11. Correspondence: Mitchell Berger, MPH, 203 Ravenwood Rd, Exton, PA 19341 ([email protected]). Clinical Infectious Diseases® 2015;61(9):1492–3 © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. [email protected]. DOI: 10.1093/cid/civ604 CORRESPONDENCE • CID 2015:61 (1 November) • 1493