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Quick Facts on Viral Hemorrhagic Fevers

• Viral Hemorrhagic Fevers (VHF) are caused by 4 viral families
• • Arenaviruses
  • • Argentine hemorrhagic fever
    • Bolivian hemorrhagic fever
    • Sabia-associated hemorrhagic fever
    • Lassa fever
    • Lymphocyctic choriomeningitis
    • Venezuelan hemorrhagic fever
  • Filoviruses
  • • Ebola hemorrhagic fever
    • Marburg hemorrhagic fever
  • Bunyaviruses
  • • Crimean-Congo hemorrhagic fever
    • Rift Valley fever (Hantaan fever)
    • Hantavirus Pulmonary Syndrome
    • Hemorrhagic Fever with Renal Syndrome (HFRS)
  • Flaviviruses
  • • Tick-borne encephalitis
    • Kyasanur Forest disease
    • Omsk hemorrhagic fever
• Viral hemorrhagic fevers share the following characteristics:
• • They are all RNA viruses
  • They are all zoonotic (natural reservoir is an arthropod or other animal host)
  • Disease is restricted to habitat of the host
  • Humans become infected by contact with host
  • Some viruses can be transmitted from human to human
• Transmission to humans (depends upon specific virus)
• • By contact with rodent urine, feces, saliva, blood
  • From mosquito or tick bites
  • Contact with vector-infected livestock
• Pathophysiology
• • The target organ is the vascular bed. Dominant clinical features are due to microvascular damage and changes in vascular permeability
  • In most cases of viral hemorrhagic fever, the coagulopathy is multifactorial, including: hepatic damage, disseminated intravascular coagulation, primary marrow injury to megakaryocytes
• Symptoms
• • Fever, fatigue, dizziness, myalgias, and prostration
  • Signs of bleeding range from only conjunctival hemorrhage, mild hypotension, flushing, and petechiae to shock and generalized mucous membrane hemorrhage and evidence of pulmonary, hematopoietic, and neurologic dysfunction
  • Renal insufficiency is proportional to cardiovascular compromise except in Hemorrhagic Fever and Renal Syndrome in which it is an integral part of the disease
• Clinical syndromes
• • Epidemiologic information is usually the most helpful clue to the diagnosis, although some viral hemorrhagic fevers do present with suggestive clinical syndromes
  • • Jaundice and hepatitis dominate the clinical presentation in some cases of Rift Valley, Congo-Crimean, Marburg, and Ebola hemorrhagic fevers, and yellow fever
    • Biphasic illnesses with pulmonary symptoms followed by central nervous system manifestations are characteristics of Kyasanur Forest disease and Omsk hemorrhagic fever
    • Severe peripheral edema without significant hemorrhage suggests Lassa fever
    • Severe hemorrhage and nosocomial transmission suggests Congo-Crimean hemorrhagic fever
    • Fever, hemorrhage, shock, renal failure, and polyuria is the classic presentation of Hemorrhagic Fever and Renal Syndrome
    • Adult Respiratory Distress Syndrome is a sequela of Hantavirus
• Diagnosis
• • Key is a detailed travel history and a high index of suspicion
  • • Suspect viral hemorrhagic fever in any patient who has traveled to an endemic area and has a severe febrile illness with evidence of vascular involvement
  • Consider the possibility of a bioterrorist attack if one of the diseases occurs in persons not known to have traveled to an endemic area
  • Laboratory findings
  • • Thrombocytopenia is common to most viral hemorrhagic fever infections with the exception of Lassa fever
    • Leukopenia is common to most viral hemorrhagic fever infections with the exceptions of Lassa, Hantaan, and some cases of Congo-Crimean hemorrhagic fevers
    • Proteinuria with or without hematuria is common and is always found in Argentine hemorrhagic fever, Bolivian hemorrhagic fever, and Hemorrhagic Fever and Renal Syndrome
    • Virologic diagnosis
    • • Rapid enzyme immunoassays
      • Viral culture (requires 3 to 10 days)
• Differential Diagnosis
• • The major entity in the differential diagnosis is malaria
  • Other entities that mimic viral hemorrhagic fevers include typhoid fever, leptospirosis, rickettsial infections, shigellosis, relapsing fever, fulminant hepatitis, and meningococcemia
  • Noninfectious mimics include acute leukemia, systemic lupus erythematosus, immune thrombocytopenic purpura, thrombotic thrombocytopenic purpura, and hemolytic uremic syndrome
• Treatment
• • For most viral hemorrhagic fevers, there is no effective treatment other than supportive care.
  • Ribavirin, which is available via compassionate use protocols, reduces morbidity in Hemorrhagic Fever and Renal Syndrome, and reduces morbidity and mortality in Lassa fever
  • Convalescent plasma is being used experimentally to treat Argentine hemorrhagic fever
• Prevention
• • Vaccination
  • • The only licensed vaccine available is for yellow fever
    • Experimental vaccine for Argentine hemorrhagic fever is under investigation
  • Control of rodent populations
  • Control of insect and other arthropod populations
• Isolation and containment
• • Viral hemorrhagic fever patients, with the exception of hantavirus and dengue fever infections, have significant infectious virus in the blood and body secretions
  • Strict adherence to standard precautions
  • • Keep patients in isolation
    • Use of gowns, gloves, masks, eye protection

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