Viral Hemorrhagic Fever

Aka: Viral Hemorrhagic Fever, Hemorrhagic Fever Syndrome

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II. Pathophysiology

  1. Natural host species (e.g. animal carcasses, infected bats) are specific to certain geographic regions
    1. Natural outbreaks typically start in these regions
    2. However, person to person spread may occur in new regions if patients travel
      1. Responsible for most cases in humans
  2. Transmission
    1. Natural exposure to body fluids
    2. Bioterrorism exposure to aerosolized infectious agent
  3. Pathogenesis
    1. All Viral Hemorrhagic Fevers result in vascular endothelial damage
      1. Results in Flushing, edema, Petechiae, Ecchymosis, Hemorrhage and shock

III. Causes

  1. Background
    1. Four families of lipid-enveloped single-stranded RNA viruses
  2. Arena Virus (Arenaviridae, Rodent Reservoir)
    1. Lassa Fever
    2. Junin
    3. Machupo
    4. Lujo
    5. Sabia
    6. Chapare
  3. Bunyavirus (Bunyaviridae)
    1. Rift Valley Fever
    2. Crimean Congo Hemorrhagic FeverVirus
    3. Hantavirus Hemorrhagic Fever
  4. Flavivirus (Flaviviridae)
    1. Yellow Fever
    2. Dengue Fever
    3. Omsk Hemorrhagic Fever
    4. Kyasanur Forest Disease
  5. Filovirus (Filoviridae, Bat Reservoir)
    1. Ebola Virus
    2. Marburg Hemorrhagic Fever

IV. Findings

  1. Incubation: 2-21 days
  2. Non-specific symptoms (initial phase)
    1. Fever
    2. Headache
    3. Myalgias
    4. Arthralgias
    5. Rash
  3. Gastrointestinal symptoms (second phase)
    1. Abdominal Pain
    2. Vomiting
    3. Diarrhea
  4. Bleeding
    1. Conjunctival Injection
    2. Mucosal Bleeding (gums, Gastrointestinal Tract)
    3. Hemoptysis
    4. Epistaxis
    5. Hemoptysis
    6. Bloody Diarrhea
    7. Petechiae, Purpura and Ecchymosis
  5. Other late findings
    1. Shock with Multisystem organ failure
    2. Encephalitis

V. Diagnosis: Hemorrhagic Fever Syndrome (WHO)

  1. Fever <3 weeks AND
  2. Severely ill patient AND
  3. Two hemorrhagic findings (without known host predisposing factors)
    1. Hemorrhagic or Purpuric rash
    2. Epistaxis
    3. Hematemesis
    4. Hemoptysis
    5. Blood in stools

VI. Labs

  1. Diagnostic specimens are sent to specialized labs (e.g. CDC or U.S. Army Medical Research Institute of Infectious Diseases)

VII. Complications

  1. Multiorgan Failure
    1. Hepatic Failure
    2. Renal Failure
  2. Hemorrhagic Shock
  3. Septic Shock

VIII. Management: General

  1. See Specific causes
  2. Strict patient isolation
  3. Supportive care
  4. Antiviral management
    1. Ribavirin (see below)
    2. Monoclonal Antibody treatments have been developed for several hemorrhagic fevers
      1. See Ebola
  5. Personal Protective Equipment for care givers
    1. Transmission from the body fluids (percutaneous, mucosal contact) is common at the end stages of the disease
    2. See Personal Protection Equipment for protection against Viral Hemorrhagic Fevers
    3. See Donning and Doffing PPE
  6. Disinfection with dilute bleach
    1. Use 1:10 bleach solution to disinfect bodies and excretions
    2. Use 1:100 bleach solutions to disinfect surfaces, equipment, bedding and reusable PPE

IX. Management: Ribavirin (Virazole)

  1. Indications
    1. Lassa Fever
    2. Arenaviridae
    3. Bunyaviridae
    4. May be used in other Viral Hemorrhagic Fevers (e.g. ebola)
  2. Ribavirin Protocol
    1. Load 30 mg/kg (up to 2 g) IV
    2. Then 16 mg/kg (up to 1 g) IV every g hours for 4 days
    3. Then 8 mg/kg (up to 500 mg) IV every 8 hours for 6 days

X. References

  1. Black, Martin, DeVos (2018) Crit Dec Emerg Med 32(8): 3-12
  2. Charbonnet and Mace (2023) Crit Dec Emerg Med 37(4): 4-10
  3. Gladwin (2014) Clinical Microbiology, MedMaster, Miami, p.306-7, 398
  4. Rathjen (2021) Am Fam Physician 104(4): 376-85 [PubMed]

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Related Studies

Ontology: Hemorrhagic Fevers, Viral (C0019104)

Definition (MSHFRE) Maladies virales d'étiologies diverses mais regroupées sur leurs caractéristiques cliniques. Les fièvres hémorragiques sont caractérisées par leur début brutal. Elles associent de la fièvre, des céphalées, des myalgies généralisées, des courbatures, une conjonctivite, une prostration sévère, puis apparaissent divers symptômes hémorragiques. On retrouve une augmentation de la perméabilité capillaire, une leucopénie et une thrombocytopénie. La fièvre hémorragique, avec atteinte rénale, est appelée fièvre hémorragique avec syndrome rénal.
Definition (MEDLINEPLUS)

Viral hemorrhagic fevers (VHFs) are a group of illnesses caused by four families of viruses. These include the Ebola and Marburg, Lassa fever, and yellow fever viruses. VHFs have common features: they affect many organs, they damage the blood vessels, and they affect the body's ability to regulate itself. Some VHFs cause mild disease, but some, like Ebola or Marburg, cause severe disease and death.

VHFs are found around the world. Specific diseases are usually limited to areas where the animals that carry them live. For example, Lassa fever is limited to rural areas of West Africa where rats and mice carry the virus.

The risk for travelers is low, but you should avoid visiting areas where there are disease outbreaks. Because there are no effective treatments for some of these viral infections, there is concern about their use in bioterrorism.

Centers for Disease Control and Prevention
Definition (MSH) A group of viral diseases of diverse etiology but having many similar clinical characteristics; increased capillary permeability, leukopenia, and thrombocytopenia are common to all. Hemorrhagic fevers are characterized by sudden onset, fever, headache, generalized myalgia, backache, conjunctivitis, and severe prostration, followed by various hemorrhagic symptoms. Hemorrhagic fever with kidney involvement is HEMORRHAGIC FEVER WITH RENAL SYNDROME.
Definition (CSP) syndrome that occurs in perhaps 20-40 percent of infections by a number of different viruses of the families Arenaviridae, Bunyaviridae, Flaviviridae, Filoviridae, etc; some types of hemorrhagic fever are tick borne, others mosquito borne, and some seem to be zoonoses; clinical manifestations are high fever, scattered petechiae, gastrointestinal tract and other organ bleeding, hypotension, and shock; kidney damage may be severe and neurologic signs may appear.
Concepts Disease or Syndrome (T047)
MSH D006482
ICD10 A99
SnomedCT 187415006, 186736002, 240523007
English Fever, Viral Hemorrhagic, Fevers, Viral Hemorrhagic, Hemorrhagic Fever, Viral, Hemorrhagic Fevers, Viral, Viral Hemorrhagic Fevers, Hemorrhagic fever, Unspcf vir haemorhagc fever, Unspecified viral haemorrhagic fever, Unspecified viral hemorrhagic fever, [X]Unspcf vir haemorhagc fever, [X]Unspecified viral haemorrhagic fever, [X]Unspecified viral hemorrhagic fever, Hemorrhagic fever NOS, Haemorrhagic fever NOS, Hemorrhagic Fevers, Viral [Disease/Finding], viral hemorrhagic fevers, fever hemorrhagic viral, fevers haemorrhagic viral, fevers hemorrhagic, haemorrhagic fever, viral hemorrhagic fever, fever hemorrhagic, hemorrhagic fever, viral hemorrhagic fever (diagnosis), VHFs, Hemorrhagic Fevers, [X]Unspecified viral haemorrhagic fever (disorder), [X]Unspecified viral hemorrhagic fever (disorder), Haemorrhagic fever, VHF - Viral haemorrhagic fever, VHF - Viral hemorrhagic fever, Viral haemorrhagic fever, Viral hemorrhagic fever, Viral hemorrhagic fever (disorder), fever; hemorrhagic, viral, fever; hemorrhagic, hemorrhagic fever; viral, infection; viral, hemorrhagic fever, viral; hemorrhagic fever, virus; hemorrhagic fever, Viral Hemorrhagic Fever, Hemorrhagic Fever
Italian Febbre emorragica, Febbre emorragica NAS, Febbri emorragiche virali
Dutch hemorragische koorts NAO, hemorragische koorts; viraal, infectie; viraal, hemorragische koorts, koorts; hemorragisch, viraal, koorts; hemorragisch, viraal; hemorragische koorts, virus; hemorragische koorts, Niet gespecificeerde virale hemorragische koorts, hemorragische koorts, Hemorragische koorts, virale, Hemorragische koortsen, virale, Koorts, hemorragische virale, Koortsen, hemorragische virale
French Fièvre hémorragique SAI, Fièvre hémorragique, Fièvres hémorragiques virales
German haemorrhagisches Fieber NNB, Nicht naeher bezeichnete haemorrhagische Viruskrankheit, haemorrhagisches Fieber, Hämorrhagische Fieber, virale
Portuguese Febre hemorrágica NE, Febre hemorrágica, Febres Hemorrágicas Virais
Spanish Fiebre hemorrágica NEOM, fiebre hemorrágica vírica, fiebre viral hemorrágica, no especificada (trastorno), fiebre viral hemorrágica, no especificada, [X]fiebre hemorrágica viral no especificada (trastorno), [X]fiebre hemorrágica viral no especificada, fiebre hemorrágica viral (trastorno), fiebre hemorrágica viral, Fiebre hemorrágica, Fiebres Hemorrágicas Virales
Japanese 出血熱, 出血熱ＮＯＳ, ｼｭｯｹﾂﾈﾂNOS, ｼｭｯｹﾂﾈﾂ
Swedish Hemorragiska febrar, virala
Czech hemoragické horečky virové, Hemoragická horečka, Hemoragická horečka NOS
Finnish Virusverenvuotokuumeet
Russian GEMORRAGICHESKIE LIKHORADKI VIRUSNYE, ГЕМОРРАГИЧЕСКИЕ ЛИХОРАДКИ ВИРУСНЫЕ
Korean 상세불명의 바이러스 출혈열
Croatian Not Translated[Hemorrhagic Fevers, Viral]
Polish Gorączki krwotoczne wirusowe
Hungarian haemorrhagiás láz, Haemorrhagiás láz, haemorrhagiás láz k.m.n.
Norwegian Viral hemoragisk feber, Viral blødningsfeber
Derived from the NIH UMLS (Unified Medical Language System)

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