A discussion of hemorrhagic fever

1. HX
●27 y/o CzekBat infantryman
●5 d hx/o high fever, rigors, malaise
●Severe Lumbar Pain and marked N/V
●Transfered for Renal Failure

2. Exam
●Subconjunctival Hemmorhage
●Petechial rash of Palate
●Marked Dermatographism

3. Laboratory
●WBC 20 K
●Platlets 105 K
●pH 7.32, pCO2 24, pO2 104 (RA)
●BUN 60, Creat 6.4
●K+ 3.7 meq/dl

4. Hemodynamics
●RA 4 torr
●PA 24/12 torr (mean 18)
●PAOP 12 torr
●MAP 90 (HR 74)
●RADIAL ARTERIAL Sat 95.4%, Mixed
Venous O2 Sat 84%
●C.O./C.I. 12.4 L/min/5.8 L/min

5. Korean Hemmorhagic
Fever -Nephropathia Epidemica
Frank Meissner, LtCol, USAF, MC, FS
Emergency Medicine

6. The fact that illness is associated
with the poor-who are, from the
perspective of the privileged,
aliens in one's midst-reinforces
the association of illness with the
foreign: with an exotic, often
primitive place.
Susan Sontag

7. History I
●1950s United Nations troops in Korea
epidemic- serious febrile illness
associated with hemorrhages, capillary
leak phenomena, and renal failure
●Korean epidemic hemorrhagic fever

8. History II
●1913 eastern Russia, various regions of
Russia and China, including Siberia and
Manchuria, Korea and Japan
●1982 and 1983 same illness reported in
various parts of France
●A milder form - nephropathia epidemica
in Scandinavia - 1935

9. Biology
●Genus Hantavirus at least 4 species
●Hantaan virus (Korean hemorrhagic
fever)
●Seoul virus (milder form of Korean
hemorrhagic fever)
●Puumala virus (nephropathia
epidemica)
●Prospect Hill virus (isolated meadow
voles Maryland no disease)

10. Biology
●Family Bunyaviridae Genus Hantavirus
●3 molecules per virion
●Nonmessenger ss-RNA genome
●Spherical 80-115 nm Diameter
●Helical Capsid symmetry
●Lipo- and glycoprotein Envelope

11. Serology
●Viremia not usuallly noted at
presentation
●IgM & IgG antibodies usually present at
clinical presentation
●Immunfluorescent antibody test
available
●Antigen-antibody complexes in serum
may be cause of tubular nephropathy

12. Epidemiology I
●Hantaviruses isolated rodents
world-wide
●42% of Norway rats- Baltimore (1980
and 19860 (+) antibodies Hantaan virus
●Increased number naturally acquired
and lab- associated infections in Europe
●Recent outbreak in Belgium lab rats

13. Epidemiology II
●Virus in urine, feces, and saliva various
rodents, including field and laboratory
mice, rats, and voles
●Transmission rodent to rodent
respiratory
●Human transmission inhalation
infectious aerosols rodent excreta
●No evidence human-to-human

14. Clinical
●5 Stages
●febrile
●hypotensive
●oliguric
●diuretic
●convalescent

15. Clinical
●Incubation period is 7 to 36 days
●Usually 10 to 25 days
●Severity of illness varies considerably
●Approx 65% of cases mild
●10 to 15% severe

16. Febrile
●Onset abrupt : chills, fever, backache,
abdominal pain, myalgia
●Fever peaks- 3rd or 4th day
●Relative bradycardia
●Severe illness, confusion, meningismus,
and convulsions occur
●Mortality with severe disease
approximately 40 percent

17. Febrile (dermatological
findings)
●Typical early findings diffuse reddening
of the face (sunburn)
●Dermatographism > 90% of patients
●Petechiae 3rd to 5th day, initially on
palate, pressure areas (axillary folds)
●Conjunctival hemorrhages

18. Hypotensive
●5th day, shock or hypotension may
occur (hypotensive phase)
●Mild cases, fall in BP is only transient
●Hct increases and marked proteinuria,
leukocytosis, and thrombocytopenia
develop.

19. Oliguric
●About 8th day
●BP returns to normal
●Oliguria develops
●BUN levels increase rapidly
●Hemorrhagic manifestations more
prominent

20. Diuresis
●About the 11th day
●CNS and pulmonary complications may
be seen
●Convalescent phase lasts 3 to 6 wk.

21. Prognosis
●Most patients survive the period of
oliguria
●Total illness of two to three weeks'
duration
●No specific therapy (??????)
●Overall mortality - five to 30 percent
●Residual renal dysfunction uncommon
in Korea may be more common in

22. NE
●Nephropathia epidemica milder illness
●Seen in Scandinavia
●Sudden onset of high fever, headache,
backache, and abdominal pain
●On 3rd or 4th day, conjunctival
hemorrhages, palatine petechiae, and a
truncal petechial rash appear

23. NE
●Approx 20% of patients develop a toxic
condition become mentally obtunded
●Oliguria and azotemia develop
concomitantly with the hemorrhagic
manifestations
●Urinalysis reveals proteinuria,
hematuria, and pyuria
●Rash subsides in about 3 days
●Develops polyuria recovers weeks

24. Controlled Clinical Trial
●In China, 242 patients who had
serologically confirmed hemorrhagic
fever with renal syndrome
●Patients who had received intravenous
ribavirin - marked reduction in mortality
●Marked reduction in the risk of oliguria
and of hemorrhage

25. Theraputic Regimen
●Intravenous ribavirin- loading dose of 33
mg/kg
●Loading dose was followed by 16 mg/kg
every six hours for four days and by 8
mg/kg every eight hours for three days

26. Clinical Laws of Thought
●Uncommon presentations of common
diseases is more common than
common presentations of uncommon
diseases
●PREVALENCE OF DISEASES HAVE
CHANGED
●WHERE ARE YOU FROM, WHERE
HAVE YOU BEEN?

27. Clinical Laws of Thought
●Meissner’s Ultimate Law
●EVERYTHING,
Depends!