This document discusses a 27-year-old male patient presenting with fever, renal failure, and hemorrhagic symptoms who is diagnosed with Korean hemorrhagic fever (KHF). KHF is caused by hantaviruses carried by rodents. It presents initially as fever and progresses through hypotensive, oliguric, and diuretic stages. While severe cases have high mortality, intravenous ribavirin treatment was shown to reduce mortality and complications in a Chinese clinical trial. KHF and related illnesses like nephropathia epidemica are occupational hazards for those exposed to infected rodents.

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!