Viral Haemorrhagic Fevers

Dr Stella O. Enyinnaya
Department of Medical Microbiology and Parasitology
Objective
 Define and use important terminology
 Identify features of VHF and sequelae
 Understand the underlying pathophysiology
 Identify causative pathogens
 Diagnosis
 Management
Introduction
 Viral hemorrhagic fevers (VHFs) are a group of illnesses that are caused by several
distinct families of viruses.
 The term viral hemorrhagic fever (VHF) is used to describe a severe multisystem
syndrome (multisystem in that multiple organ systems in the body are affected).
 Symptoms of this type of condition can vary but often include fever and bleeding, or
hemorrhaging.
 Some VHFs cause relatively mild illness, while others can cause severe, life-
threatening disease.
 VHFs are of public health importance due to the high case fatality rate of some VHFs.
 [Case fatality rate is the proportion of people who die from a specified disease among
all individuals diagnosed with the disease over a certain period of time].
 While endemic in certain regions they have a worrisome pandemic potential.
Characteristics of VHF
 All known VHFs are caused by single-stranded enveloped RNA viruses.
 Low infectivity dose (1 -10 viruses can cause infection
 Their survival is dependent on an mammalian or invertebrate host: the natural
reservoir.
 Humans are not the natural reservoirs but can transmit the virus.
 They are usually restricted to areas where their host species live.
 Found in both temperate and tropical habitats
 They spread to people when a person encounters an infected animal or insect
host (e.g bites, ingestion/contact with excretions).
 After the initial spread into the human population, some VHF viruses can
continue to spread from person- to-person.
Characteristics of VHF
 They usually cause outbreaks sporadically and irregularly. Occurrence of
outbreaks cannot be easily predicted.
 Nosocomial transmission is particularly important
 The mode of transmission and clinical course would vary depending on the
specific pathogen
 They cause severe multisystem syndrome (multiple organs are affected)
 Vascular system damage and the body looses the ability to regulate itself
 Accompanied by bleeding through orifices
 Many VHF cause life threatening diseases, others may not be life threatening
 Most have no established treatment or cure.
VECTORS OF THE VIRUSES
 Viruses associated with most VHFs are zoonotic. They are totally dependent
on their hosts for replication and overall survival.
 For the most part, rodents and arthropods are the main reservoirs for viruses
causing VHFs.
 The multimammate rat, cotton rat, deer mouse, house mouse, and other field
rodents are examples of reservoir hosts.
 Arthropod ticks and mosquitoes serve as vectors for some of the illnesses.
 However, the hosts of some viruses remain unknown: Ebola and Marburg
viruses are well-known examples
Aetiology
 VHFs are caused by several distinct families of viruses.

 Families implicated include:

❖Arenaviridae
❖Bunyaviridae
❖Filoviridae
❖Flaviviridae
Classification of VHF based of viral families
Arenaviruses
 A group of enveloped viruses
which are typically spherical or
pleomorphic, measuring about 40-
200nm in diameter, with club-
shaped projections (spikes).

 Arenavirus genome has two or

three single-stranded ambisense
RNA molecules.
Arenaviruses
 Arenaviruses are classified into two categories: Old World and New World,
based on geographic location in Africa and the Americas, respectively.
 Old World arenaviruses: Lujo and Lassa virus
 New World arenaviruses:
 Junin virus (Argentine HF)
 Machupo virus (Bolivian HF)
 Guanarito virus (Venezuelan HF)
 Sabia virus (Brazilian HF)
Lassa fever
 Lassa fever virus was first isolated in
Lassa village, Northeastern Nigeria in
1969 form a missionary nurse who
presumably acquired the infection from
an obstetric patient, died a week later, and
two other nurses were subsequently
infected.
 The multimammate rat, Mastomys
natalensis, is the natural host and
reservoir for this Lassa fever virus.
Epidemiology

 Lassa fever has been reported

all year round
 Most cases are recorded in dry
season i.e. November to May
 An estimated 300,000-500,000
Lassa fever cases and 5,000
related deaths occur annually
in West Africa.
 Cases occur throughout West
Africa, particularly in Nigeria,
Sierra Leone, Guinea, and
Liberia.
Distribution map of
Lassa fever outbreaks
(adapted from
Centers for Disease
Control and
Prevention. Lassa
fever.
www.cdc.gov/vhf/las
sa/index.html).
Courtesy BMJ
TRANSMISSION
 Direct contact with fluids/faeces of infected
rodent
 Ingestion of contaminated foods/drinks
 Contact with infected objects and surfaces
 Person-to-person transfer –contact with bodily
fluids/faeces
 Aerosol spread is possible
 Infection typically occurs following inhalation of
or contamination by infected rodent urine and/or
faeces.
 Population at risk:
❖ Affects all age groups
❖ People living in/ visiting WestAfrica
❖ Individuals in poorly sanitized areas
❖ Healthworkers
Pathogenesis
 Extensive reticuloendothelial involvement
 Multifocal hepatocellular necrosis with Councilman-like bodies, cytoplasmic
degeneration of hepatocytes, and minimal inflammatory response
 Focal adrenal necrosis and adrenal cytoplasmic inclusions
 Interstitial pneumonia
Clinical manifestations
 The incubation period of LF ranges from 7 to 21 days.
 No specific symptom
 Mild and undiagnosed ~80%
 The clinical disease begins as a flu-like illness characterized by fever, general
weakness, and malaise, which may be accompanied by cough, sore throat, and severe
headache.
 Mild onset over days include: fever, malaise, headache, general weakness, joint pain,
anorexia, nausea, vomiting, diarrhoea, abdominal pain, cough, dyspnoea, chest pain
 At late stage: Agitation, confusion, tremor, coma, convulsions, Haemorrhage(from
mouth, nose, gastrointestinal tract, sub-conjunctival, IV cannula access and vagina)
 Multiple organ failure -Death
 Case fatality:1%
 ~15-20% of hospitalized die
 Can be as high as 50% in epidemic
 Lassa virus infections cause fetal death in more than 75% of pregnant
women
 Death particularly↑ in 3rd trimester pregnancies (both for mother>80% and
foetus~ 95% IUCD)
 Abortion decreases death risk in mothers
Diagnosis
Clinical diagnosis –initially difficult, there should be a high index of suspicion in patients
with severe persistent fever and pharyngitis
Lab: Microbiology
 Enzyme-linked Immunosorbent serologic assays(ELISA)-detection of IgM and IgG
antibodies
 Electron microscopy
 Antigen detection tests
 Viral cell culture
 Reverse-transcriptase polymerase chain reaction (RT-PCR) assay is the most sensitive and the
fastest diagnostic method.
 Other Lab Findings: Lymphocytopenia, thrombocytopenia, elevated aspartatetransaminase
 Specimens are hazardous and should only be isolated or studied under Biosafety Level 4
(BSL4) containment.
Treatment
 Ribavirin a purine nucleoside with broad-spectrum antiviral properties has been used for
treatment so far.
❖ Ribavirin is effective when taken early (within the first 6hrs improves the prognosis
remarkably).
 Other supportive treatments-
❖ Rehydration
❖ Antipyretics
❖ Electrolyte balancing
❖ Oxygenation
❖ Blood pressure control
❖ Blood transfusion
❖ Management of complications
Prevention
 No approved vaccine yet.
 The main approach to prevention is to interrupt the spread of rodents to humans,
from person to person, and from infected specimens to laboratory workers.
 Rats should be excluded from houses.
 Person-to-person spread within hospitals has been a problem with LF. Sadly, several
health workers have died as a result of infection
 Practice standard precautions at all times:
 good hand hygiene, Use of PPE
 Isolation/barrier nursing of pts suspected to have Lassa fever
 Appropriate disposal of infected items
 Regular cleaning of the hospital
 High index of suspicion
Bunyaviridae
 This largest family of RNA viruses has more than 350
named isolates that can be found worldwide.
 Its members can infect invertebrates, vertebrates, and
plants.
 Comprises of five genera:
 Orthobunyavirus
 Phlebovirus
 Hantavirus
 Nairovirus
 Tospovirus
Virology
 Bunyaviridae are spherical, lipid membrane-enclosed viruses that are
 90 to 110 nm in diameter.
 They contain three negative-sense RNA.
Mandell, Douglas, and Bennett’s
Principles and Practice of
INFECTIOUS DISEASES
Hantavirus
 Hantaviruses are classified in the Hantavirus genus of the Bunyaviridae family.
 The viruses are found worldwide and cause two serious and often fatal human diseases: hemorrhagic
fever with renal syndrome (HFRS) and Hantavirus pulmonary syndrome (HPS).
 Hemorrhagic fever with renal syndrome (HFRS) may be caused by seven hantaviruses (e.g.,
Hantaan, Seoul, Dobrava, Saaremaa, Amur, Puumala, and Far East).
 After an incubation period of 2 to 3 weeks, patients present with abrupt onset of fever in association
with malaise, headache, myalgias, back pain, abdominal pain, nausea, and vomiting.
 Conjunctival injection or hemorrhage with palatal and upper torso petechiae is commonly seen on
physical examination.
 During this phase, a characteristic erythematous flush that blanches with pressure may be observed,
usually affecting the face, neck, and upper torso.
 After the 3- to 7-day febrile phase, a period of hypotension and severe shock ensues that is
characterized by hemorrhagic manifestations.
 Overall, about 20% of the patients manifest severe disease, with death from shock and renal failure in
5% to 10% of cases.
 Hantavirus pulmonary syndrome may be caused by multiple hantaviruses including Sin
Nombre virus.
 Some forms of hantavirus pulmonary syndrome (e.g., Andes) can present as conjunctivitis,
facial flushing, and variable numbers of fine petechiae on the trunk, axillary folds, soft
palate, or neck.
Crimean-Congo hemorrhagic fever (CCHF)
 Crimean-Congo hemorrhagic fever (CCHF) is caused by infection with a tick-borne
virus (Nairovirus) in the family Bunyaviridae.
 The disease was first characterized in the Crimea in 1944 and given the name
Crimean hemorrhagic fever.
 It was then later recognized in 1969 as the cause of illness in the Congo, thus
resulting in the current name of the disease.
 Crimean-Congo hemorrhagic fever is found in Eastern Europe, particularly in the
former Soviet Union, throughout the Mediterranean, in northwestern China, central
Asia, southern Europe, Africa, the Middle East, and the Indian subcontinent.
 Transmission is by Ixodid (hard) ticks, especially those of the genus, Hyalomma, are
both a reservoir and a vector for the CCHF virus.
 Numerous wild and domestic animals, such as cattle, goats, sheep and hares, serve as
amplifying hosts for the virus.
 Transmission to humans occurs through contact with infected ticks or animal blood.
Crimean-Congo hemorrhagic fever (CCHF)
 CCHF can be transmitted from one infected human to another by contact
with infectious blood or body fluids.
 The spread of CCHF has also occurred in hospitals due to improper
sterilization of medical equipment, reuse of injection needles, and
contamination of medical supplies.
 The onset of CCHF is sudden, with initial signs and symptoms including
headache, high fever, back pain, joint pain, stomach pain, and vomiting.
 Red eyes, a flushed face, a red throat, and petechiae (red spots) on the
palate are common.
 Symptoms may also include jaundice, and in severe cases, changes in
mood and sensory perception.
 As the illness progresses, large areas of severe bruising, severe
nosebleeds, and uncontrolled bleeding at injection sites can be seen,
beginning on about the fourth day of illness and lasting for about two
weeks.
Diagnosis
Hantavirus
 Antigen-detection ELISA
 RT-PCR assay
 ELISAs for antiviral IgM antibodies in blood and cerebrospinal fluid.
CCHF
 Antigen-capture enzyme-linked immunosorbent assay (ELISA)
 Real-time polymerase chain reaction (RT-PCR),
 Virus isolation
 Detection of antibody by ELISA (IgG and IgM).
Treatment
 Ribavirin has been used for Hanta fever.
 Effective supportive care is important in all of the severe bunyavirus diseases.
 Careful management of coma, cerebral edema, and seizures is critical in patients.
 May require hemodialysis or peritoneal dialysis during the oliguric phase.
 Plasma protein or whole blood, or both, may be useful in treating hemorrhage or
shock.
 Treatment for CCHF is primarily supportive.
 Care should include careful attention to fluid balance and correction of electrolyte
abnormalities, oxygenation, and hemodynamic support, and appropriate treatment of
secondary infections.
 The virus is sensitive in vitro to the antiviral drug ribavirin. It has been used in
treating CCHF patients reportedly with some benefit.
Prevention
 No approved vaccine.
 The mainstay of prevention is avoidance of rodent contact, use of mosquito and tick
repellents.
 Agricultural workers and others working with animals should use insect repellent on
exposed skin and clothing
 Individuals should also avoid contact with the blood and body fluids of livestock or
humans who show symptoms of infection
 Appropriate long-sleeved shirts, gloves, dresses, and trousers when outdoors.
 Some countries have tried aerial spraying of slow-release insecticides over forested
areas to reduce mosquito vectors.
 Healthcare workers to use proper infection control precautions to prevent
occupational exposure.
Filoviridae
 The family Filoviridae is divided into two genera: Marburg virus and Ebola
virus.
 Although the Marburg genus contains a single species, the Ebola genus
consists of 6 species:
 Zaire
 Sudan
 Taï Forest (formerly Côte d'Ivoire ebolavirus)
 Bundibugyo
 Reston
 Bombali (identified in bats, but it is unknown if it causes illness in either
animals or people).
 Filoviruses are enveloped, nonsegmented, negative-strand RNA viruses.
 Filovirus particles take on a variety of forms, from circular or “6”-shaped to
prototypical straight filaments, for which the virus family is named.
Epidemiology
 The first documented outbreak of VHF caused by a filovirus occurred in 1967
when there were three concurrent episodes of lethal MARV infections in
Marburg and Frankfurt, Germany following laboratory exposure to blood from
imported Green monkeys.
 Ebola was first recognized during near-simultaneous explosive outbreaks in
1976 in small communities in the former Zaire (now the Democratic Republic
of Congo) and Sudan.
 Ebola virus disease occurs sporadically in the Central African Republic and
Sudan, where it is endemic, however the greatest outbreak of EVD to date
occurred between 2014 and 2016 and involved Guinea, Sierra Leone, Liberia,
and Nigeria with over 28,652 confirmed cases and 11,325 deaths.
 The occurrence of EVD outbreaks has been associated with hunting and
handling of bush meat while that of MVD outbreaks have often been linked to
entry into caves or working in decommissioned mines in which bats roosts.
 Transmission -initially infection through contact with an infected animal, such
as a fruit bat or nonhuman primate “a spillover event”. After that, the virus
spreads from person to person,
 The virus spreads through direct contact (such as through broken skin or
mucous membranes in the eyes, nose, or mouth) with:
 Blood or body fluids of infected person.
 Contaminated fomites
 Infected fruit bats or nonhuman primates (such as apes and monkeys).
 Semen from a man who recovered from EVD (through oral, vaginal, or anal
sex) -no evidence of spread through vaginal
Outbreaks of Ebola in sub-Saharan Africa.

Malvy et al The Lancet

Volume 393 Issue 10174 Pages 936-948 (March 2019)
DOI: 10.1016/S0140-6736(18)33132-5
Pathogenesis
 Filoviruses are thought to enter the host through mucosal surfaces, small
abrasions and/or tears in the skin, or by parenteral introduction.
 Both EBOV and MARV have a broad cell tropism, infecting a wide variety of
cell types (macrophage system, dendritic cells, interstitial fibroblasts, and
endothelial cells).
 Very high titers of virus are present in many tissues, including the liver, spleen,
lungs, and kidneys, and in blood and other fluids.
 Extensive hepatocellular necrosis with intracytoplasmic viral inclusions
 Necrosis involving parenchymal cells, macrophages, and endothelial cells in
major organs.
 These viruses have the highest mortality rates (25–90%) of all the viral
hemorrhagic fevers
Clinical features
 The incubation period is 3–9 days for Marburg disease and 2–21 days for Ebola.
 Non-specific early symptoms - acute onset of fever, severe frontal headache, anorexia,
malaise, and myalgias.
 These signs and symptoms are followed 2 to 3 days later by clinical deterioration heralded by
pharyngitis, conjunctivitis, severe nausea and vomiting, abdominal pain, and watery diarrhea.
 Late symptoms of maculopapular rash on the trunk and back that is followed by the
appearance of petechiae, ecchymoses, subconjunctival haemorrhages, epistaxis, haemoptysis,
haematemesis, and melaena.
Clinical features
 End stage – DIC, Coma, hemorrhagic shock may progress to death.
 Patients with Marburg virus infection may develop a scarlatiniform rash rather
than a maculopapular rash.
 Considerations in the differential diagnosis of African haemorrhagic fevers also
include yellow fever and Lassa fever, but these illnesses are not accompanied by
a rash.
Diagnosis
 Direct electron microscopy
 Antigen detection (immunohistochemistry and antigen
capture ELISA).
 Reverse transcriptase PCR (RT-PCR)
 Viral cell culture followed by antisera typing or
immunofluorescence.
 Serology (IgM and IgG)
 For filoviruses, RT-PCR, antigen detection, and IgM are the more valuable
techniques for acute-case diagnosis.
 Because of the time required for culture and the biohazard, isolation data for
these viruses are usually available only retrospectively.
 Marburg virus and Ebola viruses are usually easily isolated from acute-phase
serum samples.
 A rising IgM or IgG ELISA titer constitutes a strong presumptive diagnosis.
 Since IgM titers do not persist for long, a decreasing titer suggests a recent
infection which occurred perhaps only within several months.
Treatment and prevention
 Inmazeb (atoltivimab, maftivimab, and odesivimab-ebgn), a mixture of three
monoclonal antibodies and Ebanga (Ansuvimab-zykl), a human monoclonal
antibody, were approved in 2020 by the US FDA for the treatment for Zaire
ebolavirus.
 Supportive management.
 Prevention:
 Earlyrecognition, patient isolation, and barrier nursing, effective IPC,
education.
 rVSVΔG-ZEBOV-GP Ebola vaccine (brand name Ervebo) against Zaire
ebolavirus.
Flaviviridae
 Flaviviruses belong to a group of viruses called Arthropod-borne
viruses (arboviruses). They are transmitted to a vertebrate host
through the bite of an infected arthropod.
 Flaviviruses are icosahedral, approximately 50 nm in diameter.
 Single-stranded, positive-sense RNA viruses consisting of a lipid
envelope covered densely with surface projections consisting of
M (membrane) and E (envelope) glycoproteins.
 The flaviviruses include yellow fever, Omsk hemorrhagic fever,
dengue, Japanese Encephalitis, West Nile Encephalitis, St. Louis
Encephalitis, Tick-Borne Encephalitis, Kyasanur Forest Disease,
Alkhurma Hemorrhagic Fever, and Zika.
Chapter 3 - Flaviviruses,
Editor(s): Adnan I. Qureshi,
Zika Virus Disease,
Academic Press,
2018,
Pages 47-61,
ISBN 9780128123652,
https://doi.org/10.1016/B978-0-12-812365-2.00004-4.
Yellow Fever
EPIDEMIOLOGY
 Yellow fever (YF) is found in tropical South
America and sub-Saharan Africa.
 Aedes aegypti

 Disease is severe with high morbidity and mortality.

 Two patterns of transmission occur:
 Urban (epidemic): Occurs via human-to-human
transmission via the bite of Aedes aegypti
mosquitoes.
 Jungle (enzootic): The infection is maintained in
monkeys, transmission occurs via Haemagogus
(South America) and Aedes (Africa) mosquitoes.
Human cases occur when susceptible people are
bitten by mosquitoes e.g farmers, hunters, forestry
workers.
 ˃100,000 cases occur annually in Africa with death
rates of 20-50% Haemagogus mosquito
Pathogenesis
 The virus is inoculated by mosquitoes and replicates in local lymph nodes,
subsequently spreads via the bloodstream to other lymphoid sites and tissues.
 Viraemia peaks around days 5-6 corresponding with an increase in
inflammatory cytokine production and the onset of symptoms.
 Haemorragic manifestations occurs in mucosal surfaces, skin, and viscera.
 Gastric erosions may manifest as haematemesis
 Hepatocellular necrosis may occur.
 Renal and neurological impairment may follow
 Others include myocarditis, coagulation deficiency, sepsis.
Clinical features

 Incubation period is 3 to 6 days.

 Symptoms range from asymptomatic to haemorrhagic fever.

 First phase: headache, fever and myalgia for 3 to 4 days. Most
recover at this stage.
 Second phase: Hours to days after the 1st phase, severe cases go on
to develop high fever, back pain, nausea, vomiting abdominal pain,
drowsiness, jaundice, bleeding (haematemesis, melaena, petechiae
or purpura, renal failure (oliguria, uraemia). Arrythmias, seizures,
unconsciousness may follow.
Diagnosis
 Viral antigen ELISA.
 Real-time reverse transcriptase PCR (RT-PCR) is the technique of choice.
 Viral cell culture (in duck, chicken embryo, monkey, or hamster kidney cells)
 The infecting virus causes characteristic cytopathic effects (CPE) (e.g.,
plaques, cell fusion, and/or syncytium formation). CPE patterns can assist in
determining the genus and possibly the family of virus.
 Serology. IgM detection by ELISA is over 95% sensitive in serum samples
taken 7-10 days after illness onset in primary infections. In secondary
infections, IgG and IgM are 100% sensitive at day 5 of illness. A rising titre of
up to 4-fold confirms the diagnosis.
Other lab findings
Laboratory findings
 Leucopenia in early stages
 Thrombocytopenia
 Coagulation abnormalities
 Raised transaminases (AST˃ALT in myocarditis)
 Raised blood urea
 Metabolic acidosis
 Albuminuria (a characteristic feature of yellow fever hepatitis)
 Raised CSF protein
Treatment and prevention
 Mainly supportive: fluid balance, management of
coagulopathy and renal insufficiency, reducing the
risk of GI bleeding etc.
 Prevention: Prevent mosquito bites;
• Use insect repellent
• wear long-sleeved shirts and pants
• treat clothing and gear
 Vaccination; A single dose can provide long-term
protection in 95% of people. Travelers to endemic
areas are advised to receive the vaccine every 10
years.
 Vaccine is recommended for people aged 9 months
or older
Dengue Aedes aegypti

 It is a Flavivirus and arbovirus transmitted by Aedes

mosquitoes.
 Four distinct serotypes (DENV-1 to DENV-4).
It causes fever and can be complicated by
haemorrhage and shock.
Infection with one provides brief cross protection to
all 4 after which immunity to only the infecting
serotype remains. A later secondary infection is then
associated with an increased risk of severe disease
(Dengue Haemorrhagic Fever).
Epidemiology
• Dengue is widely distributed throughout the tropics and subtropics.
• Dengue occurs in the regions where its vector is
found.
• Aedes are day-biting mosquitoes, they breed in
open water (domestic containers, puddles etc).
• A. aegypti is the principal mosquito vector.
• Aedes albopictus, Aedes polynesiensis are also
vectors.
Pathogenesis
 The virus disseminates in the blood within 2-3 days of a bite from an infected
mosquito.
 There is viraemia typically for 4 to 7 days in plasma and infected monocytes.
 The malaise and influenza-like symptoms that typify dengue probably reflect
patients’ cytokine response; however, myalgia, a cardinal feature of the illness,
may also indicate pathologic changes in muscle, typified by a moderate
perivascular mononuclear infiltrate with lipid accumulation.
Clinical features
• Incubation period is 4-7 days.
• Non severe disease (Dengue Fever) accounts for 80% of cases.
 Abrupt fever, headache, muscle pain, rash, back and abdominal pain.
 Fever may subside in 2-7 days and then recur.
 Minor mucosal bleeding may occur (esp in people with previous peptic ulcer disease), hepatitis, neurological features
etc.

• Severe disease [Dengue shock syndrome (DSS), Dengue Haemorrhagic fever

(DHF)] is infrequent (~2% to 4% of apparent cases) but potentially fatal.
 Signs of shock
 Pleural effusion, ascites
 Thrombocytopaenia, development of petechiae
Diagnosis
 Leucopaenia, low platelets and abnormal raised liver enzymes are common
laboratory findings.
 RT-PCR is detection technique of choice.
 Antigen detection by ELISA is also very useful due to its rapid turn-around-
time and application in field settings. The NS1 antigen is the target. It is more
useful than serology in the early stages of the illness.
 Serology. This is less specific due to cross reactivity between flaviviruses.
 Viral cell culture
Treatment and prevention
 Supportive management (anti-pyretics, fluid, circulatory
support).
 Prevention is mainly by vector control.
 No licensed vaccine yet.
59