Management and Treatment Congo hemorrhagic fever

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Management and Treatment Congo hemorrhagic fever

• Dr. D. Steyn
• Department of
• Internal Medicine
• UOFS

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Syndromes - Zoonotic viruses

• VHFs are zoonotic infections and only
  occasionally cause illness in man
• fever and myalgia
• arthritis and rash
• encephalitis
• haemorrhagic fever

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Crim-Congo Haemorrhagic Fever

• 1944 - Crimean region (Soviet Union)
• 1956 - Congo
• 1981 - 1st case in RSA (10 - 12 cases/y)
• Reservoirs cattle, sheep, goats, birds
  (ostriches) and hares
• Vector Hyalomma tick (bontpootbosluis)
• Humans become infected by contact with ticks or
  blood (not airborne)

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• Larvae and nymphs feed on small mammals
• up to hare size
• and ground-frequenting birds
• while adults prefer
• large animals
• Prof. R Swanepoel

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Humans gain infection from tick bite
or from contact of infected fresh blood (or
other tissues) with broken skin
infected blood/tissues coming either from human
patients (nosocomial infections - needle sticks
etc) or other animals, commonly sheep and
cattle Prof. R Swanepoel
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Airborne transmission

• Airborne transmission involving humans is
  considered a possibility only in rare instances
  from persons with advanced stages of disease
• (e.g., one patient with Lassa fever who had
  extensive pulmonary involvement may have
  transmitted infection by the airborne route)

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Clinical manifestation

• Incubation period 3-6 days !!
• Abrupt onset (Flu-like symptoms)
• High fever with chills (400C, /- 8 days)
• Severe headache
• Myalgia (back ache)
• Arthralgia
• Abdominal pain

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Clinical manifestation

• Nausea/vomiting
• Sore Throat
• Conjunctivitis
• Jaundice (hepatomegaly 50)
• Splenomegaly (2-25)
• Photophobia
• Flushing of the face
• Dry tongue, with a coating of dry blood

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Complications of CCHF

• Diarrhoea, vomiting, dizziness, confusion and
  abnormal behaviour
• Haemorrhagic manifestations
• oozing from arterial or venous puncture sites
• petechiae, purpura, ecchymosis
• mucosal bleeding
• epistaxis, hemoptysis
• haematemesis/ melena
• adrenal bleeding

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Complications of CCHF

• DIC in the most severe cases
• Hepatic dysfunction
• severe hepatitis and necrosis
• Kidney failure
• Respiratory failure (ARDS)
• Mostly in the severely ill, gt 5th day

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Complications of CCHF

• uncontrollable haemorrhage
• shock
• intercurrent infection
• multi-organ failure
• nuchal rigidity, excitation, coma
• Mortality /- 30 (15 to 70)

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Laboratory results

• leucopenia (WCC lt 1000/mm3)
• severe thrombocytopenia
• hepatic dysfunction
• markedly elevated liver enzymes
• prolonged PT/PTT
• Proteinuria / hematuria
• Markers of organ failure

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Poor prognostic markers

• WCC ? 10 x 109/l
• Platelet count ? 20 x 109/l
• AST ? 200 U/l
• ALT ? 150 U/l
• APTT ? 60 seconds
• Fibrinogen ? 110 mg/dl
• Any one of these during the first 5 days are
  highly predictive of a fatal outcome

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Diagnosis

• Physician awareness
• contact with livestock/blood of Pt with CCHF/
  bitten by a tick/ crushed tick with bare hands
• The longer the delay in making the diagnosis, the
  greater the cost
• specific Ab/ virus detection
• (biosafety level 4 lab)

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Differential diagnosis

• Meningococ- septicaemia
• Malaria
• Typhoid
• Gram- septicaemia
• Severe Rickettsial Diseases (Tick-bite fever)
• Hepatitis (fulminant)
• DIC/ anticoagulant therapy
• Systemic herpes, VZ, CMV, EBV and haemorrhagic
  measles
• Snake-bite

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Criteria for Clinical dx of CCHF

• 1.) History of exposure to infection
• 2.) Signs and symptoms
• 3.) Clinical pathology during first 5 days of
  illness
• Total gt 12 Points
• Treat as a case
  of CCHF
• R Swanepoel, J H Mynhardt, Harvey - 1987

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1.) History of exposure

• Incubation period
  lt 1w / gt1w
• Bitten or crushed tick 3
  2
• Direct contact with blood/
• tissues of livestock 3
  2
• Direct contact with blood/
• secretions from CCHF Pt 3
  2
• Resided or visited rural
• environment 2
  1

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2.) Signs and Symptoms

• Sudden onset 1
• Fever gt 38o C 1
• Severe headache 1
• Myalgia 1
• Nausea /- Vomiting 1
• Bleeding tendency 3

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3.) Clinical pathology (1st 5 days)

• WCC lt 3 or gt 9 1
• Platelets lt 150
  1
• Platelets lt 100
  2
• gt 50 ? WCC/ Pl within 3 days
  1
• Abnormal PI
  1
• Abnormal PTT 1
• AST gt 100
  1
• ALT gt 100 1

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Management of a suspected case of VHF

• Universal precautions are generally sufficient
  during the pre-hospital evaluation and transport
• Pts are less likely to vomiting, diarrhoea or
  haemorrhage
• respiratory symptoms (cough or rhinitis)
• face shields or surgical masks and eye protection
  

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Hospitalization

• A negative pressure room is not required during
  the early stages of illness
• barrier precautions
• cough, vomiting, diarrhoea, or haemorrhage
• additional precautions are indicated to prevent
  possible exposure to airborne particles
• Notification
• Observation of Contact Persons (2-3 w)

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Transfer

• Contact your referral hospital
• Ideally patients should be managed at the
  hospital where they are first admitted
• they do not tolerate the stress of transfer well,
  and evacuation increases the potential of
  secondary transmission
• If indicated transfer before bleeding start
• Mmeticulous infection practice
• Sedation

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Treatment

• Treatment of CCHF is mainly supportive
• fluid and electrolyte balance
• intensive care / ventilation
• Support of specific organ failure
• Intensive supportive sometimes for prolonged
  periods
• Management of severe bleeding
• Multiple platelet transfusions
• Fresh frozen plasma

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Treatment

• Secondary infections should be treated
  aggressively with broad-spectrum antibiotics
• Convalescent immune serum (first 3 days)
• Ribavirin
• Convalescence is often slow
• Discharge of Patient (/- after 3 weeks)
• Observation of contact persons (2-3 weeks)

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Notification
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