Crimean-Congo haemorrhagic fever among children in north-eastern Turkey

Changing Disease Course of Crimean-Congo Hemorrhagic Fever in Children, Turkey

Crimean-Congo hemorrhagic fever (CCHF), endemic in certain regions of the world, is listed as a priority disease with pandemic potential. Since CCHF was first identified in Turkey, children have been known to experience milder disease than adults. However, during the COVID-19 pandemic, we observed an unusually severe disease course, including hemophagocytic lymphohistiocytosis (HLH). We examined cytokine/chemokine profiles of 9/12 case-patients compared with healthy controls at 3 time intervals. Interferon pathway-related cytokines/chemokines, including interleukin (IL) 18, macrophage inflammatory protein 3α, and IL-33, were elevated, but tumor necrosis factor-α, IL-6, CXCL8 (formerly IL-8), and cytokines acting through C-C chemokine receptor 2 and CCR5 were lower among case-patients than controls. Interferon pathway activation and cytokines/chemokines acting through CCR2 and CCR5 improved health results among children with severe CCHF. Children can experience severe CCHF, including HLH, and HLH secondary to CCHF can be successfully treated with intravenous immunoglobulin and steroid therapy.

Increased Retinal Vessel Tortuosity Associated With Crimean-Congo Hemorrhagic Fever in Children

BACKGROUND

To evaluate the ocular symptoms and findings of children diagnosed with Crimean-Congo hemorrhagic fever (CCHF).

METHODS

In this prospective study, children diagnosed with CCHF who underwent a complete ophthalmologic examination during the hospitalization period were included.

RESULTS

Twenty-four children with a mean age of 12.4 ± 3.6 years were included study. The most common ocular finding was conjunctival hyperemia and was observed in 50% of patients. Nine (37.4%) children had abnormalities in fundus examination. Two (8.3%) of them had dilated retinal veins, and 7 (29.1%) had tortuous retinal vessels. No significant difference was found between mild to moderate and severe disease groups in terms of ocular symptoms and ophthalmologic examination findings (P > 0.05, for all).

CONCLUSIONS

The increased retinal vessel tortuosity was detected as a fundus examination finding in children with CCHF. Both ophthalmologists and pediatricians should be aware of the various ocular manifestations of CCHF for rapid diagnosis and management.

Analysis of Pediatric Intensive Care Unit Admissions for Crimean–Congo Hemorrhagic Fever in Turkey

Objective The aim of this study was to determine the clinical characteristics, course of disease, and outcomes of patients admitted to our pediatric intensive care unit (PICU) for Crimean–Congo hemorrhagic fever (CCHF).

Methods Data of all patients with CCHF who were admitted to PICU during a 3-year period and whose diagnosis was confirmed by serological methods or polymerase chain reaction were retrospectively reviewed. Their presenting characteristics, treatments, and outcomes were extracted from the hospital's electronic database. Disease severity scoring was performed using the severity scoring index and severity grading score system.

Results The data of 22 of 123 patients with suspected CCHF who were admitted to PICU were evaluated. Among them, 68.2% were males and mean age of all patients was 13.4 ± 2.2 years. The average length of stay of 10 patients was >10 days. On average, 3.72 units of platelet suspension per patient was transfused. In the course of the disease, the highest laboratory values were reached on day 3 of admission.

Conclusion Poor CCHF outcome depends on thrombocytopenia severity, prolonged coagulation tests, high-liver enzyme levels, and disseminated intravascular coagulation. Poor outcomes can be avoided by CCHF awareness and preparedness, early diagnosis of the disease, and supportive treatment with appropriate fluid and blood product transfusion. Randomized controlled trials on prophylactic transfusion and ribavirin use are needed.

Crimean-Congo hemorrhagic fever among children in Iran

Crimean-Congo hemorrhagic fever (CCHF) is a viral zoonotic disease which is endemic in Iran. The etiological agent of CCHF is an RNA virus belonging to the genus Nairovirus of the family Bunyaviridae. CCHF virus (CCHFV) can be transmitted to humans through bites from infected ticks and direct contact with infected blood or tissues. Although the disease has been observed in different age groups, the rate of disease is lower in children and elderly. This study was designed to characterize CCHFV-infected children in Iran. Between 2000 and 2016, a total of 908 CCHF suspected cases (in children less than 19 years old) were evaluated for CCHFV infection by CCHF IgM ELISA and RT-PCR. CCHFV infection was observed in 161 (17.73%) of subjects. Most CCHF positive children were male (70.8%) and >15 years of age (65.8%). Contact with livestock was the main risk factor (35.4%). Sistan and Baluchestan provinces had the highest frequency within the infected cohort (68.3%). The overall mortality rate was 11.8%. This study also revealed a significant reduction in CCHF-fatality rates in Iranian children when compared to earlier studies in Iran. Having contact with livestock was the major risk factor and CCHF was more common in male children of an older age.

Viral haemorrhagic fever in children

Viral haemorrhagic fevers (VHFs) are currently at the forefront of the world's attention due to the recent Zaire ebola virus epidemic in West Africa. This epidemic has highlighted the frailty of the world's public health response mechanisms and demonstrated the potential risks to nations around the world of imported cases of epidemic diseases. While imported cases in children are less likely, the potential for such a scenario remains. It is therefore essential that paediatricians are aware of and prepared for potential imported cases of tropical diseases, VHFs being of particular importance due to their propensity to cause nosocomial spread. Examining the four families of viruses--Filoviridae, Arenaviridae, Bunyaviridae and Flaviviridae--we describe the different types of VHFs, with emphasis on differentiation from other diseases through detailed history-taking, their presentation and management from a paediatric perspective.

Crimean-Congo hemorrhagic fever in Turkey: Current status and future challenges

Crimean-Congo hemorrhagic fever (CCHF) is a tick-borne viral disease of humans that affects a wide geographic area of Africa and Eurasia, including Turkey, Iran, Pakistan, Afghanistan and Russia. Since the first detection of CCHF cases in Turkey in 2002, more than 9700 patients have been reported, with an overall mortality rate just under 5%. This article assesses the present epidemiological situation of CCHF in Turkey, with an updated literature review, describes national practices and summarizes lessons learned in preparation for future outbreaks.

Important of Angiopoietic System in Evaluation of Endothelial Damage in Children with Crimean-Congo Hemorrhagic Fever

BACKGROUND

Crimean-Congo hemorrhagic fever (CCHF) causes endothelial activation and dysfunction by affecting the endothelium directly or indirectly. In maintaining the vascular integrity, vascular endothelial growth factor (VEGF-A) and its receptor (VEGFR1) and angiopoietin-2 (Ang-2) and its receptor (Tie-2) are very important mediators. For this reason, we aimed at studying the association of Ang-2 and VEGF and their receptors Tie-2 and VEGFR1 with CCHF infection.

METHODS

Thirty one CCHF patients and 31 healthy controls (HC) were included in the study. CCHF patients were classified into 2 groups in terms of disease severity (severe and nonsevere). VEGF-A, VEGFR1, Ang-2 and Tie-2 levels were measured in all groups.

RESULT

Serum levels of Tie-2, Ang-2, VEGF-A and VEGFR1 were significantly increased in CCHF patients compared with the HC. Furthermore, serum Tie-2, Ang-2, VEGF and VEGFR1 levels were found to be significantly higher in the severe group than in the nonsevere and HC groups (P < 0.05 and P < 0.001, respectively). Also, Tie-2, Ang-2, VEGF-A and VEGFR1 levels were significantly higher in the nonsevere group than in the HC group (P < 0.05).

CONCLUSION

Having statistically significant higher Ang-2, Tie-2, VEGF-A and VEGFR1 levels in the severe group when compared with the other groups suggested that VEGF-related Ang-2/Tie-2 system played a critical role in the pathogenesis of the disease, and these markers could be used as the severity criteria.

Evaluation of serum perforin, caspase-3, sFasL and M-30 levels as apoptotic markers in children with Crimean-Congo hemorrhagic fever

BACKGROUND

Apoptosis is a main regulator in responses of cellular immunity throughout systemic viral infections. Perforin, soluble Fas ligand, caspase-3 and caspase-cleaved cytokeratin-18 (M-30) are mediators of apoptosis. The aim of this study is the evaluation of Crimean-Congo hemorrhagic fever (CCHF) disease changes in the levels of these apoptotic markers and the relation of these changes with disease severity.

METHODS

Forty-nine hospitalized children with CCHF and 36 healthy controls were enrolled in this prospective study. The CCHF patients were classified into 2 groups based on disease severity (severe group and nonsevere group). Demographic characteristics and clinical and laboratory findings of all patients were recorded on admission.

RESULTS

Serum perforin, caspase-3 and soluble Fas ligand levels were found to be significantly higher both in the severe and nonsevere CCHF groups than the healthy control group (P < 0.05), but there was no significant difference in these apoptotic markers between severe and nonsevere CCHF groups (P > 0.05). In addition, serum M-30 levels did not differ significantly among all groups (P > 0.05). There was a positive correlation between serum values for perforin, caspase-3 and M-30 and the disease's severity criteria such as aspartate aminotransferase and/or alanine aminotransferase. The serum levels of all these markers were negatively correlated with disease severity criteria such as the platelet count.

CONCLUSIONS

In this study, we concluded that the interactions of cytolytic granules containing perforin and caspase cascade and Fas-FasL may play an important role in the pathogenesis of CCHF in children.

Cytokine concentrations in pediatric patients with Crimean-Congo hemorrhagic fever

Crimean-Congo hemorrhagic fever is a zoonotic disease that can be a severe illness in humans. We investigated concentrations of interleukin (IL)-6, tumor necrosis factor-α and IL-10 in serum samples obtained from 25 pediatric Crimean-Congo hemorrhagic fever cases and 35 control children with no signs of infection. Lower cytokine values in our patients could be a good prognostic factor to for a better outcome.

Evaluation of children with Crimean-Congo hemorrhagic fever in the central Blacksea region

BACKGROUND

Crimean-Congo hemorrhagic fever (CCHF) is endemic in some regions of our country. It is seen in all age groups; however, its prevalance is low in children. The studies on CCHF have been mostly in adults. The aim of this study was to evaluate the epidemiologic, demographic, clinical and laboratory findings of children with CCHF.

METHODS

Between May 2008 and September 2011, the medical records of patients who were admitted to the Children Infectious Diseases Service of Ondokuz Mayis University School of Medicine with positive blood IgM by enzyme-linked immunosorbent assay or polymerase chain reaction positive for CCHF were retrospectively evaluated. Epidemiologic and demographic features, clinical and laboratory data and therapy were recorded.

RESULTS

Fifty-four patients with the diagnosis of CCHF were recorded between May 2008 and September 2011. Main symptoms during hospital admission were fever (98%), vomiting (59%), headache (39%), nausea (39%), diarrhea (22%), abdominal pain (22%), bleeding (22%) and rash (20%). During admission, thrombocytopenia was found in 74%, elevated aspartate aminotransferase in 61%, leucopenia in 57%, elevated creatine kinase (33%) and alanine aminotransaminase (29%), and prolonged prothrombin time and partial thromboplastine time in 28% were noted. Thirty-nine patients received ribavirin treatment. During clinical follow up, bradycardia was recorded in 18 patients (33%) all of whom received ribavirin treatment. One patient died.

CONCLUSIONS

This study reports the largest series of children with CCHF and the first to describe bradycardia associated with ribavirin therapy.

Evaluation of the serum levels of soluble IL-2 receptor and endothelin-1 in children with Crimean-Congo hemorrhagic fever

We aimed to assess the association between serum levels of soluble IL-2 receptor (sIL-2r) and endothelin-1 and severe infection in children with Crimean-Congo hemorrhagic fever (CCHF). Fifty-two patients under 18 years of age with a laboratory- confirmed diagnosis of CCHF and 38 healthy controls were enrolled in the study. Patients were classified into two groups based on disease severity (severe group and non-severe group). The sIL-2r and endothelin-1 levels were observed to be significantly higher in patients with severe CCHF compared with those with non-severe CCHF and the control group (p < 0.05). In addition, those with non-severe CCHF were also found to have a significantly higher sIL-2r level relative to the control group (p < 0.001). Although there was a positive correlation between sIL-2r and endothelin-1 levels, serum levels of both sIL-2r and endothelin-1 were negatively correlated with the platelets count. In children with CCHF, serum levels of sIL-2r and endothelin-1 were increased, and this increase is related to the severity of the disease. In this study, we concluded through prognosis that serum levels of sIL-2r and endothelin-1 might be related, and that hemophagocytic lymphohistiocytosis and endothelial injury might contribute to a pathogenesis of the disease.

Evaluation of Crimean-Congo hemorrhagic fever virus infection in children

Crimean-Congo haemorrhagic fever (CCHF) is a fatal viral infection and an important public health issue in Turkey because of its high case fatality rate. Severity criteria of CCHF were defined previously in adults on the basis of epidemiological, clinical, and laboratory findings,. This study evaluated the course of CCHF in children. Between January, 2009, and November, 2012, 41 patients aged between 1 and 17 years (mean 9.78 ± 4.85) with a diagnosis of CCHF were included in the study. According to results of our study, Turkish pediatric patients had a milder course of CCHF.

Can the mild clinical course of crimean-congo hemorrhagic fever in children be explained by cytokine responses?

Cytokines are possibly one of the factors responsible for death due to Crimean-Congo hemorrhagic fever (CCHF). This study aimed to determine the differences between the cytokine levels in children and adult patients with CCHF; the influence of cytokines; and the severity of the course of the disease, which seems to be milder in children. Thirty-four children and 36 adult patients diagnosed with CCHF between 2010 and 2011 were included in this study. Diagnosis was performed by serology or by the polymerase chain reaction for CCHF virus. Levels of IFN-γ, TNF-α, IL-1β, IL-2, IL-4, IL-5, IL-6, IL-9, IL-10, IL-12 p70, IL-13, IL-17A, and IL-22 were measured in all serum samples. Although the disease had a fatal course in three adult patients, there were no deaths in children. Statistically significant differences were not observed between the cytokine concentrations in the adults and children. No differences were detected between the serum cytokine levels in the children with moderate and those with a severe clinical course of the disease. In the adult patients with fatal outcome, significantly higher serum levels of IL-2, IL-5, IL-9, IL-12 p70, and IL-13 were detected as compared to the cytokine levels in patients who survived the infection. No differences were detected between the serum levels of IFN-γ, IL-1β, IL-17A, IL-22, IL-10, IL-6, IL-4, and TNF-α in the patients who died and those who survived. Thus, the milder clinical course in children with CCHF cannot be explained by the cytokine network alone. The incomplete maturation of the immune system and timing and scale of immune responses could change the outcome dramatically.

Pediatric cases of Crimean-Congo hemorrhagic fever in Turkey

BACKGROUND

The aim of the present study was to identify the epidemiological, clinical and laboratory features of Crimean-Congo hemorrhagic fever (CCHF) virus infection in children.

METHODS

Fifty children infected with CCHF virus in 2005-2010, and hospitalized in the Dr Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital in Ankara, were included. All the patients had positive IgM and/or polymerase chain reaction for CCHF virus.

RESULTS

Of the 50 patients, 19 were female and 31 were male. Patients were between 8 months and 15 years of age. The majority (82%) of patients had a history of tick bite. Fever (100%), hemorrhagic symptoms (76%), nausea-vomiting (60%), tonsillopharyngitis (50%), malaise (50%), myalgia (46%) and maculopapular rash (24%) were the most common presenting clinical features. Mean platelet count on admission was 110,880/mm(3) , and the lowest was 7000/mm(3) . The mean of the lowest white blood cell count was 2860/mm(3) . Other pathological laboratory findings (asparate aminotransferase, alanine aminotransferase, lactate dehydrogenase and creatine kinase) were elevated, and prothrombin time and activated partial thromboplastin time were prolonged. Twenty-three patients (46%) were given ribavirin. No side-effect of ribavirin was seen. No patient died because of CCHF disease.

CONCLUSION

CCHF virus infections are seen mostly in boys and school children and the adolescent age group. Tick bite is the major risk factor. Fever and hemorrhage are the most frequent presenting symptoms. Tonsillopharyngitis and rash on face or body are probably the most remarkable clinical findings in this disease. The CCHF disease course in Turkey may be mild in children.

Cardiac findings in children with Crimean-Congo hemorrhagic fever

Background

Crimean-Congo hemorrhagic fever (CCHF) involves the multi-organ systems. The involvement of the heart in adult patients has been described previously. We investigated the electrocardiographic and echocardiographic findings of pediatric patients with CCHF.

Material/Methods

Patients younger than 16 years of age diagnosed with CCHF were enrolled in the study. The diagnosis of CCHF infection was based upon typical clinical and epidemiological findings and serological tests. All patients underwent a thorough cardiologic evaluation. A standard 12-lead electrocardiography and echocardiography were performed.

Results

Twenty-three consecutive patients who were hospitalized with diagnosis of CCHF were enrolled in the study (mean age: 12±2 years, 6 female). All electrocardiographic parameters were within normal ranges according to age. Seven patients (30%) had minimal (<1 cm) pericardial effusion. Fifteen (65%) patients had segmental wall motion abnormalities (hypokinesia). A second echocardiography revealed that all wall motion abnormalities had disappeared; the pericardial effusion persisted in only 2 of 7 patients (28%).

Conclusions

Cardiac involvement appears to be more frequent in children with CCHF disease than in adults, but it is slighter and almost totally reversible; however, the course of the disease in children is milder than it is in adults.

Recent progress in the treatment of Crimean–Congo hemorrhagic fever and future perspectives

Crimean–Congo hemorrhagic fever (CCHF) caused by the CCHF virus, a member of the family Bunyaviridae, genus Nairovirus, is a tick-borne acute viral hemorrhagic fever with a high case–fatality rate. Ribavirin has been used as a treatment for patients with CCHF. Although the efficacy of ribavirin in the treatment of CCHF has not yet been proven conclusively, its use in the early stage of the disease is recommended. A number of clinical and virological insights into CCHF have been revealed. Virus-associated hemophagocytic syndrome has been found to contribute to the exacerbation of CCHF in some patients, and the administration of methylprednisolone at high doses was observationally undertaken in patients with CCHF and virus-associated hemophagocytic syndrome, with promising results. It is expected that effective therapeutics and preventive measures will be developed in the future.

Crimean-Congo hemorrhagic fever in children

Background

Crimean-Congo hemorrhagic fever (CCHF) virus causes a severe disease in humans with a mortality up to 30%. In Turkey there has been an increase in the number of cases during years since 2002. Humans of all ages living in endemic areas,especially those who are working as shepherds and toddlers, have high risk of acquiring CCHF.

Objectives

The epidemiological, clinical, and laboratory characteristics of the children, who were diagnosed as Crimean-Congo hemorrhagic fever (CCHF) were described.

Study design

The children infected with CCHF virus between April 2008 and October 2009, and hospitalised in Ankara Dışkapı Children's and Research Hospital were included.

Results

Laboratory diagnosis was set by detection of CCHF IgM antibodies and/or genetic detection of CCHF virus. Thirtyone cases included to the study, and all were from the northeastern Anatolia and the southern parts of Black sea region. The mean age was 9.45 ± 4.9 years, the proportion of females was 38.7%. The majority (87%) of the cases had the history of tick bite. There was no fatal case. All the patients had the history of fever. Malaise,tonsillopharyngitis, nausea-vomiting, headache, diarrhea, myalgia and rash were the most common symptoms. The mean AST and ALT levels on the admission were 116 (range 25–389) and 61 (range 8–180) U/L respectively. The mean platelet count on admission was 125,000/mm³, and the lowest was 23,000/mm³. The mean of the lowest white blood cell count was 2353/mm³ and the mean of the highest lactate dehydrogenase was 861 IU/L.

Conclusions

The clinical course of CCHF among children seems to be milder than in adults. Tonsillopharyngitis is a common symptom among children with CCHF.