Evaluation of clinical and laboratory predictors of fatality in patients with Crimean-Congo haemorrhagic fever in a tertiary care hospital in Turkey

A case of Crimean-Congo haemorrhagic fever complicated with portal vein thrombosis and hemophagocytosis

OBJECTIVES

Crimean-Congo haemorrhagic fever (CCHF) is a zoonotic viral infection which is an important public health problem in Turkey. CCHF causes fever and bleeding and can lead to severe health outcomes. The study aims to report a case of a male patient with severe CCHF, hemophagocytic lymphohistiocytosis (HLH) treated with steroids and portal vein thrombosis.

CASE REPORT

A 37-year-old man was admitted to the emergency department with complaints of high fever, headache, myalgia and diarrhoea. The patient travelled to the endemic region of Turkey. In laboratory findings, thrombocytopenia, abnormal liver function tests and elevated coagulation parameters were observed. Real-time polymerase chain reaction assay was used for diagnosis of CCHF. Hypofibrinogenemia, hypertriglyceridemia, elevated ferritin and d-dimer levels were observed in the clinical follow-up. Prednisolone treatment was performed due to considered the diagnosis of HLH. Portal vein thrombosis was detected on abdominal computed tomography scan. He was successfully treated with ribavirin, corticosteroids, anticoagulant and supportive therapy.

CONCLUSION

The clinical presentation of CCHF can range from self-limiting flu-like to severe symptoms possibly fatal. Acute portal vein embolism is a rare complication that has not been reported before to our knowledge. Corticosteroids may be a life-saving treatment for CCHF patients presenting with HLH.

Analysis of liver fibrosis equations as a potential role of predictive models in Crimean-Congo hemorrhagic fever

Crimean-Congo Hemorrhagic Fever (CCHF) is a formidable global health concern, characterized by its rapid onset and high fatality rate. Distinguishing between patients at different stages remains challenging because of overlapping clinical features. This study aimed to evaluate the diagnostic efficacy of 14 hepatic fibrosis indices for distinguishing fatal cases and intensive care unit requirement (ICU) in CCHF. This study enrolled 194 patients with confirmed CCHF. Laboratory measurements were performed using auto analyzers. Indirect indicators of fibrosis were calculated for each patient based on previously described formulas. Time-dependent receiver operating characteristic (tdROC) curve analyses were employed to evaluate the predictive effects of hepatic fibrosis indices on both intensive care unit requirement and overall survival among patients. Regarding the tdROC analyses results, the highest area under the curve statistics were obtained for the baseline S-INDEX, KING, and GPRI scores (0.920, 0.913, and 0.909 respectively) in the estimation of ten-day survival, and the baseline KING, Goteborg University cirrhosis index (GUCI), and gamma-glutamyl transferase to platelet ratio index (GPRI) scores (0.783, 0.773, and 0.769 respectively) in the estimation of intensive care requirements for up to ten days. S-index and KING index emerged as early predictors of ten-day survival, while KING, GUCI, and GPRI indices demonstrated predictive capabilities for ICU admission on the first day. The identified indices have the potential to assist healthcare providers in making timely and informed decisions regarding patient management and treatment strategies. Further research and validation are warranted to solidify the role of these hepatic fibrosis indices in the clinical setting and enhance their broader applicability in the management of CCHF.

Crimean-Congo Hemorrhagic Fever: An Emerging Viral Infection in India, Revisited and Lessons Learned

Crimean-Congo hemorrhagic fever (CCHF) is a zoonotic disease caused by the CCHF virus. It was first recognized in 1944 in the Crimea region of the former Soviet Union and then was subsequently isolated in Congo, from a child with similar symptoms. Hence, the virus was termed the Crimean-Congo hemorrhagic fever virus. CCHF is an emerging disease with more than 1000 human cases being reported every year from South-Eastern Europe and Western Asia. The disease is endemic in Africa, the Balkans, the Middle East, and Asia, with an estimated 10,000 to 15,000 CCHF infections each year. The geographic range of the CCHF virus is most extensive among the tick-borne viruses that infect humans. The first outbreak of CCHF in India was described in 2011 in the state of Gujarat with four cases being reported. Since then, there have been sporadic cases in India occurring in small clusters with community and nosocomial spread. Here, we describe three cases that were treated at a tertiary care teaching hospital in the Gujarat state of India. All of them had nonspecific symptoms of viremia initially, followed by rapid deterioration of the general condition. Two of the three patients died. Because of its resemblance with other hemorrhagic fevers, diagnosis of CCHF remains a challenge, especially in non-endemic areas. We aim to sensitize the readers to this emerging arboviral disease because the virus is highly infectious and carries high mortality, and hence, it is crucial to suspect and diagnose the index case at the earliest.

The Relationship Between Cytokine Concentrations and Severity Scoring Index for Crimean-Congo Hemorrhagic Fever

Background This study aimed to investigate the effects of serum high mobility group box-1 (HMGB1), interleukin (IL)-6, IL-8, IL-1β, IL-10, and tumor necrosis factor alpha (TNF-α) levels on disease severity and mortality in Crimean-Congo hemorrhagic fever (CCHF) patients. Materials and methods This study was performed prospectively in the intensive care unit (ICU) and infection ward of a tertiary hospital in the Republic of Türkiye. Patients aged 18 years and older diagnosed with CCHF were included. Results Our study included 30 patients, of whom 83.3% were male, where the mean age was 51.6±14.35 years. The most common clinical findings in patients were malaise (90%) and myalgia (63.3%). In our study, IL-1β levels were found to be 1173.6 (783.0-1823.0) pg/mL, IL-6 69.9 (56.8-133.1) pg/mL, IL-8 191.2 (152.8-516.9) pg/mL, TNF-α 129.5 (104.9-270.8), HMGB1 37.01 (29.26-75.18), and IL-10 190.1 (IQR: 147.8-387.8) pg/mL. The patients' median Severity Scoring Index (SSI) score was found to be 2.5 (1.8-5.5). There was a moderate correlation between the patients' SSI score and serum IL-6 (r=0.464, p=0.010), TNF-α (r=0.420, p=0.021), and IL-10 levels (r=0.518, p=0.003), and a weak correlation between serum HMGB1 (r=0.392, p=0.032). The correlation between SSI and creatine phosphokinase (CPK) levels (r=0.499, p=0.036) was observed to be moderate. Conclusion It was seen that IL-10, IL-6, TNF-α, HMBG-1, and CPK levels evaluated at the CCHF patients' time of admission to the clinic and SSI clinical score were found to be significantly related. It is clear that more studies with patients and groups of healthy volunteers are needed on this subject.

Value of C-reactive protein in differentiating viral from bacterial aetiologies in patients with non-malaria acute undifferentiated fever in tropical areas: a meta-analysis and individual patient data study

C-reactive protein (CRP) is used to discriminate common bacterial and viral infections, but its utility in tropical settings remains unknown. We performed a meta-analysis of studies performed in Asia and Africa. First, mean CRP levels for specific tropical infections were calculated. Thereafter, individual patient data (IPD) from patients with non-malarial undifferentiated fever (NMUF) who were tested for viral and bacterial pathogens were analysed, calculating separate cut-off values and their performance in classifying viral or bacterial disease. Mean CRP levels of 7307 patients from 13 countries were dengue 12.0 mg/l (standard error [SE] 2.7), chikungunya 41.0 mg/l (SE 19.5), influenza 15.9 mg/l (SE 6.3), Crimean-Congo haemorrhagic fever 9.7 mg/l (SE 4.7), Salmonella 61.9 mg/l (SE 5.4), Rickettsia 61.3 mg/l (SE 8.8), Coxiella burnetii 98.7 mg/l (SE 44.0) and Leptospira infections 113.8 mg/l (SE 23.1). IPD analysis of 1059 NMUF patients ≥5 y of age showed CRP <10 mg/l had 52% sensitivity (95% confidence interval [CI] 48 to 56) and 95% specificity (95% CI 93 to 97) to detect viral infections. CRP >40 mg/l had 74% sensitivity (95% CI 70 to 77) and 84% specificity (95% CI 81 to 87) to identify bacterial infections. Compared with routine care, the relative risk for incorrect classification was 0.64 (95% CI 0.55 to 0.75) and the number needed to test for one extra correctly classified case was 8 (95% CI 6 to 12). A two cut-off value CRP test may help clinicians to discriminate viral and bacterial aetiologies of NMUF in tropical areas.

Association Between Severity Grading Score And Acute Phase Reactants In Patients With Crimean Congo Hemorrhagic Fever

As the COVID-19 pandemic continues, countries still have to struggle with their endemic diseases such as Crimean-Congo hemorrhagic fever (CCHF). Severity grading score (SGS) is a practical approach and may shed light on the course of the CCHF, whose pathogenesis is not clearly understood, and have no effective treatments. It is aimed to assess the association between SGS and acute phase reactants (APR). Laboratory-confirmed patients were categorized by severity scores, and the relationship between APR and SGS was evaluated. A significant correlation between SGS and C-reactive protein (CRP) was found (p < 0.001). High SGS was associated with mortality and high CRP levels were used to predict the mortality at the beginning of the hospital admission. To predict the outcome of the disease and for appropriate patient management, SGS and APR can be used simultaneously.

Crimean-Congo hemorrhagic fever: An update

Crimean-Congo hemorrhagic fever (CCHF) is a severe form of hemorrhagic fever caused by a virus of the genus Nairovirus. The amplifying hosts are various mammal species that remain asymptomatic. Humans are infected by tick bites or contact with animal blood. CCHF has a broad geographic distribution and is endemic in Africa, Asia (in particular the Middle East) and South East Europe. This area has expanded in recent years with two indigenous cases reported in Spain in 2016 and 2018. The incubation period is short with the onset of symptoms in generally less than a week. The initial symptoms are common to other infectious syndromes with fever, headache, myalgia and gastrointestinal symptoms. The hemorrhagic syndrome occurs during a second phase with sometimes major bleeding in and from the mucous membranes and the skin. Strict barrier precautionary measures are required to prevent secondary and nosocomial spread. CCHF may be documented by PCR detection of the virus genome during the first days after the onset of illness, and then by serological testing for IgM antibodies as from the 2nd week after infection. Patient management is mainly based on supportive care. Despite a few encouraging retrospective reports, there is no confirmed evidence that supports the use of ribavirin for curative treatment. Nevertheless, the World Health Organization continues to recommend the use of ribavirin to treat CCHF, considering the limited medical risk related to short-term treatment. The prescription of ribavirin should however be encouraged post-exposure for medical professionals, to prevent secondary infection.

Importance of biochemical parameters in order to predict clinical severity in patients diagnosed with Crimean-Congo haemorrhagic fever

Objective

We aimed to investigate new biochemical indicators to predict the clinical course of patients following the diagnosis of Crimean-Congo haemorrhagic fever (CCHF).

Material and methods

We retrospectively evaluated patients diagnosed with CCHF. They were divided into three groups based on a scoring system known as severity grading score in order to predict severity. Red cell distribution width (RDW), mean platelet volume (MPV), creatinine phosphokinase (CPK), alkaline phosphatase (ALP), glutamyl transferase (GGT) and C-reactive protein (CRP) levels were evaluated on the first day of admission. These biochemical parameters may predict the clinical course of our three patient groups.

Results

In our study, there were 38 (70.4%) male and 16 (29.6%) female patients, and the mean age was 44.33±16.94 years. Based on our scoring system, 17 (31.4%), 30 (55.5%) and 7 (12.9%) patients were in group 1, 2 and 3, respectively. Statistically significant difference was observed between groups 1–3 and groups 2–3 for ALP values; however, a statistically significant difference was observed among all three groups for GGT values. Significant differences were not observed among the groups for RDW, MPW, CPK and CRP levels (p>0.05).

Conclusion

ALP and GGT values can be used as auxiliary indicators to predict the clinical course for patients with CCHF. However, CPK, CRP, MPV and RDW values were not observed to be important for prognosis.

The pulmonary findings of Crimean-Congo hemorrhagic fever patients with chest X-ray assessments

Background

Crimean–Congo hemorrhagic fever (CCHF), characterized by fever and/or hemorrhage, is a zoonotic viral disease with high mortality. The agent causing CCHF is a Nairovirus. The virus is typically transmitted to humans through tick bites. CCHF is a life-threatening disease observed endemically over a wide geographical regions in the world, and there is limited information about pulmonary findings in CCHF patients.

Purpose

We aimed to investigate the pulmonary findings belonging to a large CCHF patient cohort and to determine if there is any relationship between laboratory findings and disease severity.

Materials and methods

A total of 165 patients who were diagnosed with CCHF and examined through chest X-ray (CXR) due to respiratory symptoms at their first examination and/or during their hospitalization were included in this study. In addition to demographical and laboratory findings of the patients, chest X-rays were also examined.

Results

Of the 165 patients examined, 96 were male (58.2%) and 69 were female (41.8%). The mean age was 51.64 ± 17.95 years (4–81 years). Single and/or multiple pathological findings were detected in 93 patients (56.4%) as a result of chest X-ray during their first examination. On chest X-ray, consolidation in 74 patients (44.8%), pleural effusion in 64 patients (39.8%), ground glass opacity in 49 patients (29.7%), and atelectasis in 30 patients (18.2%) were detected.

Conclusion

According to the results of our study, it can be suggested that radiological examination in lungs should be performed primarily with CXR and pulmonary involvement (pleural effusion and consolidation) affects survival in CCHF negatively.

Factors related to fatalities and clinical progression of Crimean-Congo hemorrhagic fever patients and the effects of IL 28-B gene polymorphism

Mortality rates of Crimean-Congo hemorrhagic fever (CCHF) vary from 5% to 80%. However, there is no clear information available about why this disease is fatal for some people while others recover. In this study, the factors related to fatalities and serious clinical progression of CCHF patients and the correlation between serious prognosis and IL 28-B gene polymorphism were investigated. The study included 107 patients with a preliminary diagnosis of CCHF, and the patients were found positive for CCHFV RNA based on polymerase chain reaction (PCR) analysis. The IL 28-B rs12979860 polymorphism was identified by PCR "restriction fragment length polymorphism" (PCR-RFLP) analysis using blood samples from the patients. In addition to the IL 28-B analysis results, a variety of data along with laboratory records obtained during the hospital stay were evaluated using statistical analysis. Of the 107 cases, nine were fatal (8.4%), while the other patients recovered and were discharged. Twenty-four patients had the CC genotype (22.43%), 64 had the CT genotype (59.81%), and 19 had the TT genotype (17.76%). Of the nine patients who died, three had the CC genotype (33.33%) and six had the CT genotype (66.67%). None of the patients who died had the TT genotype. Symptoms and findings of diarrhea, abdominal pain, hemorrhage, and rash were more common in fatal cases than in non-fatal cases. The IL 28-B rs12979860 polymorphism was not found to have a statistically significant correlation with fatality or symptoms indicating serious clinical progression in CCHF patients. As has been observed in previous studies, our study showed that leukocytosis, abdominal pain and diarrhea were more common in fatal cases.

Effects of Paraoxonase-1 variants on course of severity and mortality of Crimean-Congo hemorrhagic fever

Crimean-Congo hemorrhagic fever (CCHF) is an acute viral hemorrhagic fever caused by Crimean Congo hemorrhagic fever virus (CCHFV). Paraoxonase-1 (PON1) is a high density lipoprotein (HDL)-binding protein which defense the body against oxidative stress. To investigate the role of the PON1 gene in CCHF, we screened the genotypes of two single nucleotide polymorphisms (Q192R [rs662] and L55M [rs854560]) in CCHF patients stratified according to course of severity and mortality by using PCR-based RFLP assay. Overall, 132 patients diagnosed as CCHF were enrolled in this study. The frequencies of the three genotypes and two alleles of Q192R and L55M polymorphisms didn't show any statistically significant differences in terms of mortality and disease severity (p > 0.05). Any statistically significant differences were not found between severe and mild and fatal and non-fatal CCHF patients according to seven composite genotypes (p > 0.05). When we analyzed the clinical characteristics of CCHF patients stratified according to PON1gene polymorphisms, any statistically significant differences were not also observed (p > 0.05). Our study showed no possible association between genotypes of PON1 gene Q192R and L55M polymorphisms and CCHF.

Aetiology of PCR negative suspected Crimean-Congo hemorrhagic fever cases in an endemic area

Crimean–Congo hemorrhagic fever (CCHF) is a potentially fatal tick-borne viral infection that is widely distributed worldwide. The diagnosis is frequently missed due to the non-specific initial symptoms and the differential diagnosis included many infectious and non-infectious causes. This retrospective study describes the clinical features and final diagnoses of 116 suspect CCHF cases that were admitted to a tertiary CCHF center in Turkey, and were CCHF IgM and PCR negative.

Predictors of Prolonged Hospitalization in Patients with Fever

Objective: The study was conducted to analyze the predictors of prolonged hospitalization in patients with fever.

Patients and Methods: This was a prospective cohort study conducted from July - December 2015 at Ayub Teaching Hospital, Pakistan. Convenience sampling was used to enroll the patients who visited the hospital during the study duration. A sample size of 115 patients was calculated. It included patients who presented with a new onset fever which started in the last month, and the cause of fever was undiagnosed at the time of admission. Critical patients were excluded. Data for more than 30 variables was collected on a pro forma. Univariate regression methods were used to analyze the data in the Statistical Package for Social Sciences (SPSS), version 23.

Results: A total of 115 patients were analyzed. Males constituted 66/115 (57.4%). The mean age for patients was 43.6 years (standard deviation (SD) = 20.2). On admission, low platelet counts (p = 0.001), high erythrocyte sedimentation rate (ESR) counts (p = 0.007), a high total leukocyte count (TLC) (p = 0.029), and involvement of nervous (p = 0.021), cardiovascular (p = 0.04), respiratory (p = 0.043), gastroenterological (p = 0.042), hematological (p = 0.028), or urogenital system (p = 0.016) were associated with a longer stay in the hospital.

Conclusion: Patients with an undiagnosed and new onset fever will have a longer hospital stay if, on admission, they have low platelet counts, a higher ESR, a high TLC, or involvement of nervous, cardiovascular, respiratory, gastrointestinal, hematological, or urogenital systems. An early identification of risk factors can lead to better treatment and may also lead to a decreased hospital stay.

Prognostic factors, pathophysiology and novel biomarkers in Crimean-Congo hemorrhagic fever

Crimean-Congo hemorrhagic fever (CCHF) is a geographically widespread tick-borne zoonosis. The clinical spectrum of the illness varies from mild infection to severe disease and death. In severe cases, hemorrhagic manifestations develop, with fatality rates of 4-20%, depending on the geographic region and quality of the health care. Although vast majority of the CCHF cases were reported from Turkey, mortality rate is lower than the other regions, which is 5% on average. Prediction of the clinical course of the disease enables appropriate management planning by the physician and prompt transportation, if needed, of the patient to a tertiary care hospital for an intensive therapy. Thus, predicting the outcome of the disease may avert potential mortality. There are numerous studies investigating the prognostic factors of CCHF in the literature. Majority of them were reported from Turkey and included investigations on clinical and biochemical parameters, severity scoring systems and some novel biomarkers. Somnolence, bleeding, thrombocytopenia, elevated liver enzymes and prolonged bleeding times are the most frequently reported prognostic factors to predict the clinical course of the disease earlier. High viral load seems to be the strongest predictor to make a clinical decision about the patient outcome. The severity scoring systems based on clinically important mortality-related parameters are especially useful for clinicians working in the field to predict the course of the disease and to decide which patient should be referred to a tertiary care hospital for intensive care. In the light of the pathophysiological characteristics of CCHF, some new biomarkers of prognosis including cytokines, soluble adhesion molecules, genetic polymorphisms and coagulopathy parameters were also investigated. However most of these tests are not available to clinicians and they were obtained mostly for research purposes. In spite of the various studies about prognostic factors, they have several inherent limitations, including large variability in the results and confusing data that are not useful for clinicians in routine practice. In this paper, the results of diverse studies of the prediction of the prognosis in CCHF based on epidemiological, clinical and laboratory findings of the disease were summarized and suggestions for future studies are provided.

A retrospective controlled study of thiol disulfide homeostasis as a novel marker in Crimean Congo hemorrhagic fever

OBJECTIVES

Crimean Congo hemorrhagic fever (CCHF) is the second most common hemorrhagic fever worldwide. This study aimed to evaluate the oxidant-antioxidant balance of patients with CCHF by detecting dynamic thiol disulfide homeostasis (TDH), which is a novel oxidative stress marker, and other molecules, including paraoxonase (PON), arylesterase (ARES), ceruloplasmin (CLP), myeloperoxidase (MPO), and catalase.

METHODS

This retrospective, cross-sectional, controlled study, which involved patients with CCHF and healthy volunteers, measured dynamic TDH using a novel automated method developed by Erel.

RESULTS

We recruited 69 adult patients with CCHF (31 females, 38 males, median age 46 years). The case fatality rate was 1.49% (1/69). Increased disulfide/native thiol and disulfide/total thiol ratios, decreased total antioxidant status (TAS), and increased total oxidant status (TOS) were found in patients with CCHF. TAS, PON, and ARES values were found to be positively correlated with both native and total thiol levels, whereas TOS and CLP were negatively correlated with both, at a significant level. MPO activity was similar in both groups.

DISCUSSION

This is the first study in the literature to evaluate dynamic TDH in CCHF. TDH shifts to the oxidative side in patients with CCHF, leading to an increase in TOS.

Current situation of Crimean-Congo hemorrhagic fever in Southeastern Europe and neighboring countries: a public health risk for the European Union?

Crimean-Congo hemorrhagic fever (CCHF) is the most widespread tick-borne viral infection of humans, occurring across western China through southern Asia, Middle East, and Southeastern Europe (SEE) and in the most of African countries. CCHF virus is maintained through vertical and horizontal transmission in several genera of ticks, mainly in Hyalomma, which spreads the virus to a variety of wild and domestic mammals, which develop a transient viremia without signs of illness. Human infections occur through tick bite or exposure to the blood or other body fluids of an infected animal or of a CCHF patient. In SEE the number of clinical cases of CCHF as well as the areal of the infected ticks continuously rapidly increased after 2000. The aim of this study was to present actual situation of CCHF in SEE. Sources of information include published literature and personal unpublished data.

CONCLUSIONS

Based on: 1. Hyaloma's presence in Western EU countries, 2. Changes in climatic conditions and 3. Absence of an active vaccination against CCHF, it can be expected that this disease will continue to present real threat for human health in SEE and Southwestern Europe (SWE).

Serum sTREM-1 level is quite higher in Crimean Congo Hemorrhagic Fever, a viral infection

Members of triggering receptor expressed on myeloid cells (TREM) family are known as immunmodulators in several infectious or noninfectious inflammatory disorders. The information about their role in viral infections is very limited. To enlighten if there is a relation between soluble TREM-1(sTREM-1) and a viral infection, Crimean Congo Haemorrhagic Fever (CCHF), we investigated the levels of sTREM-1 in the sera of 39 CCHF patients both at admission and at recovery and compared with 40 healthy controls by using microELISA technique. Statistical analysis was made by using Statistical Package for Social Sciences (SPSS) for Windows 20 programme. Value of P < 0.05 was accepted as significant for statistical analyses. Median sTREM-1 level was higher in CCHF group when compared to the control group (1,961 vs. 151.1 pg/ml, respectively; P < 0.001). In CCHF patients, sTREM-1 levels were significantly decreased at recovery compared to initial level measured at hospital admission (1,961 vs. 948 pg/ml, respectively; P = 0.019). ΔsTREM-1 is correlated with ΔCRP, ΔWBC, and ΔPlt. We found that serum levels of sTREM-1 higher than 405.9 pg/ml existed as a cut off point for differentiating CCHF patients and control group with a sensitivity of 94.9% and specifity of 87.5%. It is proved that sTREM-1 is increased and correlates with the clinical and laboratory findings in CCHF, a viral infection characterized by activation of inflammation. This finding may lead new studies to enlighten the pathogenesis of infections developing by activation of inflammatory cascades and high level cytokine releases, especially. J. Med. Virol. 88:1473-1478, 2016. © 2016 Wiley Periodicals, Inc.

Does the course of laboratory parameters help us to predict the outcome of CCHF?

BACKGROUND/AIM

This study was performed to identify the characteristics distinguishing fatal and nonfatal cases of patients diagnosed with Crimean-Congo hemorrhagic fever (CCHF).

MATERIALS AND METHODS

A total of 92 patients with confirmed diagnosis of CCHF in 2009-2013 were included in the study.

RESULTS

A high level of urea and aPTT on the third day of hospital stay, diarrhea, somnolence, and the interval from the beginning of the symptoms to hospital admission were independently associated with fatality. Each 10-unit increase in aPTT and urea levels increased the fatality rate by 3.379-fold and 1.236-fold, respectively. Delay in hospital admission increased the fatality rate 1.453-fold for each day of delay. When comparing first and third admission-day laboratory values, the increase in leukocyte counts and the decrease in CPK, urea, creatinine, aPTT, PT, INR, and hemoglobin levels were significant in nonfatal cases.

CONCLUSION

This study showed that the course of these laboratory tests helps us to predict the outcome of the disease. In a few days of hospitalization, persistence or progress of the abnormal laboratory parameters may warn us about poor prognosis.

Crucial parameter of the outcome in Crimean Congo hemorrhagic fever: Viral load

BACKGROUND

Crimean Congo hemorrhagic fever (CCHF) is a fatal disease with a mortality rate of 5-30%. CCHF can be asymptomatic or it may progress with bleeding and cause mortality.

OBJECTIVES

To evaluate relation of viral load with mortality, clinical and laboratory findings in CCHF.

STUDY DESIGN

A total of 126 CCHF patients were included. Serum samples obtained from all patients on admission for measurement of viral load.

RESULTS

In our study, mortality rate was 11.1%. The most important prognostic factor was viral load. Mean viral load was 8.3×10(7)copy/ml and 4.6×10(9)copy/ml in survived and dead patients, respectively (p<0.005). Probability of survival is found to be significantly reduced where AST >1130U/l, ALT >490U/l, CPK >505U/l, LDH >980U/l, platelet count <23×10(3)/l, creatinine >1.4mg/dl, INR >1.3, d-dimer >7100ng/dl, and viral load >1.03×10(8)copy/ml. Patients with 10(8)copy/ml or higher viral load had diarrhea, headache, unconsciousness, bleeding, and seizure significantly more frequently (p<0.05). WBC, hemoglobin, platelet counts were significantly lower whereas AST, ALT, CPK, LDH, creatinine levels, PT and aPTT time, d-dimer levels, and INR were found to be significantly higher in these group.

CONCLUSIONS

There are several severity criteria for prognosis of CCHF. In addition to these parameters, we introduce creatinine as a predictive factor for prognosis. Our study, which has the largest number of patients among studies that evaluate viral load on CCHF shows that viral load is the most effective parameter on mortality.

Health care response to CCHF in US soldier and nosocomial transmission to health care providers, Germany, 2009

Early recognition and implementation of appropriate infection control measures were effective in preventing further transmission.

In 2009, a lethal case of Crimean–Congo hemorrhagic fever (CCHF), acquired by a US soldier in Afghanistan, was treated at a medical center in Germany and resulted in nosocomial transmission to 2 health care providers (HCPs). After his arrival at the medical center (day 6 of illness) by aeromedical evacuation, the patient required repetitive bronchoscopies to control severe pulmonary hemorrhage and renal and hepatic dialysis for hepatorenal failure. After showing clinical improvement, the patient died suddenly on day 11 of illness from cerebellar tonsil herniation caused by cerebral/cerebellar edema. The 2 infected HCPs were among 16 HCPs who received ribavirin postexposure prophylaxis. The infected HCPs had mild or no CCHF symptoms. Transmission may have occurred during bag-valve-mask ventilation, breaches in personal protective equipment during resuscitations, or bronchoscopies generating infectious aerosols. This case highlights the critical care and infection control challenges presented by severe CCHF cases, including the need for experience with ribavirin treatment and postexposure prophylaxis.

Diagnosis of Crimean-Congo hemorrhagic fever

Crimean-Congo hemorrhagic fever (CCHF) virus is the most extensive tick-borne virus, it causes a severe infection, which occurs widely in Africa, Eastern Europe and Asia. In recent years, the dramatic increase in the global distribution of CCHF, with the high mortality rates, highlights the importance of improving diagnostic capacity. Clinical and epidemiological data play a crucial role for early recognition of CCHF. However, CCHF is clinically difficult to diagnose and to distinguish, a rapid and reliable laboratory confirmation is necessary. Confirmation of infection in the acute phase of the disease can be made by detection of viral nucleic acid using reverse transcription-PCR, by demonstration of viral antigen or by virus isolation. In the convalescent phase of the disease, the diagnosis is confirmed by demonstration of an antibody response. The consideration of viral replication kinetics and antiviral humoral immune responses facilitates the selection of appropriate laboratory tests and accurate interpretation of laboratory findings.

Sonographic findings in patients with Crimean-Congo hemorrhagic fever

OBJECTIVES

Crimean-Congo hemorrhagic fever (CCHF) has been endemic in Turkey since 2002. Some radiologic findings are considered common by clinicians and radiologists. In this regard, we aimed to assess the sonographic findings in patents with CCHF in a pilot study to obtain basic knowledge for planning further controlled studies.

METHODS

An observational descriptive study was planned. Patients with a CCHF diagnosis monitored by the infectious diseases department of a tertiary care hospital were included. Sonographic examinations were conducted by 2 radiologists for each patient, and the findings were recorded.

RESULTS

Twenty-five patients with CCHF were included. Hepatomegaly (40%), splenomegaly (28%), paraceliac lymphadenopathy (48%), gallbladder wall thickening (36%), increased echogenicity in the renal parenchyma (40%), and fluid/effusion in the perihepatic, perisplenic, pleural, and hepatorenal recesses of the subhepatic space (Morison pouch) as well as between the intestinal loops (52%) were the primary findings. A decrease in the gallbladder wall thickening and limited resorption of intraperitoneal and pleural effusion were noted during follow-up.

CONCLUSIONS

Hepatosplenomegaly, paraceliac lymphadenopathy, and gallbladder wall thickening as well as intraperitoneal and pleural effusion were the primary findings in CCHF, and they became prominent on the third day of the disease in some patients. The relationship between sonographic findings and disease severity will be investigated in an upcoming study.

Validation of a severity grading score (SGS) system for predicting the course of disease and mortality in patients with Crimean-Congo hemorrhagic fever (CCHF)

We aimed to validate a severity grading score (SGS) system for predicting the course of disease and fatality in Crimean-Congo hemorrhagic fever (CCHF). This SGS was established using several variables that were assumed to be associated with mortality and had clinical importance. We included patients diagnosed with CCHF from different centers. Patients who had symptoms of CCHF for <5 days were included. The patients were grouped into three categories according to mortality risk. An SGS ≤4 showed no association with mortality [n = 323 (79.9 % of the total study population), and all survived]. An SGS between 5 and 8 points was classified into the intermediate risk group (20 %), and 14 of 70 patients in this group died. An SGS ≥9 was classified as the high risk of mortality group and 11 of 11 patients in this group died (p = 0.001). The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value for an SGS >9 points at admission were 96, 100, 97, 100, and 44 %, respectively. This SGS system may help appropriate the triage of patients, decrease the cost of treatment, and improve the functionality of healthcare staff. The present study is the first investigation about the validation of an SGS system in patients with CCHF.

The relationship between the human leukocyte antigen system and Crimean-Congo hemorrhagic fever in the Turkish population

OBJECTIVES

The human leukocyte antigen (HLA) molecules have been shown to be important genetic factors in several diseases. In this study we aimed to evaluate the possible role of HLA genes in the course of Crimean-Congo hemorrhagic fever (CCHF) infection.

METHODS

A total of 57 adult patients with CCHF and 43 healthy controls living in the same regions as the patients were included in the study. Severe cases were defined according to previously reported severity criteria.

RESULTS

The frequency of HLA-A*02 was found to be significantly higher in the patients than in the healthy controls (p=0.021). However, a significantly lower frequency of HLA-B*27 was observed in the patients than in the healthy controls (p=0.01). The relative risk (RR) of HLA-A*02 allele for CCHF was found to be 1.93 (95% confidence interval 1.11 < RR < 3.36). With regard to severe and non-severe cases, there was a significantly greater frequency of HLA-A*23 in severe cases (p=0.014).

CONCLUSIONS

The results of this study indicate that while some HLA alleles could constitute a risk factor for acquiring CCHF infection, others could have a protective role against the disease. This study also presents the impact of genetic risk factors on the clinical course of the disease.

Crimean-Congo hemorrhagic fever: history, epidemiology, pathogenesis, clinical syndrome and genetic diversity

Crimean-Congo hemorrhagic fever (CCHF) is the most important tick-borne viral disease of humans, causing sporadic cases or outbreaks of severe illness across a huge geographic area, from western China to the Middle East and southeastern Europe and throughout most of Africa. CCHFV is maintained in vertical and horizontal transmission cycles involving ixodid ticks and a variety of wild and domestic vertebrates, which do not show signs of illness. The virus circulates in a number of tick genera, but Hyalomma ticks are the principal source of human infection, probably because both immature and adult forms actively seek hosts for the blood meals required at each stage of maturation. CCHF occurs most frequently among agricultural workers following the bite of an infected tick, and to a lesser extent among slaughterhouse workers exposed to the blood and tissues of infected livestock and medical personnel through contact with the body fluids of infected patients. CCHFV is the most genetically diverse of the arboviruses, with nucleotide sequence differences among isolates ranging from 20% for the viral S segment to 31% for the M segment. Viruses with diverse sequences can be found within the same geographic area, while closely related viruses have been isolated in far distant regions, suggesting that widespread dispersion of CCHFV has occurred at times in the past, possibly by ticks carried on migratory birds or through the international livestock trade. Reassortment among genome segments during co-infection of ticks or vertebrates appears to have played an important role in generating diversity, and represents a potential future source of novel viruses. In this article, we first review current knowledge of CCHFV, summarizing its molecular biology, maintenance and transmission, epidemiology and geographic range. We also include an extensive discussion of CCHFV genetic diversity, including maps of the range of the virus with superimposed phylogenetic trees. We then review the features of CCHF, including the clinical syndrome, diagnosis, treatment, pathogenesis, vaccine development and laboratory animal models of CCHF. The paper ends with a discussion of the possible future geographic range of the virus. For the benefit of researchers, we include a Supplementary Table listing all published reports of CCHF cases and outbreaks in the English-language literature, plus some principal articles in other languages, with total case numbers, case fatality rates and all CCHFV strains on GenBank.

The prognostic role of the new entity butterfly-like facial rash and cutaneous findings in patients with crimean congo haemorrhagic fever

BACKGROUND

Crimean Congo Haemorrhagic Fever (CCHF) is a deadly fever caused by Nairovirus (family Bunyaviridae). It is an important public health problem in hyperendemic regions with a high mortality rate. There have been many studies on cutaneous findings in other viral infections, however, our knowledge is limited regarding CCHF. The aim of this study was to evaluate the cutaneous manifestations of CCHF and their relationship with mortality.

METHODS

Patients who were diagnosed CCHF between April 1 and September 1, 2011 were enrolled in this study. Dermatologic examination and laboratory analysis were obtained during hospitalization.

RESULTS

A new entity that is first reported in this study as a butterfly-like facial rash was recognized in 76 patients (42.9%). It was not correlated with mortality but could coexist with other dermatological signs of CCHF. The major outcome was the increased mortality rate with other cutaneous findings (especially ecchymosis, purpura and petechia) (P < 0.01). While 12 deceased individuals had one or more skin findings, only one patient died without any cutaneous manifestations. Mortality rate was higher in patients with purpura than the patients with pethesia. The statistically significant correlation was observed between cutaneous manifestations and elevation of aspartate aminotransferase (AST) levels (P = 0.009). Platelet levels were lower in patients with cutaneous involvement (P < 0.01). No statistically significant relationship was found between cutaneous findings and alanine aminotransferase (ALT), white blood cell (WBC), Haemoglobin (Hb), creatinine kinase (CK) and lactate dehydrogenase (LDH) levels.

LIMITATIONS

Histopathologic examination of facial rash could not be done because of haemostatic failure.

CONCLUSION

The results of this study confirm that cutaneous findings can be a clue regarding the prognosis of the patients with CCHF. Physicians should be aware that CCHF may present with a butterfly-like rash on the face.

Mean Platelet Volume in the Diagnosis and Prognosis of Crimean–Congo Hemorrhagic Fever

Introduction:

Crimean–Congo hemorrhagic fever (CCHF) is a viral tick-borne zoonosis, which is a severe illness, causing hemorrhages in humans. Mean platelet volume (MPV) is used as a surrogate marker of platelet function and has been shown to be a sign of inflammation. The objective of the present study is to examine the association between MPV and CCHF. We also aimed to investigate the association between MPV and coagulopathy markers in the mortality rates and prognosis of patients with CCHF.

Patients and Methods:

Ninety-three patients with CCHF were enrolled retrospectively into the study and 15 of them were excluded according to the exclusion criteria. Twenty-five healthy individuals were included as a control group which was age and gender matched with CCHF patients. We compared the levels of MPV between the patient and the control groups. We also compared the coagulopathy markers of fatal CCHF patients (n = 9) with nonfatal cases (n = 69).

Results:

Platelet counts were significantly lower in the CCHF group. Levels of international normalized ratio (INR), prothrombin time (PT), and activated partial thromboplastin time (aPTT) were significantly higher in CCHF group ( P < .001, <.001, <.001, respectively). A statistically significant increase in MPV was observed in patients with CCHF compared with healthy controls (8.63 ± 1.23 fL vs 7.65 ± 0.42 fL, P < .001). Receiver–operating characteristic curve analysis suggested that the optimum MPV level cutoff points for patients with CCHF was 8.15 fL, with a sensitivity and specificity of 65% and 88%, respectively. The MPV levels were not significantly different between group 2 (nonsurvivor) and group 1 (survivor). However, platelet count, d-dimer, INR, PT, and aPTT were also positively correlated with the mortality rates ( P = .008, <.001, <.001, <.001, and <.001, respectively). Multivariable logistic regression model showed an independent correlation between MPV and mortality rate ( P < .001).

Conclusion:

In conclusion, MPV may be a beneficial marker in the diagnosis of CCHF, especially in cases with thrombocytopenia, the MPV levels are high. We also conclude that MPV may independently predict the prognosis of patients with CCHF.

Species distribution and detection of Crimean Congo Hemorrhagic Fever Virus (CCHFV) in field-collected ticks in Ankara Province, Central Anatolia, Turkey

Ticks may act as vectors for a number of infectious diseases including Crimean Congo Hemorrhagic Fever (CCHF). The causative agent is Crimean Congo Hemorrhagic Fever Virus (CCHFV), a member of Bunyaviridae, causing extensive ecchymosis, visceral bleeding and hepatic dysfunction with a high fatality rate in the affected individuals. CCHF was initially recognized in Turkey in 2002 and the current number of reported cases exceeds 4,400. This study was conducted to confirm the presence of tick species established as potential CCHFV vectors and investigate CCHFV activity in ticks at Ankara province, Turkey's second most-densely populated province, where CCHF cases were demonstrated. A total of 1,196 adult ticks, collected from various animals and vegetation in 12 sites located in 5 counties of Ankara during April-July 2010 were identified to species level. Twenty-two tick pools from county K2 were also evaluated for the presence of CCHFV RNA via a one-step real-time RT-PCR assay and reactive results were further confirmed by an in house nested RT-PCR assay. Nine tick species were identified: Rhipicephalus bursa (44.9%), R. sanguineus (18.9%), R. turanicus (18.1%), Haemaphysalis parva (8.3%), Hyalomma marginatum marginatum (5.4%), H. aegyptium (1.4%), H. anatolicum excavatum (1.3%), Hae. punctata (0.3%) and Dermacentor marginatus (0.2%). A total of five tick pools (22.7%) were reactive in real-time and nested RT-PCR assays. The pools included R. bursa, H. m. marginatum and Hae. parva ticks, collected from mammal hosts from two villages in one county. This is the first documentation of CCHFV activity in ticks from Ankara province, which indicates requirement for detailed surveillance to predict high risk zones in the region.