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CHAPTER 80: Viral Hemorrhagic Fevers 743

pulmonary edema secondary to reabsorption of extravascular fluid and Supportive care provided in the ICU should emphasize a careful fluid
intravascular overexpansion require aggressive dialysis, which decreases management as excessive fluid infusion readily results in pulmonary
mortality. During the subsequent polyuric phase dehydration and elec- edema. IV ribavirin is recommended for LF, South American arenaviral
trolyte abnormalities are common. HF, HFRS, and CCHF. Immune plasma is effective for Junin HF where
73
HFRS is usually benign when due to SEOV and PUUV, but more available. Persons at high risk of exposure to LF may benefit from oral
severe when due to HTNV and DOBV. However, severe illness may ribavirin prophylaxis. 153
Diagnosis Hantavirus serology IgM is usually positive at the time of ■ BIOTERRORISM AND WEAPONIZATION OF VHF AGENTS
occur with any of the viruses.
admission to the hospital. In case of bioterrorism-related release of a VHF agent in a population,
Hantavirus RT-PCR is much more specific, but may be negative. multiple HF cases would occur nearly simultaneously, most likely in
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Treatment Supportive treatment emphasizes careful fluid support during a city. Pathogens that could be weaponized by high-tech laboratories
the hypotensive phase, dialysis during the oligoanuric phase, and hydra- include Ebola, Marburg, Lassa, Junin, Machupo, RVF, and CCHF
tion during the polyuric phase. viruses. However, the successful use of such pathogens by low-tech
Intravenous ribavirin decreases severity of illness if given within the bioterrorists is unlikely because of the challenges involved in col-
first 4 days. 149 lecting and creating aerosols of these lethal viruses without BSL-4
2,24
Vaccines In China and Korea, hantavirus vaccines are provided to people facilities.
living in endemic areas (2 million doses used per year). 150
■ APPROACH TO PATIENTS WITH HEMORRHAGIC FEVER

Early consideration of VHF in the proper setting is crucial. VHF is a KEY REFERENCES
rare condition in the ICU, and the prodrome is nonspecific, leading to • Bausch DG, Nichol ST, Muyembe-Tamfum JJ, et al. Marburg hem-
diagnostic delays. A number of VHF viruses (Lassa, Junin, Machupo, orrhagic fever associated with multiple genetic lineages of virus.
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VHF should be considered when a traveler to an endemic region is • Feldmann H, Geisbert TW. Ebola hemorrhagic fever. Lancet.
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2 weeks (2-5 weeks for HFRS) after returning from the trip. It is impor- • Jentes ES, Poumerol G, Gershman MD, et al. The revised global
tant to determine the detailed itinerary and circumstances of the trip. yellow fever risk map and recommendations for vaccination,
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Acquiring LF during a trip to West Africa would be a significant risk
only in the minority of travelers who spend much time in rural areas, • Jonsson CB, Figueiredo LTM, Vapalahti O. A Global Perspective
take care of patients without adhering to standard precautions, or study on Hantavirus Ecology, Epidemiology, and Disease. Clin Microbiol
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Africa than to the Amazon, but is nil in vaccine recipients. The risk of • MacNeil A, Ksiazek TG, Rollin PE. Hantavirus pulmonary syn-
filovirus infection is negligible except for rare travelers who visit specific drome, United States, 1993–2009. Emerg Inf Dis. 2011;17(7):1195-
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If the diagnosis of a VHF pathogen other than DHF is considered, the • Madani TA, Al-Mazrou YY, Al-Jeffri MH. Rift Valley fever
patient should be put on strict isolation and barrier precautions for VHF. epidemic in Saudi Arabia: epidemiological, clinical, and labora-
In brief, the patient should be placed in a pressure-negative room with tory characteristics. Clin Inf Dis. 2003; 37:1084-1092. Seminal
an anteroom where the supplies needed to maintain barrier-nursing article.
precautions and to perform disinfection procedures are located. Strict
barrier precautions use gloves, gowns, masks, shoe covers, and protec- • McElroy AK, Erickson BR, Flietstra TD, et al. Ebola hemorrhagic
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the patient. 152 • Ruzek D, Yakimenko VV, Karan LS, et al. Omsk hemorrhagic
Most VHF pathogens (Ebola, Marburg, Lassa, Junin, Machupo, fever. Lancet. 2010;376:2104-2113. Seminal article.
Guanarito, Sabiá, CCHF, Omsk HF, KFD, and Alkhurma HF viruses) • Simmons CP, Farrar JJ, van Vinh Chau N, Wills B. Dengue. N
require BSL-4 facilities to attempt viral isolation. Other pathogens Engl J Med. 2012;366:1423-1432.
require BSL-3 (hantaviruses, YF virus, RVF virus) or even BSL-2 • Yu XJ, Liang MF, Zhang SY, et al. Fever with thrombocytope-
( dengue) facilities. 2,152 Diagnostic testing should be performed in accor- nia associated with a novel Bunyavirus in China. N Engl J Med.
dance with detailed CDC recommendations. Calling either the CDC 2011;364:1523-1532. Seminal article.
Office of Biosafety or the State Health Department Proper will help with
the specific procedures required. 152
Serologic testing can be performed on site using the CDC mobile
laboratory, which can be transported emergently to any location within
the USA. Autopsy and handling of corpses require adherence to bar- REFERENCES
152
rier precautions, avoidance of aerosol formation, and decontamination
protocols. 152 Complete references available online at www.mhprofessional.com/hall

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