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Yellow Fever Clinical Presentation

  • Author: Mary T Busowski, MD; Chief Editor: Mark R Wallace, MD, FACP, FIDSA  more...
 
Updated: Jun 26, 2015
 

History

To arrive at a diagnosis, consider the patient's clinical features and his or her places and dates of travel, including the epidemiologic history of the places visited, immunizations, and activities.

After an incubation period of 3-6 days, most individuals with yellow fever have a mild, self-limiting illness consisting of fever, headache, myalgia, and malaise. More serious illness develops in 15% of cases and presents with the abrupt onset of general malaise, fever, chills, headache, lower back pain, nausea, and dizziness. Physical findings include pulse-fever dissociation (Faget sign), conjunctival injection, and facial flushing.

Significant laboratory findings usually include leukopenia with relative neutropenia. Transaminase levels may rise 48-72 hours after initial symptoms appear. This is followed by a period of remission, with normalization of symptoms and temperature for up to 24 hours. The patient may then either recover or progress to fatal illness (up to half of cases).

Remission followed by the return of symptoms is classified as the period of intoxication. Viremia is reduced, and humoral-mediated reactions are responsible for marked physical illness.[11] This stage is marked by fever, vomiting, abdominal pain, renal failure, and hemorrhage. Petechiae, ecchymoses, epistaxis, and bleeding from gums and venipuncture sites can progress to melena, hematemesis, and metrorrhagia.

Jaundice worsens as the levels of transaminases increase, with serum aspartate aminotransferase (AST) levels typically higher than those of alanine aminotransferase (ALT) owing to direct viral injury to skeletal muscle tissue and myocardium. Progressive liver involvement and humoral-mediated responses can lead to consumption coagulopathy. Prolonged clotting and prothrombin times and reduced levels of fibrinogen and clotting factors II, V, VII, VIII, IX, X occur; also, fibrin split products appear.

Hepatorenal disease carries a mortality rate of 20%-50%; with death occurring 7-10 days after onset of symptoms. The terminal phase is marked by delirium, stupor, and coma due to cerebral edema and microscopic perivascular hemorrhage.

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Physical Examination

Physical examination findings for yellow fever include fever, relative bradycardia for the degree of fever (Faget sign), conjunctival injection, and skin flushing.

Other physical findings, such as scleral icterus, jaundice, epigastric tenderness, and hepatomegaly, develop as disease progresses. Early appearance of jaundice indicates a poor prognosis.

Disseminated intravascular coagulation (DIC), induced by liver dysfunction, leads to consumption of platelets and clotting factors. This process clinically presents as a combination of a bleeding diathesis and organ ischemia secondary to fibrin deposition throughout the microcirculation. Petechiae, purpura, mucosal bleeding, and gastrointestinal bleeding (gross or hemoccult) will often be apparent.

Ischemia primarily affects the kidneys and central nervous system leading to altered mental status and/or signs of volume overload (jugular venous distension, presence of rales, and S3 gallop, or edema).

Late stages

In late stages of disease, shock and multiorgan dysfunction syndrome (MODS) dominate the clinical picture. These septic patients present with tachycardia, hypothermia or hyperthermia, and hypotension. Individuals who are severely hypoperfused appear mottled and cyanotic. They are also often obtunded.

Tachypnea and hypoxia with impending respiratory failure may develop as a consequence of sepsis and acute respiratory distress syndrome (ARDS).

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Contributor Information and Disclosures
Author

Mary T Busowski, MD Chief, Division of Infectious Diseases, Orlando VA Medical Center; Infectious Disease Faculty Practice/Internal Medicine Faculty Practice, Orlando Health; Assistant Professor of Medicine, Florida State University College of Medicine; Assistant Professor of Medicine, University of Central Florida College of Medicine

Mary T Busowski, MD is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American College of Physicians, American Medical Association, Florida Medical Association, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

Mark R Wallace, MD, FACP, FIDSA Clinical Professor of Medicine, Florida State University College of Medicine; Clinical Professor of Medicine, University of Central Florida College of Medicine

Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, International AIDS Society, Florida Infectious Diseases Society

Disclosure: Nothing to disclose.

Janelle L Robertson, MD Staff Physician, Department of Infectious Diseases, Wilford Hall Medical Center

Janelle L Robertson, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Mark R Wallace, MD, FACP, FIDSA Clinical Professor of Medicine, Florida State University College of Medicine; Clinical Professor of Medicine, University of Central Florida College of Medicine

Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, International AIDS Society, Florida Infectious Diseases Society

Disclosure: Nothing to disclose.

Acknowledgements

Joseph U Becker, MD Fellow, Global Health and International Emergency Medicine, Stanford University School of Medicine

Joseph U Becker, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Richard B Brown, MD, FACP Chief, Division of Infectious Diseases, Baystate Medical Center; Professor, Department of Internal Medicine, Tufts University School of Medicine

Richard B Brown, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, and Massachusetts Medical Society

Disclosure: Nothing to disclose.

Dan Danzl, MD Chair, Professor, Department of Emergency Medicine, University of Louisville Hospital

Dan Danzl, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Kentucky Medical Association, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Aleksandr Gleyzer, MD, FAAEM Assistant Professor, Department of Emergency Medicine, State University of New York Downstate Medical Center; Attending Physician, Department of Emergency Medicine, Kings County Medical Center and Brooklyn Veterans Affairs Medical Center

Aleksandr Gleyzer, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and International Society of Travel Medicine

Disclosure: Nothing to disclose.

Thomas E Herchline, MD Professor of Medicine, Wright State University, Boonshoft School of Medicine; Medical Director, Public Health, Dayton and Montgomery County, Ohio

Thomas E Herchline, MD is a member of the following medical societies: Alpha Omega Alpha, Infectious Diseases Society of America, and Infectious Diseases Society of Ohio

Disclosure: Nothing to disclose.

Emily Nichols, MD Clinical Assistant Instructor, State University of New York Downstate Medical Center, Kings County Hospital Center

Emily Nichols, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Emergency Medicine Residents Association, and National Medical Association

Disclosure: Nothing to disclose.

Mark L Plaster, MD, JD Executive Editor, Emergency Physicians Monthly

Mark L Plaster, MD, JD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: M L Plaster Publishing Co LLC Ownership interest Management position

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark R Wallace, MD, FACP, FIDSA Clinical Professor of Medicine, Florida State University College of Medicine; Head of Infectious Disease Fellowship Program, Orlando Regional Medical Center

Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

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Yellow fever virus. Image courtesy of the Centers for Disease Control and Prevention.
This female Aedes aegypti mosquito is shown after landing on a human host. The A aegypti mosquito is a known transmitter of dengue fever and yellow fever. A aegypti is sometimes referred to as the yellow fever mosquito. The viruses are transferred to the host when he or she has been bitten by a female mosquito. Image courtesy of the CDC/World Health Organization (WHO).
Global distribution of yellow fever. Image courtesy of the Centers for Disease Control and Prevention.
Transmission cycles of yellow fever in Africa and South America. Adapted from Annu Rev Entomol. 2007. 52:209-29.
 
 
 
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