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CBRNE - Viral Hemorrhagic Fevers Workup

  • Author: David C Pigott, MD; Chief Editor: Zygmunt F Dembek, PhD, MPH, MS, LHD  more...
Updated: Mar 30, 2015

Laboratory Studies

Because of risks associated with handling infectious materials, perform the minimum necessary laboratory testing for diagnostic evaluation and patient care. Considerations in ordering lab tests are as follows:

  • A complete blood count often indicates leukopenia and thrombocytopenia (these findings may not be present in Lassa fever)
  • Elevated hepatic transaminases are observed in viral hemorrhagic fever (VHF) and are predictive of high mortality in Lassa fever infection
  • Prothrombin time, activated partial thromboplastin time, international normalized ratio, and clotting times are prolonged.
  • A disseminated intravascular coagulation profile including fibrinogen level, fibrin degradation products, and platelet count may be useful

Other Tests

Most patients are viremic at the time of presentation (Hantavirus is an exception). Specific viral diagnosis can be made using serologic tests, including enzyme-linked immunosorbent assay (ELISA) and polymerase chain reaction. Difficult cases may require tissue cultures. During the 2000-2001 Ebola outbreak in Uganda, reverse transcriptase-PCR (RT-PCR) emerged as a very effective means for detecting Ebola virus in patient serum, plasma, and whole blood.

Because of the need for specialized microbiologic containment and handling of these viruses, initiate contact with the Centers for Disease Control and Prevention (CDC; Atlanta, GA) as soon as possible and prior to transport of specimens for virus-specific diagnosis. Specific state and federal statutes govern the shipment of highly infectious disease agents.

The CDC and the US Army Medical Research Institute for Infectious Diseases (USAMRIID; Frederick, MD) are among the 8 Biosafety Level 4 (BSL-4) laboratory facilities in the US with such diagnostic facilities. At least seven more are under construction.

Report all suspected cases of viral hemorrhagic fever (VHF) immediately to local and state public health departments and to the CDC.

Contributor Information and Disclosures

David C Pigott, MD RDMS, FACEP, Professor of Emergency Medicine, Co-Director of Emergency Ultrasound, Vice Chair for Academic Development, Department of Emergency Medicine, University of Alabama at Birmingham School of Medicine

David C Pigott, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents' Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Zygmunt F Dembek, PhD, MPH, MS, LHD Associate Professor, Department of Military and Emergency Medicine, Adjunct Assistant Professor, Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine

Zygmunt F Dembek, PhD, MPH, MS, LHD is a member of the following medical societies: American Chemical Society, New York Academy of Sciences

Disclosure: Nothing to disclose.

Additional Contributors

Jerry L Mothershead, MD Medical Readiness Consultant, Medical Readiness and Response Group, Battelle Memorial Institute; Advisor, Technical Advisory Committee, Emergency Management Strategic Healthcare Group, Veteran's Health Administration; Adjunct Associate Professor, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences

Jerry L Mothershead, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians

Disclosure: Nothing to disclose.


The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous author, Thomas W McGovern, MD, to the development and writing of this article.

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Ebola virus. Electron micrograph courtesy of the Centers for Disease Control and Prevention.
Marburg virus. Negative stain image courtesy of the Centers for Disease Control and Prevention.
Mastomys rodent, natural host of Lassa virus. Image courtesy of the Centers for Disease Control and Prevention.
Bunyavirus infection. Ecchymoses encompassing left upper extremity one week after onset of CCHF. Ecchymoses often are accompanied by hemorrhage in other locations: epistaxis, puncture sites, hematemesis, melena, and hematuria. Image provided by Robert Swaneopoel, PhD, DTVM, MRCVS, National Institute of Virology, Sandringham, South Africa.
Apodemus agrarius, the vector of Korean hemorrhagic fever caused by a hantavirus. Photo courtesy of David McClain, MD.
Bunyavirus infection - Hantaan virus. Patient with Korean hemorrhagic fever caused by Hantaan virus demonstrating typical 'sunburn flush' of cheeks, chin, and base of neck. Photo courtesy of John Huggins, PhD.
Bunyavirus infection. A patient with Korean hemorrhagic fever demonstrating conjunctival hemorrhages, facial petechiae, and "sunburn flush" of the cheeks. Photo courtesy of John Huggins, PhD.
Filovirus disease - Ebola fever. Patient with Ebola hemorrhagic fever during 1976 outbreak in Zaire demonstrating palatal petechiae and hemorrhage. Photo courtesy of Joel Breman.
Patient with morbilliform exanthem of dengue fever. Note islands of sparing characteristics for dengue. Photo courtesy Duane Gubler, PhD.
Patient with dengue hemorrhagic fever complicated by ecchymoses. Photo courtesy of Duane Gubler, PhD.
Dengue Virus Notice posted outside Maracanã Stadium, Rio de Janeiro, Brazil, 2012. Translation: This site is a strategic point for controlling Dengue.
Mastomys natalensis, natural host of Lassa virus. Photo courtesy of BioMed Central, originally published in Kelly JD, Barrie MB, Ross RA, Temple BA, Moses LM, Bausch DG. Housing equityfor health equity: a rights-based approach to the control of Lassa fever inpost-war Sierra Leone. BMC Int Health Hum Rights. 2013 Jan 2;13:2.
Table. Viral Families Causing Viral Hemorrhagic Fever
Virus Family Disease (Virus) Natural Distribution Usual Source of Human Infection Incubation (Days)
Arenavirus Lassa fever Africa Rodent 5-16
  Argentine HF (Junin) South America Rodent 7-14
  Bolivian HF (Machupo) South America Rodent 9-15
  Brazilian HF (Sabia) South America Rodent 7-14
  Venezuelan HF (Guanarito) South America Rodent 7-14
Phlebovirus Rift Valley fever Africa Mosquito 2-5
Nairovirus Crimean-Congo HF Europe, Asia, Africa Tick 3-12
Hantavirus Hemorrhagic fever with renal syndrome, hantavirus pulmonary syndrome Asia, Europe, worldwide Rodent 9-35
Filovirus Marburg and Ebola Africa Fruit bat 3-16
Flavivirus Yellow fever Tropical Africa, South America Mosquito 3-6
  Dengue HF Asia, Americas, Africa Mosquito Unknown for dengue HF, 3-5 for dengue
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