CBRNE - Viral Hemorrhagic Fevers Workup

  • Author: David C Pigott, MD, RDMS, FACEP; Chief Editor: Robert G Darling, MD, FACEP   more...
 
Updated: Apr 18, 2011
 

Laboratory Studies

  • Because of risks associated with handling infectious materials, perform the minimum necessary laboratory testing for diagnostic evaluation and patient care.
  • 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.
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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 7 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.
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Contributor Information and Disclosures
Author

David C Pigott, MD, RDMS, FACEP  Associate Professor of Emergency Medicine, Co-Director of Emergency Ultrasound, Vice Chair for Academic Development, Associate Scientist, UAB Center for Emerging Infections and Emergency Preparedness, University of Alabama School of Medicine

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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 and National Association of EMS Physicians

Disclosure: Nothing to disclose.

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

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert G Darling, MD, FACEP  Adjunct Clinical Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Associate Director, Center for Disaster and Humanitarian Assistance Medicine

Robert G Darling, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Telemedicine Association, and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine 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.
Table. Viral Families Causing Viral Hemorrhagic Fever
Virus FamilyDisease (Virus)Natural DistributionUsual Source of Human InfectionIncubation (Days)
Arenaviridae
ArenavirusLassa feverAfricaRodent5-16
Argentine HF (Junin)South AmericaRodent7-14
Bolivian HF (Machupo)South AmericaRodent9-15
Brazilian HF (Sabia)South AmericaRodent7-14
Venezuelan HF (Guanarito)South AmericaRodent7-14
Bunyaviridae
PhlebovirusRift Valley feverAfricaMosquito2-5
NairovirusCrimean-Congo HFEurope, Asia, AfricaTick3-12
HantavirusHemorrhagic fever with renal syndrome, hantavirus pulmonary syndromeAsia, Europe, worldwideRodent9-35
Filoviridae
FilovirusMarburg and EbolaAfricaUnknown3-16
Flaviviridae
FlavivirusYellow feverTropical Africa, South AmericaMosquito3-6
Dengue HFAsia, Americas, AfricaMosquitoUnknown for dengue HF, 3-5 for dengue
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