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Dermatologic Manifestations of Viral Hemorrhagic Fevers

Sections Dermatologic Manifestations of Viral Hemorrhagic Fevers
Overview
Presentation
DDx
Workup
Treatment
- Medical Care
- Consultations
- Diet
- Activity
- Prevention
- Show All
Medication
Media Gallery
Tables
References

Workup

Laboratory Studies

Although the clinical findings can suggest a hemorrhagic fever, laboratory studies are required to identify disease, to distinguish it from other conditions, and to confirm its etiology.

As a rule, clinical blood and/or urine tests reveal leukopenia (except in Lassa fever, Hantaan viral fever, and some severe cases of CCHF), thrombocytopenia (except in Lassa fever), and proteinuria and/or hematuria (in Argentinian viral hemorrhagic fever, Bolivian viral hemorrhagic fever, and hemorrhagic fever with renal syndrome [HFRS]; common in other viral hemorrhagic fevers). Such tests include the following:

Full blood cell count determination
Red blood cell and sedimentation rate analysis
White blood cell differential count determination
Platelet count
Tests for parasites, malaria, trypanosomiasis, or relapsing fever
Coagulation studies
Liver and kidney function tests
Bacterial culture and virus isolation from feces and urine samples
Electron microscopic examination of blood and urine samples
Positive tourniquet test in dengue fever (This test may also be helpful in other viral hemorrhagic fevers.)

The specific diagnosis is based on viral isolation or the demonstration of seroconversion, that is, the presence of specific immunoglobulin M (IgM) antibody or a 4-fold increase in the antibody titer.

Specialized infectious disease containment is required for the safe handling of these viruses. Biochemical tests are available for the rapid detection of viral antigen during viremia or in postmortem specimens. Such tests include the following:

Immunofluorescence antibody (IFA) tests can be performed.
Reversed (or indirect) passive hemagglutination (RPHA) tests may be helpful.
Acute serum samples can be tested by using a polymerase chain reaction (PCR).
Enzyme-linked immunosorbent assays (ELISA) can be used to detect specific IgM or immunoglobulin G (IgG) antibodies or viral antigens in acute serum samples from patients with Lassa fever, Argentinian fever, RVF, CCHF, or yellow fever. Lassa- and Hantavirus-specific IgM antibodies are often detectable during acute illness.
Tests for viral genetic material are favored in diagnoses of acute arenaviral infections.
Virus cultivation and identification techniques require 3-10 days or longer for definitive identification. Viral isolation is a lengthy process, especially in Hantaan, Ebola, Marburg, and Congo-Crimean fevers.
Postmortem immunocytochemical analyses can be used to identify the viral phenotype.
Reverse transcriptase loop-mediated isothermal amplification (RT-LAMP) can be used for the rapid detection of Marburg virus.^[69]
Reverse-transcription polymerase chain reaction has high sensitivity and specificity to detect the Ebola virus genome. False-negative results may be present in the first 3 days of illness, and repetition of the test may be required.^[70]

Other Tests

Electron microscopy of the infected tissue may be helpful.

Treatment & Management

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Media Gallery

New World Arenavirus - Machupo. Oral mucosal hyperemia and hemorrhage in a patient with Bolivian hemorrhagic fever.
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.
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.

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Table 1. Geographic Distribution of Viral Hemorrhagic Fevers

Virus Family and Genus

Type of Hemorrhagic Fever

Reservoir Host

Geographic Distribution

Arenaviridae

Guanarito

Junin

Machupo

Lassa

Sabia

Venezuelan

Argentinian

Bolivian

Lassa (West Africa)

Brazilian or Sao Paulo

Rodents

Venezuela

Argentina

Bolivia

West Africa

Brazil

Bunyaviridae

Nairovirus

Phlebovirus

Hantaan virus

Crimean-Congo

Rift Valley

Korean

HPS

Ticks

Mosquito and contact with infected blood in slaughter houses

Contact with infected rodents and their excreta

Crimea, Central Africa, South Africa, Iraq, Pakistan, Turkey, Iran, Afghanistan, Russia

Africa, Egypt

Korea, Eastern Europe, Russia, Scandinavia

North, Central, and South America

Flaviviridae

Flavivirus

Yellow

Dengue

Chikungunya

Omsk

Mosquito

Tick

Tropical Africa, South America

Entire tropical zone

India, Southeast Asia

Siberia

Filoviridae

Marburg

Ebola

Marburg

Ebola

Infected monkeys were implicated but no known definite reservoir

Africa

West Africa

Table 2. Viral Hemorrhagic Fever Outbreaks from January 2018 to April 2019 According to WHO Emergencies Preparedness, Response Disease Outbreak News. ^[36]

Year

Disease

Country

2019

2018

Ebola virus disease

Rift Valley fever

Yellow fever

Lassa fever

Dengue fever

HPS

Yellow fever

HPS

Yellow fever

Rift Valley fever

Dengue

Ebola virus disease

Lassa fever

Yellow fever

Rift Valley fever

Lassa Fever

Democratic Republic of the Congo

Mayotte (France)

Brazil

Nigeria

Jamaica

Argentine Republic

Nigeria

Republic of Panama

Kingdom of the Netherlands

Democratic Republic of the Congo

French Guyana (France)

Kenya

Reunion, France

Democratic Republic of the Congo

Nigeria

Brazil

Gambia

Liberia

Table 3. Viral Hemorrhagic Fever Mortality Rates

Virus Family and Type of VHF

Mortality Rate, %

Arenaviridae

Argentinian and Bolivian

Lassa (West African)

Venezuelan and Sao Paulo

10-30

30-40

Bunyaviridae

Korean and Seoul

Rift Valley

Congo-Crimean

HPS

5-15

10-50

15-50

Flaviviridae

Yellow

Dengue

< 1

Filoviridae

Marburg

Ebola

23-25

25-100

Back to List

Author

Amira M Elbendary, MBBCh, MSc Visiting Dermatopathology Fellow, Ackerman Academy of Dermatopathology; Assistant Lecturer, Department of Dermatology, Kasr Alainy University Hospitals, Cairo University, Egypt

Amira M Elbendary, MBBCh, MSc is a member of the following medical societies: Bloom’s Syndrome Association, Egyptian Medical Syndicate, International Dermoscopy Society, Medical Dermatology Society

Disclosure: Nothing to disclose.

Coauthor(s)

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Military Dermatologists, Phi Beta Kappa, Texas Dermatological Society

Disclosure: Nothing to disclose.

Jeffrey P Callen, MD Professor of Medicine (Dermatology), Chief, Division of Dermatology, University of Louisville School of Medicine

Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, American College of Rheumatology

Disclosure: Received income in an amount equal to or greater than $250 from: Genentech as a consultant for a potential study on a drug that has yet to be approved for any use<br/>Received honoraria from UpToDate for author/editor; Received royalty from Elsevier for book author/editor; Received dividends from trust accounts, but I do not control these accounts, and have directed our managers to divest pharmaceutical stocks as is fiscally prudent from Stock holdings in various trust accounts include some pharmaceutical companies and device makers for these trust accounts; I served on a safety monitoring committee for Principia Biopharma (ended 9-2021) for: Stocks held in various trust accounts: Allergen; Pfizer; 3M; Johnson and Johnson; Merck; Abbott Laboratories; AbbVie; Procter and Gamble; Amgen; Gilead.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD<br/>Served as a speaker for various universities, dermatology societies, and dermatology departments.

Acknowledgements

Ally N Alai, MD, FAAD Former Professor, Department of Dermatology, Clinical Faculty and Preceptor, Department of Family Practice, University of California, Irvine, School of Medicine; Former Professor and Preceptor, Department of Family Practice Residency Training, Downey Medical Center; Medical Director, The Skin Center at Laguna; Expert Medical Reviewer, Medical Board of California; Expert Consultant, California Department of Consumer Affairs; Expert Reviewer, California Department of Registered Nursing

Ally N Alai, MD, FAAD is a member of the following medical societies: American Academy of Dermatology and American Society for MOHS Surgery

Disclosure: Nothing to disclose.

Eiman N Anvari, DO, MSc Resident Physician, Department of Radiology, Philadelphia College of Osteopathic Medicine

Eiman N Anvari, DO, MSc is a member of the following medical societies: American College of Physicians, American Medical Student Association/Foundation, and American Osteopathic Association

Disclosure: Nothing to disclose.

Arash M Saemi, MD Resident Physician, Department of Radiology, Dartmouth-Hitchcock Medical Center

Arash M Saemi, MD is a member of the following medical societies: American College of Physicians, Radiological Society of North America, Sigma Xi, and Society of Interventional Radiology

Disclosure: Nothing to disclose.

Sections Dermatologic Manifestations of Viral Hemorrhagic Fevers
Overview
Presentation
DDx
Workup
Treatment
- Medical Care
- Consultations
- Diet
- Activity
- Prevention
- Show All
Medication
Media Gallery
Tables
References

Dermatologic Manifestations of Viral Hemorrhagic Fevers Workup

Laboratory Studies

Other Tests

References

Tables

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