Case history
Case history #1
A 17-year-old woman presents to a Turkish hospital with 5-days history of fever, malaise, headache, myalgia, nausea, vomiting, and epistaxis. She is from a rural village of northeastern Anatolia and works with livestock. She has no sick contacts, no recent travel, and no underlying medical conditions. On admission, her temperature is 38.3ºC, with epistaxis, conjunctival injection, and abdominal tenderness on palpation. White blood cell count (WBC) is 1.1 × 10⁹/L, haemoglobin is 93 g/L (9.3 g/dL), platelet count is 106 × 10⁹/L. On day 2 of hospitalisation, her WBC drops to 0.5 × 10⁹/L, haemoglobin level to 53 g/L (5.3 g/dL), and platelet count to 89 × 10⁹/L. Large bruises and ecchymoses at the antecubital fossae are noted at prior phlebotomy sites. Liver enzymes show an elevated AST (3195 IU/L), ALT (1443 IU/L), lactate dehydrogenase (8190 IU/L), and creatine phosphokinase (1427 IU/L). Prothrombin time is also elevated at 22.9 seconds, activated partial prothrombin time (aPTT) 65 seconds, and international normalised ratio (INR) 1.23. One unit of packed red blood cells is given, with some subjective improvement. On hospital day 3, the patient is noted to have bilateral axillary lymphadenopathy and mild, tender hepatomegaly. CCHF is considered as a possible diagnosis, and oral ribavirin is given. On the fourth day of ribavirin the patient shows some clinical improvement, WBC is 4.5 × 10⁹/L, and platelet count 100 × 10⁹/L. She continues to improve slowly, though with persistent fatigue and malaise. Fevers abate on hospital day 6, and the patient is discharged home on hospital day 8 given improved haematological parameters and clinical improvement. The patient completes a 10-day course of ribavirin. Three weeks after admission, a blood sample sent for CCHF virus reverse transcription-polymerase chain reaction (RT-PCR) returns positive.
Case history #2
A 27-year-old nurse experiences a needlestick injury during a phlebotomy of a patient with severe CCHF infection. She does not receive ribavirin as post-exposure prophylaxis. Three days after the incident she develops fever and presents to the emergency department the following day with severe headache and muscle pain. Her platelet count is 80 x× 10⁹/L, WBC is 2.5 × 10⁹/L, PT 13 seconds, aPTT 35 seconds, creatine kinase 123 IU/L, ALT level is 67 IU/L, and AST level is 129 IU/L. Her renal function and observations are normal apart from a fever (38.2ºC). She is admitted and isolated with suspected CCHF and commenced on ribavirin treatment. The following day she develops diarrhoea and vomiting, is commenced on intravenous fluids, and her platelet count reduces to 40 × 10⁹/L. The following day she complains of bleeding from her gums, and is noted to have ecchymoses on her flank and at injection sites. Her RT-PCR for CCHF virus is reported positive from the reference laboratory. Her ALT and AST have elevated to 489 IU/L and 790 IU/L respectively, her platelets reduced to 13 × 10⁹/L, and rising PT (22 seconds) and aPTT (46 seconds). She is given 2 units of platelets and 1 unit of fresh frozen plasma. She deteriorates in the next 24 hours with increasing confusion and evidence of lower GI bleeding and progressive ecchymoses. Platelet counts remain around 10-20 × 10⁹/L with continued platelet transfusion (2 units), and PT and aPTT continue to rise (26 seconds, 100 seconds) despite 3 units of fresh frozen plasma. ALT has raised to 1809 IU/L and AST >2000 IU/L. Creatinine is elevated to 214.8 micromol/L (2.43 mg/dL) and she is transferred to intensive care for higher level care and haemodialysis on day 5. Respiratory function becomes impaired with evidence of ARDS and pulmonary haemorrhage on day 6, requiring invasive ventilation that is followed by development of septic shock requiring vasopressor support. She has progressive multi-organ failure and dies on day 7 of illness.
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