Case history
Case history #1
A 35-year-old male agricultural worker from southeast Cordoba province, Argentina, presents to a local health facility during May. It is harvest time in the southern hemisphere and he has spent many long days harvesting his crops in the fields. He presents with a 3-day history of fever of 38.5°C and complains of malaise, headache, and myalgia. He is diagnosed with a non-specific viral illness and sent home with advice to rest and take paracetamol for symptom relief. He presents 3 days later with ongoing fever, but now complains of abdominal pain with associated vomiting and occasional episodes of diarrhoea. On examination he appears weak with cervical lymphadenopathy. He is noted to have mild conjunctival injection and petechiae to his soft palate and axillae. During the examination, mild pressure on his gums results in them bleeding. He has a heart rate of 105 bpm, blood pressure of 110/70 mmHg, respiratory rate of 16 breaths per minute, oxygen saturation of 99%, and a temperature of 39°C. An FBC reveals a WBC of 1.4 x 10⁹ cells/L and a platelet count of 60 x10⁹ cells/L. Electrolytes and a renal panel are normal, but liver function tests show a mildly raised AST at 58 U/L, with creatine phosphokinase also slightly raised at 240 U/L. Due to concerns regarding his symptoms and the results of his FBC, he is admitted to hospital in an isolation unit and tested for Argentine haemorrhagic fever by reverse transcription-polymerase chain reaction (RT-PCR) for Junin virus. The RT-PCR result returns the following day and is positive. While waiting for the test result, the patient's condition has deteriorated and is becoming irritable and lethargic. On mobilising he is noted to be mildly ataxic. Although in short supply, the hospital is able to obtain one course of immune plasma and 500 mL (calculated to be equivalent to 3500 therapeutic units of neutralising antibodies/kg bodyweight) is administered intravenously on day 8 of symptoms. A good effect is observed and over the following 48 hours his fever settles and he becomes more alert. His symptoms gradually resolve over the next few days. A repeat RT-PCR on day 14 is negative and an enzyme-linked immunosorbent assay (ELISA) is positive for IgM and IgG. A semen test is also done on day 14 and is negative for Junin virus on RT-PCR. He is discharged on day 17 from onset of symptoms, with follow-up in the outpatient clinic in 1 week's time. He is advised to use barrier protection during sexual intercourse until he has had several negative semen samples, due to the small risk of sexual transmission of the disease in the convalescent period. At follow-up he complains of hair loss and fatigue, but otherwise appears to be doing well. Repeat semen testing by RT-PCR is negative. Two weeks later the patient presents to the hospital complaining of fever, headache, tremor, and difficulty walking. On examination he is noted to be ataxic, with a tremor and nystagmus; he also has a right-sided palsy of the VI cranial nerve. His temperature is 38.3°C, with a heart rate of 90 bpm at rest. Other observations are stable. He is admitted and a lumbar puncture is performed which reveals a cerebrospinal fluid (CSF) WBC of 70 cells/microlitre (predominantly lymphocytes), but a normal CSF glucose and protein level. An ELISA reveals high titres of antibodies to Junin virus in the CSF, which are markedly higher than the serum antibody titres. All other blood tests are normal. The patient is observed on the ward for a few days and managed symptomatically. His symptoms gradually settle and he is discharged home 5 days later. He is monitored in the outpatient clinic weekly for the first few weeks and then monthly. His hair loss subsides and his fatigue improves. While his VI nerve palsy improves gradually and completely resolves in the next few weeks, he has a persistent nystagmus for several months. His semen testing is consistently negative by RT-PCR for Junin virus. He is discharged from the outpatient clinic 6 months following his acute illness with complete resolution of all symptoms.
Case history #2
A 19-year-old male student returned from his gap year in northern Bolivia 2 days ago. He had been working at an agricultural facility, assisting with the harvest. He presents with a fever of 39°C and complains of headache, arthralgia, and myalgia. Prior to his trip he had been immunised for yellow fever, typhoid fever, and hepatitis A. On examination he appears unwell, but with no focal signs. He has a relative bradycardia of 50 bpm, blood pressure of 120/75 mmHg, respiratory rate of 14 breaths per minute, and oxygen saturation of 99%. His temperature is recorded as 39.3°C.
Other presentations
Presentations in the advanced stages of disease may be more specific and the patient is often severely unwell. Severe neurological and haemorrhagic symptoms occur in approximately 30% of patients in the later stages of disease, usually in the second week of symptoms.[2][3][5][6] Neurological symptoms often present with confusion, ataxia, and seizures and may progress to prostration and a comatose state.[2][3][5][6] Haemorrhagic symptoms may initially present as bleeding from gums or epistaxis, but may also be in the form of gastrointestinal haemorrhage such as melaena, rectal bleeding, or haematemesis.[2][3][5][6] Metrorrhagia is a common feature in women with haemorrhagic disease.[5] While haemorrhagic symptoms may be relatively common, catastrophic haemorrhage is uncommon and death usually results from multiple organ failure.[5]
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