CHAPTER Viral Hemorrhagic Fever 3 A ee ese = Viral Hemorthagic Fever © Chikungunya = Arboviruses © Kyasanur Forest Disease © Dengue VIRAL HEMORRHAGIC FEVER Viral hemorrhagic fevers (VHF) are defined as a group of illnesses caused by different families of viruses that cause vascular damage that results in symptomatic bleeding (hemorrhage). VHFs are caused by viruses of three distinct groups: 1, Arboviruses: Transmitted by arthropod vectors. Examples include dengue, yellow fever viruses 2. Filoviruses such as Ebola and Marburg viruses 3. Rodent borne viruses such as Hantaviruses and Arenaviruses. ‘Note: Rarely, bacterial infections such as scrub typhus and leptospirosis can also cause hemorrhagic fever. General Properties Hemorthagic fever viruses share a number of features. 4 They are all enveloped RNA viruses Distribution: They are geographically restricted to the areas where their host species live (e.g. Ebola viruses in Africa) + Severity: Some types of VHF (e.g. dengue) are relatively mild, whereas many of these diseases (e.g, Ebola) are severe and life-threatening 4 Reservoir: Their survival is dependent on an animal or insect vector, which servesas natural reservoir. Humans are not the natural reservoir = They can be occasionally transmitted to humans when come in contact with the excretions of infected animals or arthropods = In some instances, once the virus infects humans, person-to-person transmission can occur when an uninfected person comes in contact with the bodily fluids (e.g. Ebola) or by the bite of an arthropod vector (eg. dengue). + Symptoms: VHF presents with fatigue, fever, weakness, dizziness, and muscle aches = Patients with more severe infections show bleeding under the skin, internal organs or even from external body orifices such as the mouth, eyes, or ears © Flloviruses © Rodent Borne Viruses ‘= Other Viral Hemorrhagic Fevers = Some patients develop severe diarrhea that may also be bloody, and severely ill patients present with shock, delirium, seizures, kidney failure, and coma that often ends in death. + Epidemiological pattern: VHF cases occur either sporadically or as seasonal outbreaks (dengue in India) orsometimes as explosive epidemics (e.g, Ebola in Africa, 2014). The occurrence of outbreaks cannot be easily predicted 4 Treatment: With a few noteworthy exceptions (ribavirin for Lassa fever) there is no definitive treatment available for VHEs. Cases can only be managed by symptomatic treatment + Vaccine: No vaccine is available for VHF, with the exceptions of yellow fever and dengue. UT aa Arboviruses (arthropod-borne viruses) are diverse group of RNA viruses thatare transmitted by blood sucking arthropods (insect vectors) from one vertebrate host to another, ‘Viruses must multiply inside the insects and establish a lifelong harmless infection in them. Thus, the viruses which are just mechanically transmitted by insects are not included in this group. INTRODUCTION Arboviruses are taxonomically diverse, belong to five different families (Table 34.1). Still, the name ‘arbovirus’ is internationally accepted as the members under this group ‘are comparable in many ecological and epidemiological factors—such as geographical distribution, mode of transmission (type of insect vector), clinical features and their control measures. Classification Members of arboviruses are RNA viruses, belonging to five different families: Togaviridae, Flaviviridae, Bunyaviridae, Reoviridae and Rhabdoviridae (Table 34.1). Scanned with CamScannerCChikungunya virus Feverand arthritis Asia, Africa ‘Aedes aegypti (rarely hemorthagic fever) O1Nyong-nyong vieus Feverand arthritis Africa ‘Anopheles * Mayaro virus Feverand arthritis South America Aedes aegypti Monkeys Ross River virus Epidemic polyarthritis Australia Aedes ‘Small animals Sindbis virus Arthralgla,and rash Africa, Europe, Australia Culex Birds, mammals Semliki Forest vius Feverand arthralgia Altica Aedes Birds, rodents Easter equine encephalitis virus Encephalitis Eastern partof North America Aedes, Culex Birds Western equine encephalitis virus Encephalitis Wester part ofNorth America Culextarsalis, Aedes Birds Venezuelan equine encephalitis virus Encephalitis Southand Central America Aedes, Culex Horses nei iekeiiee Ooo eee Japanese B encephalitis virus Encephats South Est Asia Culex Pigs Birds tntaeniorhynchus StLouis encephalitis virus Encephalitis United States Cuter Wild birds West Nile encephalitis virus Encephalitis East Africa (Uganda) Algeria, Culex Aedes, Birds Romania ‘Anopheles ‘Murray Valley encephalitis virus Encephalitis ‘America Culexannutiostis Birds Rocio virus Encephalitis ‘io Paulo, Brazil Culex : Russian spring-summer encephalitis Encephalitis Central Europe, Russia Tick Rodents, other virus ‘mammals birds Powassan virus Encephalitis ‘America Tick Rodents Louping:ill views Encephalitis Europe Tick Sheep Dengue virus Hemorthagicfever India ‘Aedes aegypti Yellow fever views Hemorthagicfever West Afica, Central South ‘Aedes aegypti Monkeys Ametica Kyasanur Forest disease virus Hemorthagicfever India (Karnataka) Tick Monkeys and rats COmskhemorthagicfevervirus _—-Hemorthagicfever Russia Tick Small mammals Zika virus Feverand arthritis First occurred in Braz then Aedes egypt Monkeys ‘spread to other countries California encephalitis virus Encephalitis USA Aedes triseriatus Rodents Oropouche virus Rash and aseptic Central and South America Culicoides paraensis _ Notknown meningitis Sandy fever virus Feverand myalgia Southern Europe, North Africa, Sandfly ‘Small mammals India RiftValley fever virus Fever and myalgia Africa Aedes Sheep, cattle ‘Crimean Congo hemorthagic fever Hemorthagicfever Africa Tick ‘Small mammals virus Ganjam virus Fever India Tick ‘Small mammals ‘Severe fever with thrombocytopenia Fever, China, Korea Tick Sheep, goat, ‘syndrome virus thrombocytopenia chicken Family: Reoviridse Colorado tick fever virus Fever rarely ‘America (mountains) Tick Rodents encephalitis (Orungo virus Fever ‘Sub-Saharan Africa Aedes a Kemerovo virus Fever,meningism Russia Tick a Vesicular stomatitis virus Oral mucosal vesicles Indiana Sandy a CChandipura virus Encephalitis India Sandy a * Not ytidentised, Fr vieuses ike dengue, come studies have shown domestic dogs can be infected with dengue virus ‘Arboviruses causing encephalitis e, Japanese encephalitis and West Nile encephalitis viruses) are dicussedin Chapter 74, Scanned with CamScannerEE SECTION 4 @ Bloodstream and Cardiovascular System Infections Individual viruses under each family are named after various features such as: % Clinical features: For example, yellow fever is named after its main clinical feature—jaundice * Place of discovery: For example, Kyasanur Forest disease virus * Vector needed for transmission: For example, sandfly fever virus + Peak season: For example, Russian spring-summer encephalitis virus Multiple features: Japanese encephalitis virus is named. after the place of discovery and clinical feature. Clinical Manifestations Arboviruses may also be arbitrarily divided based on the pattern of clinical syndromes they produce (Table 34.1). © Fever and/or rash, and/or arthralgia group © Encephalitis group Hemorrhagic fever group. However, some of them may be associated with more than one clinical syndromes, e.g. dengue virus. Epidemiology Zoonotic: Several hundred arboviruses exist in the world and all are believed to be endemic in animals. However, only about 100 are human pathogens ‘Transmission cycle: Arboviruses are maintained in the nature between animals and their insect vectors Humans are the accidental hosts and do not play any role in the maintenance or transmission cycle of the virus, except for urban yellow fever and dengue + Arthropod vector: Most arboviruses are transmitted by mosquitoes (Aedes, Culex or Anopheles) followed by ticks, and rarely sandfly and other insects (Table 34.1) Climatic variation: Arboviruses are more prevalent in the tropics than temperate climate, due to abundance of appropriate animals and arthropods in the former ® Geographical distribution: Arboviruses vary greatly in their geographical distribution which in turn depends on the various factors such as climatic condition and presence of vector. Viruses that are highly endemic in one place, may not be found in other areas (Table 34.1) = Yellow fever'is highly endemic in West Africa, but not found atall in India in spite of its vector Aedes aegypti being widely distributed in India = Encephalitic arboviruses: Eastern, Western and Venezuelan equine encephalitis viruses are prevalent in North America whereas in India, Japanese encephalitis virus is the most common arbovirus causing encephalitis. % Arboviruses found in India: Over 40 arboviruses have been detected in India, of which three are highly endemic and produce several outbreaks every year = Common arbvoviruses prevalent in India include: ¢ Hemorrhagic fever group (dengue and Kyasanur forest disease viruses) and fever with arthalgia group (chikungunya virus) + Encephalitis group: and Japanese B encephalitis, and West Nile encephalitis viruses (Chapter 74). = Rare: Sindbis, Crimean Congo hemorrhagic fever, Ganjam, Vellore, Chandipura, Bhanja, Umbre, Sathuperi, Chittoor, Minnal, Venkatapuram, Dhori, Kaisodi and sandfly fever viruses are among the rare arboviruses found in India, with limited geographical distribution. Arboviruses which are prevalentin other parts ofthe World, but notin India are not discussed, but only en! 34, + ted in Table 1, except for Zika virus and yellow fever virus. Zika virus: It causes fever, arthralgia and congenital infection; has recently caused an explosive epidemic in Brazil in 2015. It is discussed in this Chapter 79 Yellow fever virus: It is endemic in West Africa and central South America. It infects liver, causes hepatitis and jaundice and also hemorthagic fever. Because of its vaccination importance for international travelers, ithas been discussed in this book (Chapter 48). eimai Arboviral infections a a Antibody detection: ELISA (IgM and IgG specific) and immunochromatographic test (ICT) Virus Isolation: > Mosquito inoculation [adult or larval stage of Toxorhynchites (best), A. aegypti and A. albopictus] » Mosquito cell lines, such as 6/36 and AP61 > Mammalian cell lines (such as Vero and LLC-MK2 cell lines)—teast sensitive > Suckling mice (intracerebral inoculation). Detection of antig > In blood, e.g. dengue virus specific NS1 (nonstructural antigen 1) by ELISA and ICT > In fixed tissues by immunohistochemistry or direct-F. Molecular methods: RT-PCR and Real time RT-PCR. DENGUE Dengue virus (DENV) is the most common arbo\ in us found India. It belongs to family Flaviviridae. Itis an enveloped virus, containing ssRNA. ° * It is named after the Swahili word “dinga” meaning fastidious or careful, which would describe the gait of a person suffering from the bone pain of dengue fever Ithas four serotypes (DEN-| to DEN-4). Recently, the fifth serotype (DEN-5) was discovered in 2013 from Bangkok. Vector Act alb ° -des aegypti is the principal vector followed by Aedes bopictus. They bite during the day time. A. aegypti is a nervous feeder (so, it bites repeatedly to more than one person to complete a blood meal) and resides in domestic places, hence is the most efficient vector Scanned with CamScannerCHAPTER 34 © Viral Hemorrhagic Fever Aedes albopictus is found in peripheral urban areas. It is an aggressive and concordant feeder, ie. can complete its blood mealin one go; henceislessefficientin transmission Aedes becomes infective only when it feeds on viremic patients (generally from a day before to the end of the febrile period, ie. 5 days) Extrinsic incubation period of 8-10 days is needed before Aedes to become infective. However, once infected, it remains infective for life Aedes can pass the dengue virus to its offsprings by transovarial transmission Transmission cycle: Man and Aedes are the principal reservoirs. Transmission cycle of four serotypes do not involve other animals; in contrast the fifth serotype follows the sylvatic cycle, Pathogenesis Primary dengue infection occurs when apersonisinfected with dengue virus for the first time with any one serotype. Months to years later, a more severe form of dengue illness may appear (called secondary dengue infection) due to infection with another second serotype which is different from the first serotype causing primary infection. ‘Antibody Response Against Dengue Virus Infection with dengue virus induces the production of both neutralizing and non-neutralizing antibodies. © Theneutralizing antibodies are protective in nature. Such antibodies are produced against the infective serotype (which last lifelong) as well as against other serotypes (which last for some time). Hence, protection to infective serotype stays lifelong but cross protection to other serotypes diminishes over few months The non-neutralizing antibodies last lifelong and are heterotypic in nature; ie. they are produced against other serotypes but not against the infective serotype » Such antibodies produced following the first serotype infection, can bind to a second serotype during secondary dengue infection; but instead of neutralizing the second serotype, it protects it from host immune system by inhibiting the bystander 8 cell activation, against the second serotype ADE: The above phenomena is called antibody dependent enhancement (ADE). Non-neutralizing antibodies promote recruitment of mononuclear cells. followed by release of cytokines which explains the reason behind the severity of secondary dengue infection. ‘Among all the serotypes combinations, ADE is remarkably observed when serotype 1 infection is followed by serotype 2, which also claims o be the most severe form of dengue infection. Clinical Classifications The Traditional (1997) WHO Classification This classification divides dengue into three clinical stages: 1. Dengue fever (DF): Its characterized by: = Abrupt onset of high fever (also called biphasic fever, break bone fever or saddle back fever) Maculopapular rashes over the chest and upper limbs Severe frontal headache Muscle and joint pains Lymphadenopathy Retro-orbital pain Loss of appetite, nausea and vomiting Dengue hemorrhagic fever (DHE): It is characte by: = High-grade continuous fever = Hepatomegaly = Thrombocytopenia (platelet count < 1 Lakh/mm*) Raised hematocrit (packed cell volume) by 20% Evidence of hemorrhages which can be detected by: + Positive tourniquet test (>20 petechial spots per square inch area in cubital fossa + Spontaneous bleeding from skin, nose, mouth and gums. 3, Dengue shock syndrome (DSS): Here, all the above criteria of DHF are present, and inaddition manifestations of shock are present, such as: Rapid and weak pulse = Narrow pulse pressure (<20 mm Hg) or hypotension Presence of cold and clammy skin. = Restlessness. 2009 WHO Classification ‘This is the most recently described classification by WHO which grades dengue into two stages based on the severity of infection (Fig. 34.1): 1. Dengue with or without warning signs 2. Severe dengue. Factors Determining the Outcome + Infecting serotype: Type 2 than other serotypes Sequence of infection: Serotype 1 followed by serotype 2 seems to be more dangerous and can develop into dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS) more often than others Age: Though all age groups are affected equally, children, less than 12 years are more prone to develop DHF and Dss. s apparently more dangerous Dengue during Pregnancy Perinatal transmission of dengue infection can occur. Peripartum maternal infection may lead to symptomati infection in the newborn, who may present with fever, thrombocytopenia, ascites or pleural effusions; typically during the first week of life. Global Scenario Dengue is endemic in more than 100 countries with 2.5 jon people at risk, % Tropical countries of Southeast Asia and Western pacific are at highest risk Scanned with CamScannerSECTION 4 @ Bloodstream and Cardiovascular System Infections DENGUE + WARNING SIGNS CRITERIA FOR DENGUE ¢ WARNING SIGNS. Probable dengue Warning signs” Live intravel to dengue endemic area Fever and two of the following criteria: + Nausea, vomiting + Persistent vomiting ‘ Abdominal pain or tondernoss + Clinical fuid accumulation ‘SEVERE DENGUE 4. Severe plasma leakage 2. Severe hemormage 43, Severe organ impairment CRITERIA FOR SEVERE DENGUE 1. Severe plasma leakage leading to: + Shock (Dengue shock syndrome) + Fluid accumulation with i een eee tp a ee ee a ae pte a ee aaah Se re eee a ieee Lc ey een z es pein ore a acerca seequrngsezczonanon | Lng ASPALT 0 fn equa erctmezton | CNS. npled conc Fig. 34.1: Dengue case classification based on the severity (WHO 2009). Abbreviations: HT, hematocrit DSS, dengue shock syndrome; AST, aspartate aminotransferase: ALT, alanine aminotransferase; CNS, central nervous system. About 50 million of dengue cases occur every year worldwide, out of which 5 lakh cases (mostly children) proceed to DHF. Situation in India Disease is prevalent throughout India in most of the urban. cities/towns affecting almost 31 states/Union territories. % Last decade: Every year >1 Lakh cases of dengue with >200 deaths occur in India. Maximum cases have been reported (in descending order) from West Bengal, Tamil ‘Nadu, Punjab, Kerala, Delhi, Karnataka, and Maharashtra % In2019: >1.37 lakh cases were reported with >130 deaths; ‘maximum were from Karnataka and Gujarat All four dengue serotypes have been isolated from India. Serotype prevalence varies between seasons and places, but DEN-1 and DEN-2 are widespread. DEN-5 has not been reported yet. Laboratory Diagnosis ‘The outline of laboratory diagnosis of dengue is similar to that of other arboviruses as described earlier. NS1 Antigen Detection ELISA and ICT formats are available for detecting NS1 antigen in serum. They gained recent popularity because of the early detection of the infection. + NSI antigen becomes detectable from day 1 of feverand remains positive up to 18 days * Highly specific: It differentiates between flaviviruses. It can also be specific to different dengue serotypes. Antibody Detection + In primary infection: Antibody response is slow and of, low titer. IgM appears first after 5 days of fever and dis- appears within 90 days. IgG is detectable at low titer in 14-21 days of illness, and then it slowly increases Insecondary infection: IgG antibody titers rise rapidly. IgG is often cross reactive with many flaviviruses and may give false positive result after recent infection or vaccination with yellow fever virus or JE. In contrast, IgM titer is significantly low and may be undetectable + In past infection: Low levels of IgG remain detectable for over 60 years and in the absence of symptoms, is a useful indicator of past infection 4 MAC-ELISA (IgM antibody capture ELISA): his is the recommended serological testing in India. Kits are supplied by NIV, Pune ® Principle (Fig. 12.78, Chapter 12): It is a double sandwich ELISA; which captures human IgM antibodies on a microtiter plate using anti-human- IgM antibody followed by the addition of dengue virus four serotypes specific envelope protein antigens (this step makes the test specific) . There is a signal enhancement due to use of avidin-biotin complex (ABC) which makes the test more sensitive Cross-reactivity with other flaviviruses is a limitation ofthis test. Neutralization tests such as plaque reduction test, and microneutralization tests are available. ‘They are cumbersome; but are most specific serologic tests. Rapid Diagnostic Tests (ROT) for Dengue Rapid diagnostic tests (e.g. ICT) for dengue IgM antibodies, or NS1 antigen are available, but have poor sensitivity and, specificity. Government of India had passed an order in 2016, that a positive ROT for dengue NSI or IgM should be considered as probable diagnosis; must be confirmed by ELISA. Scanned with CamScannerCHAPTER 34 © Viral Hemorrhagic Fever Virus Isolation Dengue virus can be detected in blood from -1 to +5 days of onset of symptoms. Virus isolation can be done by inoculation into mosquito cell line (such as C6/36 and AP61) or in mouse. It is available for research purpose and in reference centers. Molecular Method % Detection of specific genes of viral RNA (3'-UTR region) by real time RT-PCR: = Itis the most sensitive (80-90%) and specific assay (95%), can be used for detection of serotypes and quantification of viral load in blood = Viral RNA can be detected in blood from -1 to +5 days of onset of symptoms = A negative PCR result is interpreted as “indetermi, nate”; which has to be sent for serological confirma- Contd, Itisavailable as lyophilized form; reconstituted with normal saline Contraindications: () Allergic reactions to vaccine, (i) Immunodeficient individuals (e.g. HIV), (i) Pregnant and breastfeeding women Efficacy against hospitalized dengue illness was found around 80% WHO recommends to start this vaccine in high burden countries (seroprevalence>70%) WHO also recommends Dengvaxia be used only in people previously infected with dengue. If this vaccine is given to people who have not been previously infected with dengue, then they may be at a higher risk of developing severe dengue following subsequent DENV infection Currently, the vaccine is approved in Mexico, Philippines, Brazil, Indonesia, Thailand and Singapore. In India, it is not available yet because of its safety issues. tion after the 5th day of illness. + Genotype detection: Each serotypes of dengue virus comprises of several genotypes which can be detected by molecular typing. A total of 13 genotypes have been, detected so far; three for DENV-1, two for DENV-2, four each for DENV-3 and 4 serotypes respectively. Cima: Dengue ‘There is no specific antiviral therapy. Treatment is symptomatic and supportive such as: Replacement of plasma losses @ Correction of electrolyte and metabolic disturbances G Platelet transfusion ifneeded. CHIKUNGUNYA Chikungunya fever is a re-emerging disease characterized by acute fever with severe arthralgia. It belongs to family ‘Togaviridae, of genus Alphavirus. It is an enveloped virus, containing ssRNA. History ‘The name is derived from the Makonde word “kungunyala” meaning “that which bends up or gets folded!” in reference to the stooped posture which develops as a result of the severe joint pain that occurs during the course of illness. Prevention Vaccine: Vaccine development for dengue has been a challenge asitshould be effective against all four serotypes = After so many trials, recently a vaccine has been licensed for human use since 2015 (see the highlight box below) = Several more vaccine trials for dengue are on-going including two Indian trials—a live-attenuated vaccine (TetraVax-DV) and a tetravalent dengue subunit vaccine (DSV4). 4 Mosquito control measures (as discussed for malaria, Chapter 35). Transmission Human transmission occurs by: = Aedes mosquito, primarily Aedes aegypti which bites during day time = Rarely, by vertical transmission from mother to fetus or by blood transfusion or organ transplantation. * Transmission cyele: Chikungunya virus is maintained in the environment through—urban cycle (between human and Aedes aegypti) and sylvan/jungle cycle (between monkeys and forest species of Aedes). Clinical Manifestations % Incubation period is about 5 days (3-7 days) Acute stage: Most common symptoms are fever and severe joint pain (due to arthritis), worsened at morning Dengue Vaccine (CYD-TDV) This vaccine has been licensed for human use since 2015. @ It is a Chimeric Yellow Fever-Dengue, Live-Attenuated, Tetravalent Dengue Vaccine (CYD-TDV); commercially available as dengvaxia (developed by Sanof Pasteur) It uses live attenuated yellow fever 17D virus as vaccine vector in which the target genes of all four dengue serotypes are integrated by recombinant technique ‘Age: It is indicated for 9-45 years of age Schedule: 3 injections of 0.5 ml administered subcuta- neously at 6 month intervals Contd, = Arthritis is polyarticular, migratory and edematous (joint swelling), predominantly affecting the small joints of wrists and ankles = Other symptoms include headache, muscle pain, tenosynovitis or morbilliform skin rashes = Symptoms are often confusing with that of dengue. In general, Chikungunya is less severe, less acute and hemorthagic manifestations are rare compared to dengue (Table 34.2) Scanned with CamScannerSECTION 4 @ Bloodstream and Cardiovascular System Infections Table 34.2: Mani Fever (onset, duration) Acute, 2-4 days Gradual, S~7 days Polyarthritis Frequent, maylast Less common longer(>1month) Short duration Tenosynovitis Common None Rashes appear on Day 1-4, Day 3-7, Petechiae maculopapular or maculopapular Myalgia Possible Common Leukopenia Common Infrequent ‘Thrombocytopenia —_ infrequent Common Retro-orbital pain Rare ‘Common Hypotension and shock Possible Common Minor bleeding Rare ‘Common Hematocrit Normal Increased = Chik sign (also called brownienose appearance): Rare presentation; characterized by hyperpigmentation over centrofacial area; occurs due to increased intraepidermal melanin retention triggered by the chikungunya virus. Most patients recover within a week, except for the joint pain (lasts for months). ® Chronic stage (10-15%): Most patients recover within a week, except for the joint pain (lasts for months; rarely up toa year) ® High-risk group: This group includes newborns, older adults (265 years), and persons with underlying hypertension, diabetes, or heart disease. Epidemiology (Chikungunya virus was first reported in Africa (Tanzania, 1952), was subsequently introduced into Asia and had caused several outbreaks in various African and Southeast Asian countries (Bangkok and India) India (past): Several outbreaks were reported during 1963-1973; e.g. Kolkata in 1963 and South India in 1964 (Puducherry, Chennai-Vellore region) and Barsi in Maharashtra in 1973 % Since then, itwas clinically quiescent and no outbreaks were reported between 1973-2005 from most parts of the world, except for the few sporadic cases, which occurred in various places of the world including India, (Maharashtra) # Re-emergence (Reunion Outbreak): In 2005, Chikungu- nya re-emerged in Reunion Island of Indian Ocean and affected 2,58,000 people (almost one-third of country’s population) Reasons for Re-emergence Re-emergence in 2005 was believed to be due to a novel ‘mutation in the virus and a change in vector. @ New mutation (E1-A226V): Chikungunya virus ‘underwent an important mutation. Alanine in the 226 position of E1 glycoprotein gene is replaced by valine Contd. Contd, New vector (Aedes albopictus): This mutation led to a shift of vector preference. Mutated virus was found to be 100 times more infective to A. albopictus than to A.aegypti % Spread: Following the re-emergence, it has been associated with several outbreaks in India, other Southeast Asian and African countries and has also spread to some areas of America and Europe + The most recent epidemic had occurred in Colombia during 2014-15; which witnessed 82,977 clinically confirmed cases by end of 2014 % India (at present): Chikungunya is endemic in several states = States: Karnataka, Tamil Nadu, Andhra Pradesh and West Bengal have reported higher number of cases = 1n2019, nearly 65,217 suspected and 9,477 confirmed cases were reported = Karnataka accounted for the maximum number of cases followed by Maharashtra. Laboratory Diagnosis Laboratory diagnosis of chikungunya is similar to that of other arboviruses as described before. % Viral isolation in mosquito cell lines (takes 1-2 weeks) is useful for early diagnosis (0-7 days), but available only in reference centers Serum antibody detection: [gM appears after 4 days of infection and lasts for 3 months; IgG appears late (after 2 weeks) and lasts for years. So, detection of IgM or @ fourfold rise in IgG titer is more significant = MAC (IgM Antibody Capture) ELISA (using virus lysate) is the best format available showing excellent sensitivity (95%) and specificity (98%) with only litte cross reactivity with other alphaviruses and dengue. In India, MAC ELISA kits are supplied by National Institute of Virology (NIV), Pune ® Several other rapid tests (e.g. I antigens) are also available. Molecular method: Reverse-transcriptase PCRhas been developed to detect specific gene (e.g. nsP1, nsP4) in blood Hematological finding: Such as leukopenia with lymphocyte predominance, thrombocytopenia (rare), elevated ESR and C-reactive protein. GUT chitungunya Treatment of chikungunya is only by supportive measures; no specific antiviral drugs are available. Vaccine is also not available, although vaccine trials are on going. CT using envelope KYASANUR FOREST DISEASE Kyasanur Forest disease virus was identified in 1957 from monkeys from the Kyasanur Forest in Shimoga district of Scanned with CamScanner 4CHAPTER 34 ® Viral Hemorrhagic Fever Karnataka, India. It belongs to the family Flaviviridae. It is, an enveloped virus, containing ssRNA. Epidemiology ® Vector: Hard ticks (Haemaphysalis spinigera) are the vectors of KFD virus Hosts: Monkeys, rodents and squirrels are common hosts which maintain the virus through animal-tick cycles. Monkeys are the amplifier hosts, where the virus multiplies exponentially ‘Seasonality: KFD is increasingly reported in dry months (November to June) which coincides with human activity in forest * Situation in India: KFD is currently endemic in five districts of Karnataka-Shimoga, North Kannada, South Kannada, Chikkamagaluru and Udupi = Largest outbreak had occurred in 1983-84, which has witnessed 2,167 cases with 69 deaths. Currently only focal cases occur at a rate of 100-500 cases per year = There is a declining trend of incidence after the initiation of vaccine in 1999, except for the outbreak that occurred in 2013, which witnessed 215 suspects with 61 confirmed cases. ° Clinical Manifestation in Humans % Incubation period varies from 3-8 days + First stage (hemorrhagic fever): It starts as acute high fever with malaise and frontal headaches, followed by hemorrhagic symptoms, such as bleeding from the nasal cavity, throat, and gums, as well as gastrointestinal bleeding % Second stage in the form of meningoencephalitis may occur 7-21 days after the first stage Laboratory Diagnosis Diagnosis is made by virus isolation from blood or by IgM antibody detection by ELISA. ® Recently, nested RT-PCR and real time RT-PCR have been developed detecting viral RNA (NS-5 non-coding region) in serum samples and can provide early, rapid and accurate diagnosis of the infection + Non-specific findings such as leukopenia, thrombo- cytopenia and decreased hematocrit, albuminuria and abnormal CSF are found in second stage. KD. Treatment of KFD is only by supportive measures; no specific antiviral drugs are available. Killed KFD Vaccine A formalin-inactivated chick embryo vaccine has been developed for KFD in the Haffkine institute, Mumbai. Schedule: Two-doses at interval of 2 months, followed by booster doses at 6-9 months and then every 5 years ‘ Target area: KFD vaccine is recommended in endemic areas of Karnataka (villages within 5 km of endemic foci). Cee Aa ee ie ad Viral hemorrhagic fevers can also be caused by Filoviruses (e.g. Ebola and Marburg viruses) and rodent-borne viruses such as Hantaviruses and Arenaviruses. FILOVIRUS INFECTIONS Family Filoviridae contains two antigenically distinct genera—Ebola virus and Marburg virus; both cause African hemorrhagic fever. A third genus has recently been described, Cuevavirus. % Morphology: They are pleomorphic, mostly appear as Jong filamentous threads, ranging from 80-1000 nm, the average size being 665 nm (Marburg) to 805 nm (Ebola) % Highly fatal: A great matter of concern is, ofall the viral hemorrhagic fevers, Marburgand Ebola viruses have the highest mortality rates (25-90%). Ebola Virus Disease Ebola virus has become a global threat, because of its explosive outbreak in 2014; which was declared by WHO, as a public health emergency of international concern. History Ebola virus disease in humans appeared first in 1976 in two simultaneous African outbreaks occurring in Sudan, and Democratic Republic of Congo. ‘The latter outbreak occurred in a village near the Ebola River, from which the virus takes its name. Species Ebola virus has six stable subtypes or species (Zaire, Bundibugyo, Sudan, Tat Forest, Reston and Bombali); all differ from each other by up to 40% of their nucleotide sequences. + Species of epidemiologicalimportanceare Ebola, Sudan, Tat Forest, and Bundibugyo viruses can cause disease in humans, but Reston virus causes disease in nonhuman primates, but not in people. Bombali virus was recently identified in bats % The virus that had caused an explosive outbreak in Democratic Republic of Congo and the 2014 West African outbreak belongs to the Zaire species. Geographical Distribution Since its discovery, Ebola virus has caused several outbreaks in Various African countries. % DRCoutbreak: Democratic Republic of the Congo (DRC) continues to report Ebola outbreaks in recent years—11 outbreaks reported so far; the most recent being in June 2020 Scanned with CamScannerEa SECTION 4 © Bloodstream and Cardiovascular System Infections ——£—£_=&{&;=—a=«a«~C___————_ % India: There is no confirmed case documented yet. West African Epidemic (2014-16) ‘The largest outbreak occurred in 2014-16; reported 28,616 cases with 11,310 deaths (40% mortality). @ Three primary countries affected were—Guinea, Liberia and Sierra Leone However few cases have also been reported from several other countries. Reservoir ‘The reservoir hosts for Ebola viruses are unknown, but are suspected to be infected animals, such as a fruit bat or primates (apes and monkeys). Transmission In every outbreak, Ebola virus is introduced to human population through close contact with the blood, secretions, organs or other body fluids of infected animals such as chimpanzees, gorillas, fruit bats or monkeys. Human-to-human transmission: Once introduced to humans, Ebola virus spreads among people via direct contact (through broken skin or mucous membranes of eyes, nose, or mouth) with: = Blood, secretions, organs or other bodily fluids of infected people = Infected surfaces and materials (e.g. bedding, clothing, syringes, etc.) + Health-care workers and close contacts/family members of infected individuals are at greater risk of contracting the infection Ebola virus can stay in semen for up to 3 months, although sexual transmission has not been reported yet Clinical Manifestations + Incubation period is about 2-12 days Common symptoms include fever, headache, muscle pain and sore throat, followed by: = Abdominal pain, vomiting and severe watery diarrhea = Diffuse erythematous maculopapular rash, petechiae, ecchymosis/bruising, often leading to shock and death. + Mortality: The average case fatality rate is around 50%; vary from 25 to 90% between outbreaks. Laboratory Diagnosis + Serum antibody detection: = ELISA detects both IgM and IgG separately by using recombinant nucleoprotein (NP) and glycoprotein (GP) antigens = IgM appears after seven days of symptoms and lasts for3-6months. IgG appears after 2 weeks and persists for 3-5 years or more = Other antibody detection fluorescence test and assay. + Serum antigen is detected by capture ELISA. The target proteins are NP, VP40, and GP. Immunohistochemical staining and histopathology can also be used to localize Ebola viral antigen in tissue + Molecular methods such as RT-PCR and real time RT- PCR assays are useful to detect specific RNA such as NP and GP gene. Virus is detectable after 3 days of onset of fever and remains positive for 2-3 weeks * Electron microscopy of the specimen shows typical filamentous viruses (Fig. 34.2) + Virusisolation in Vero cell line: Processing the specimen should be carried out in biosafety level-4 cabinets as there is a great risk of laboratory spread of the virus. ETT _Ebola virus disease, Supportive care such as rehydration and symptomatic treatment improves survival. No proven treatment or vaccine is available yet. assays include immuno- tibody-phage indicator Prevention (General Measures) People who may be exposed to patients suspected with Ebola should follow the following step: + Practice proper infection control and sterilization mea- sures such as strict hand hygiene and personal protective equipment (PPE such as coverall and N95 mask) + Isolate patients with Ebola from other patients + Avoid direct or indirect contact (clothes, bedding, needles) with blood or body fluids or other secretions of suspected Ebola cases + Avoid attending funeral or wear PPE while attending funeral + Iftraveling to Ebola outbreak area, should be monitored for 21 days after returning, er 5 Fig. 34.2: Ebola virus, lamentous shaped (Electron micrograph). SSource:!D# 10815, Public Health Image Library, /Centers for Disease Controt ‘and Prevention (CDQ), Atlanta (with permission) Scanned with CamScannerCHAPTER 34 © Viral Hemorthagic Fever Vaccine % No Ebola vaccine is approved for human use yet. However, several vaccine trials are going on STRIVE trial (Sierra Leone Trial to Introduce a Vaccine against Ebola): The vaccine candidate used here is ‘:VSV-ZEBOV; which is recombinant vesicular stomatitis, virus—Zaire Ebola virus vaccine. This vaccine is being used in the ongoing 2018-2019 Ebola outbreak in DRC. Marburg Virus Disease Marburg virus disease was first reported in Germany and Yugoslavia (1967) among laboratory workers exposed to tissues of African green monkeys imported from Africa. Since then, over 450 cases have been reported in various African countries such as Kenya, South Africa, Democratic Republic of Congo, Uganda and Angola The most recent outbreak was in Angola (2005), affecting 252 people with 227 deaths (with mortality rate of 90%). RODENT BORNE VIRUS INFECTIONS Rodent-borne viruses or roboviruses are transmitted from rodents to man by contact with infected body fluids or excretions. They are maintained in nature by transmission from rodent to rodent without participation of arthropod. vectors, Major rodent-borne viruses include Hantaviruses and Arenaviruses, Hantavirus Disease Genus Hantavirus belongs to the family Bunyaviridae. % Morphology: They are spherical, enveloped viruses; contain triple-segmented, negative-sense ssRNA + Clinical manifestations: They cause two categories of manifestations = Hemorrhagic fever with renal syndrome (HFRS)—is, caused by several members of hantaviruses such as Hantaan virus, Dobrava virus, Puumala virus and Seoul virus = Hantavirus pulmonary syndrome (HPS)—Is caused by another member, Sin Nombre virus. % Epidemiology: Worldwide, about 1-2 Lakh cases of hantavirus infections occur annually = HERS due to Hantaan and Dobrava viruses occur in Asia, particularly in China, Russia, and Korea = Puumala virus causes a mild form of nephritis called nephropathia epidemica, prevalent in Scandinavia = Sin Nombre virus (causing HPS) is prevalent in America 4% Diagnosis is made by detection of viral RNA by RT-PCR ¢ Treatment: There is no specific antiviral therapy for hantaviral diseases. Only supportive symptomatic treatment is given. Arenaviruses are pleomorphic, 50-300 nm in size, enveloped with large, club-shaped peplomers and contain a segmented ssRNA (two segments). Based on geographical distribution, they are grouped into: 4 New world viruses: Examples include Junin, Machupo, Guanarito and Sabia viruses. They cause South American hemorrhagic fever 4 Old world viruses: Examples include— = Lassa viruses—cause hemorrhagic fever in Africa = Lymphocytic choriomeningitis (LCM) viruses—They primarily infect mouse; rarely cause meningitis in humans. EXPECTED QUESTIONS 1. Write essay on: 1, Sunita, a 29-year-old female came to casualty with complaints of high-grade fever, severe joint pain, back pain and myalgia. Gradually, she developed ppetechial rashes over the body. On examination, she was found to have jaundice, hepatomegaly and a low platelet count (30,000/cmm). A tourniquet test done over the cubital fossa demonstrated 25. petechial spots/square inch area. On inquiry, she told that she hhas been bitten by the mosquitoes. a. What is the clinical diagnosis and how is this disease transmitted? b. What are the typical clinical presentation and pathogenesis of this condition? _Howwill you confirm the diagnosis? Il, Write short notes on: 1, Chikungunya. Answers Lc 2d aa 2. Kyasanur Forest disease, 3. Ebola virus disease. Ill, Multiple Choice Questions (MCQs): 1. Kyasanur Forest disease is transmitted by: a b. Louse © Tick d. Mosquito 2. In dengue infection, earliest detectable number of petechial spots per square inch in cubital fossa should be: a 95 b. >10 © 315 4. 320 3. Antibody dependent enhancement (ADE) is observed with: a. Dengue hemorrhagic fever b. Japanese encephalitis Yellow fever dd. Chikungunya fever Scanned with CamScanner