New insights on the bleeding disorders in CCHF

Identification of the crucial parameters regarding the efficacy of ribavirin therapy in Crimean-Congo haemorrhagic fever (CCHF) patients: a systematic review and meta-analysis

OBJECTIVES

Recently, ribavirin has been suggested as a therapeutic approach in Crimean-Congo haemorrhagic fever (CCHF) patients; however, there are controversial findings about its efficacy. In the current study, a meta-analysis was systematically performed to assess the effectiveness of ribavirin administration regarding CCHF patient survival and to explore the most important influential parameters for its efficacy.

METHODS

All of the outcomes of the clinically studied CCHF patients who were treated with ribavirin were included in the meta-analysis.

RESULTS

Overall, 24 studies met our criteria. Although the studies did not have high quality there was no heterogeneity and publication bias across studies. The results indicated that the administration of ribavirin to CCHF patients significantly decreased the mortality rate (by 1.7-fold) compared with those who did not receive this medication. Furthermore, it was found that the prescription of ribavirin in the initial phase of disease was more effective, and a delay in the start of treatment resulted in a 1.6-fold increase in mortality rate. In addition, interventional therapy resulted in an ∼2.3-fold reduction in the mortality rate of those who received ribavirin along with corticosteroids compared with those who were treated with ribavirin monotherapy.

CONCLUSIONS

This meta-analysis reveals that ribavirin should be considered as a crucial antiviral drug in the therapeutic approach used for CCHF patients, especially in early phases of the disease. Additionally, it seems that the administration of corticosteroids alongside ribavirin can play an effective role in alleviation of the disease status, particularly in haemorrhagic phases.

Ribavirin is not effective against Crimean-Congo hemorrhagic fever: observations from the Turkish experience

Crimean–Congo hemorrhagic fever (CCHF) is a viral infection associated with a high mortality rate. Ribavirin is the only drug used in the treatment of this disease. Studies investigating the effectiveness of ribavirin in CCHF have been retrospective and to date have included only a small number of cases. In recent years, due to climate changes, the number of cases of CCHF in Turkey has increased, and experience in the treatment of CCHF has improved. Several studies have evaluated the efficacy of ribavirin in Turkey, including one randomized controlled trial and two studies with a large number of cases. In these studies, ribavirin therapy was not shown to decrease mortality rates; the mortality rate was 2–9% in patients treated with ribavirin and 5.6–11% in those who were not treated with this drug. These findings suggest that patients with CCHF should be followed with supportive care only until randomized controlled trials with larger groups have been conducted.

Serum nitric oxide levels in patients with Crimean-Congo haemorrhagic fever

Crimean-Congo haemorrhagic fever (CCHF) is an acute disease affecting multiple organ systems and is characterized by fever and haemorrhages. The pathogenesis of CCHF has not been well described. Nitric oxide (NO) is an important regulator of a number of different biological processes and can participate in antimicrobial defence. In this study, we measured the level of NO in the serum of patients with CCHF and healthy controls to define the possible role of NO in the control of infection. Sixty-two patients with CCHF and 31 controls were included in the study. NO levels in CCHF patients and the control group were found to be a mean of 40.49 microM (standard deviation (SD) 23.00) and 14.89 microM (SD 7.94), respectively. NO levels were significantly higher in CCHF patients with respect to controls (p < 0.001). NO levels in the patients with non-fatal CCHF and fatal CCHF were compared and found to be a mean of 43.57 microM (SD 22.70) and 26.23 microM (SD 19.43), respectively; this difference was statistically significant (p=0.009). In conclusion, elevated levels of NO may play a protective role in CCHF.

High-dose methylprednisolone in children with Crimean-Congo haemorrhagic fever

Treatment options for Crimean-Congo haemorrhagic fever (CCHF) are limited and based on general supportive managements. Thrombocytopenia is the major risk factor of CCHF. We report our experience with high-dose methylprednisolone (HDMP). This study included five patients with CCHF. Patients were given HDMP if there were findings compatible with virus-associated haemophagocytic syndrome and the effects of HDMP were evaluated. Following this, HDMP fever subsided and platelet counts increased within 24 hours. Leukocyte counts began to increase and visceral bleedings were improved. HDMP treatment was discontinued within approximately five days. After HDMP, only one patient required blood products. HDMP is effective in CCHF, especially on fever and platelet counts. Dependency on blood products was decreased. Further controlled randomized studies with large series are needed in order to analyse the timing and duration of HDMP treatment and its effect on outcome.

Initial high rate of misdiagnosis in Crimean Congo haemorrhagic fever patients in an endemic region of Turkey

Crimean Congo haemorrhagic fever (CCHF) has been an emerging tick-borne infection in some parts of Turkey since 2002, with a number of fatalities. Many of the initial non-specific symptoms of CCHF can mimic other common infections. Additionally, the seasonal pattern of the epidemic, and the waning attention of healthcare workers to the yearly index cases caused some delays in appropriate patient care and treatment. Between March 2004 and August 2008, 140 confirmed adult cases were evaluated retrospectively for initial diagnosis and treatment delays. This study clearly demonstrated that there are particular delays (4·8 days) in the referral system to initiate effective antiviral treatment in the tertiary-care centre which significantly affect fatality rates (P>0·05). A large number of patients (n=95, 68%) received an initial misdiagnosis of various infections other than CCHF. In conclusion, continuous medical education regarding CCHF in the epidemic area is essential in order to achieve a better survival rate from this deadly infection.

Crimean-Congo haemorrhagic fever among children in north-eastern Turkey

AIM

To analyse the epidemiological and clinical features of children with Crimean-Congo haemorrhagic fever (CCHF) in north-eastern Turkey.

METHODS

A retrospective study of demographic features and physical and laboratory findings in 21 children with CCHF is described. Clinical course, treatment modalities and outcome were analysed.

RESULTS

Most patients were admitted in June and July 2008; most were from the Gumushane and Kelkit valleys and half of them lived in rural areas. Mean (SD) age was 10.3 (3.9) years and the disease was more common in males (71.4%). Approximately 70% had a history of tick bite. The main symptoms were fever (17, 80.9%), nausea (11, 52.3%), malaise (10, 47.6%) and headache (7, 33.3%). At initial examination, approximately 70% of patients had leukopenia and 65% had thrombocytopenia. Anaemia developed during follow-up in six patients. Liver involvement was seen in 12 patients and one patient had acute tubular necrosis. Six patients had haemophagocytosis. Patients were hospitalised for a median 8 days (range 3-22) and nine patients had bleeding from various sites approximately 3-5 days after hospitalisation. Subcutaneous haematoma (6), especially epistaxis and at venepuncture sites (6) were the most common sites of bleeding. Pulmonary haemorrhage developed in two patients and they required ventilatory support. Overall mortality related to CCHF was 4.7% (one patient).

CONCLUSION

Early diagnosis of CCHF and early referral to specialised centres are important for outcome. Exceptional epidemics may be seen in future owing to ecological and environmental changes.

Crimean Congo hemorrhagic fever and diffuse alveolar haemorrhage

Although the pathology of Crimean Congo haemorrhagic fever (CCHF) is mainly related to a haemorrhagic process with secondary cytokine storm, there have been no published reports of this fatal disease being a cause of diffuse alveolar haemorrhage (DAH). There are many aetiological factors emphasizing the direct role of endothelial injury on DAH. We present the case of a young adult Turkish man with diffuse bilateral alveolar haemorrhage without an episode of gross haemoptysis caused by the CCHF virus. Successful clinical results and a rapid clinical and radiological clearance were obtained within few days after starting daily oral ribavirin treatment. This fatal infection should be considered to exist in any patient presenting with DAH, and should rapidly be treated with ribavirin. Another very important factor which should always be borne in mind is the contagious character of the CCHF virus. It is one of the most dangerous microorganisms transmitted from person to person. Even the bronchoscopes contaminated with patient blood carry a high risk for nosocomial spread to medical staff and other patients.