What are the complications and management of Crimean Congo Hemorrhagic Fever (CCHF)?

Complications and Management of Crimean Congo Hemorrhagic Fever (CCHF)

Crimean Congo Hemorrhagic Fever (CCHF) is a potentially fatal viral infection with multiple serious complications requiring prompt supportive care, with mortality rates of 20-50% in severe cases.

Clinical Complications

Hemorrhagic Manifestations

• Bleeding diathesis with hematemesis, melena, metrorrhagia, hematuria
• Petechiae, ecchymoses, epistaxis, and oozing from gingiva and needle-puncture sites 1
• Severe hemorrhagic disease is a risk factor for death 1

Hepatorenal Complications

• Jaundice (scleral and dermal icterus)
• Hyperbilirubinemia (may persist up to 3 months after recovery) 1
• Elevated serum transaminases (may remain elevated for up to 2 months after onset) 1
• Renal insufficiency and acute kidney injury 1

Cardiovascular Complications

• Hypotension and shock (risk factors for death) 1
• Cardiovascular instability 1
• Myocardial damage and cardiac arrhythmias (can cause late deaths even weeks after apparent recovery) 1

Neurological Complications

• Coma and convulsions (risk factors for death) 1
• Neuropsychiatric changes 2

Other Complications

• Secondary bacterial infections (e.g., pneumonia) 1
• Prolonged convalescence (several weeks) 1

Diagnostic Approach

Laboratory Testing

• Virus-specific IgM and IgG antibodies by serologic assays 1
• Positive results should be confirmed with plaque reduction neutralization test due to cross-reactions with other flaviviruses 1
• Early in illness (first 3-4 days): virus isolation or RT-PCR for viral RNA detection 1
• Immunohistochemical staining of formalin-fixed specimens for viral antigen 1

Laboratory Abnormalities

• Leukopenia (first week) or leukocytosis (second week) 1
• Elevated prothrombin and partial thromboplastin times 1
• Decreased platelet count 1
• Presence of fibrin-split products 1
• Elevated D-dimer levels (may indicate thrombotic risk) 1

Management Protocol

Initial Assessment and Isolation

1. Immediate evaluation of circulatory and respiratory function with vigorous resuscitation if necessary 3
2. Isolate patient to prevent human-to-human transmission 4
3. Protect patient from further mosquito exposure during viremic period 1

Supportive Care (Cornerstone of Treatment)

• Rest, fluids, and nonsteroidal anti-inflammatory drugs or acetaminophen for fever and myalgias 1
• Avoid aspirin due to risk for hemorrhagic complications 1
• Critical care support with possible mechanical ventilation or hemodialysis for multisystem organ involvement 1

Thromboprophylaxis Management

• For patients with severe disease and high D-dimer levels (>5 mg/mL), consider therapeutic anticoagulation 1
• In patients with hemorrhagic manifestations, avoid anticoagulation due to bleeding risk
• Monitor D-dimer levels every 24-48 hours during the first 7-10 days 1

Antiviral Treatment

• Ribavirin has been used empirically with varying degrees of success 1, 5
• No FDA-approved specific antiviral treatment has demonstrated definitive benefit 1

Monitoring and Follow-up

• Regular monitoring of:
  • Complete blood count
  • Coagulation parameters (PT, PTT, fibrinogen)
  • Liver function tests
  • Renal function
  • Cardiac monitoring for arrhythmias

Prevention of Complications

Bleeding Prevention

• Avoid invasive procedures when possible
• Transfusion support for severe anemia or significant bleeding
• Factor replacement if coagulation abnormalities are present 3

Infection Prevention

• Strict isolation precautions for healthcare workers 6
• Proper personal protective equipment for all staff in contact with patient
• Careful handling of blood and body fluids

Prognosis

• Case-fatality ratio in severe disease: 20-50% 1
• Risk factors for death: hypotension, shock, renal failure, severe hemorrhagic disease, coma, and convulsions 1
• Convalescence often prolonged, lasting several weeks 1
• Late deaths can occur due to myocardial damage and cardiac arrhythmia 1

Differential Diagnosis

CCHF with jaundice must be differentiated from:

• Viral hepatitis
• Malaria
• Leptospirosis
• Rift Valley fever
• Typhoid
• Q fever
• Typhus
• Surgical, drug-induced, and toxic causes of jaundice 1

Other viral hemorrhagic fevers to consider:

• Dengue hemorrhagic fever
• Lassa fever
• Marburg and Ebola virus diseases
• Bolivian, Argentinean, and Venezuelan hemorrhagic fevers 1