What infections may cause hemorrhage, particularly in patients with a history of travel to endemic areas or exposure to infected individuals?

Infections That Cause Hemorrhage

Viral hemorrhagic fevers (VHF) are the primary infections that cause hemorrhage in travelers, particularly Ebola, Marburg, Crimean-Congo hemorrhagic fever, and Lassa fever, which require immediate isolation and specialized handling. 1

Critical High-Risk Hemorrhagic Infections

Viral Hemorrhagic Fevers (VHF)

• Ebola hemorrhagic fever, Marburg hemorrhagic fever, Crimean-Congo hemorrhagic fever (CCHF), and Lassa fever are the four most dangerous hemorrhagic infections requiring statutory isolation and specialized laboratory handling procedures. 1
• These infections are characterized by fever, hemorrhagic symptoms, and multiple organ failure with high mortality rates. 2
• VHF should be assessed in all patients with relevant travel history to endemic areas in Africa or eastern Europe, particularly with fever and bleeding manifestations. 3
• Immediate contact with regional infectious disease centers is mandatory if VHF is suspected, as these are biosafety level-4 pathogens. 3, 2

Geographic Distribution of Hemorrhagic Infections

• Rift Valley fever occurs in southern Africa, transmitted by mosquitoes, with an incubation period of 3-4 days and can progress to severe hemorrhagic state with liver and kidney involvement. 4
• Marburg virus disease has been documented in travelers to Zimbabwe/Rhodesia, with 7-day incubation, sudden fever, maculopapular petechial rash on day 5, and potentially fatal hemorrhagic state. 4
• Crimean-Congo hemorrhagic fever is widespread in South Africa, transmitted by Hyalomma tick bites or contact with infected animal tissues or patients. 4
• Dengue hemorrhagic fever occurs worldwide in tropical and subtropical regions and is the most common hemorrhagic infection in returning travelers. 5, 6

Non-Viral Hemorrhagic Infections

Bacterial Causes

• Amoebic dysentery (Entamoeba histolytica) causes bloody diarrhea with more indolent onset compared to bacterial dysentery. 1
• Bacterial dysentery from Shigella, Salmonella, and Campylobacter can present with bloody diarrhea and fever, suggesting invasive disease. 1
• Melioidosis (Burkholderia pseudomallei) from South East Asia can present with septicemia and requires laboratory notification for safe handling. 1

Immediate Diagnostic Approach for Hemorrhagic Presentations

Essential Travel History Details

• Obtain exact countries visited, specific dates of travel, rural vs. urban exposure, contact with animals or their carcasses, tick bites, and contact with ill individuals. 3, 4
• Determine onset of symptoms in relation to travel dates to calculate incubation period. 3
• Document activities undertaken including game park visits, cave exploration, or contact with bats or rodents. 1, 6

Critical Initial Investigations

• Three thick and thin blood films over 72 hours to exclude malaria, which can present with hemorrhagic complications. 3, 7
• Complete blood count looking specifically for thrombocytopenia (suggests dengue, malaria, or VHF) and leucopenia. 3, 8
• Liver and renal function tests to assess organ involvement characteristic of hemorrhagic fevers. 3
• Urinalysis for proteinuria, hematuria, or hemoglobinuria. 3

Infection Control Measures

• Immediate source isolation (side room, gloves, apron, mask, goggles) is required for suspected VHF cases. 1
• Alert laboratory staff immediately when VHF, brucellosis, Q fever, or melioidosis is suspected, as these pose occupational hazards requiring upgraded infection control procedures. 1
• Notify local health protection units for suspected VHF, plague, or other notifiable hemorrhagic infections as statutorily required. 1

Common Pitfalls to Avoid

• Never assume simple viral illness without excluding VHF in patients with fever and hemorrhage from endemic areas, as person-to-person transmission through body fluids is well-documented. 9
• Do not delay isolation while awaiting test results if VHF is in the differential diagnosis. 1
• Avoid aspirin in dengue hemorrhagic fever due to increased bleeding risk; provide supportive care with close platelet and hematocrit monitoring. 3
• Do not process laboratory samples under standard conditions without warning staff about potential VHF or other high-risk pathogens. 1