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The differential diagnosis for hemorrhagic fever includes meningococcemia or other septicemias, Rocky Mountain spotted fever, dengue, typhoid fever, and malaria The likelihood of acquiring hemorrhagic fevers among travelers is low
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Certain arenaviruses (the Lassa pathogen, Junin virus in its viscerotropic phase, Machupo virus) and bunyaviruses (provisionally, the Congo-Crimean Hemorrhagic Fever and Rift Valley Fever pathogens) respond to ribavirin if it is started promptly: 30 mg/kg as loading dose, followed by 16 mg/kg every 6 hours for 4 days and then 8 mg/kg every 8 hours for 3 days The filoviruses and the flaviviruses do not respond to ribavirin Vaccines are needed for these pathogens The successful yellow fever vaccine is discussed below A live attenuated Junin vaccine is undergoing trials A formalin-inactivated vaccine against the Rift Valley Fever pathogen is in use and a live-attenuated vaccine is under development Therapeutic interventions that target the hematologic system are either ineffective or only marginally effective Future studies will target combining antivirals with immune mediators
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Dengue is due to a flavivirus transmitted by the bite of the Aedes mosquito It may be caused by one of four serotypes widely distributed between the tropics of Capricorn and Cancer An estimated 50 100 million cases of dengue fever and several hundred thousand cases of dengue hemorrhagic fever occur each year The incubation period is 3 15 days (usually 7 10 days) When the virus is introduced into susceptible populations, usually by viremic travelers, epidemic attack rates range from 50% to 70% Transmission occurred in the United States in southern Texas and nearby Mexican border towns in 1986 and 1999 In 2001, a large outbreak in Hawaii was traced to a traveler returning from French Polynesia In 2005, the first outbreak of dengue hemorrhagic fever in the United States was documented The outbreak was binational and involved more than 6000 persons in Brownsville, Texas and Matamoros, Mexico with primarily serotype 2 In addition, there were 96 travel-related dengue cases among US
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Persons with symptoms compatible with those of any hemorrhagic fever and who have traveled from a pos-
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residents in 2005 Severe epidemics of dengue hemorrhagic fever (serotype 3) occurred over the past 20 years in East Africa, Sri Lanka, and Latin America
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hemorrhagic fever or shock with concomitant bacterial infection is associated with advanced age, higher fever, gastrointestinal bleeding, renal impairment, and altered consciousness
Clinical Findings
A Symptoms and Signs
Dengue fever is usually a nonspecific, self-limited biphasic febrile illness, but its presentation may range from asymptomatic to severe hemorrhagic fever and fatal shock (dengue shock syndrome) Infection is asymptomatic in 80% of infants and children The illness is more severe and begins more suddenly in adults After an incubation period of 4 5 days, there is a sudden onset of high fever, chills, and break bone aching of the head, back, and extremities accompanied by sore throat, prostration, and malaise There may be conjunctival redness and flushing or blotching of the skin Initially, the skin appears flushed, but 3 4 days after the lysis of the fever, a maculopapular rash, which spares palms and soles, appears in over 50% of cases As the rash fades, localized clusters of petechiae on the extensor surface of the limbs become apparent Hepatitis frequently complicates dengue fever Dengue hemorrhagic fever usually affects children living in endemic areas and is most likely to occur in secondary infections with serotype 2 A few days into the illness, signs of hemorrhage such as ecchymoses, gastrointestinal bleeding, and epistaxis appear Symptoms found more often among the hemorrhagic fever subset of patients include restlessness, epistaxis, and abdominal pain A subset of patients progresses to dengue shock syndrome in which acute fever, hemorrhagic manifestations, and marked capillary leak are prominent, the latter manifesting as pleural effusions, ascites, and a tendency to develop shock Before the rash of dengue appears, the infection is difficult to distinguish from malaria, yellow fever, or influenza; the rash makes dengue far more likely Continuous abdominal pain with vomiting, a decrease in the level of consciousness, and hypothermia should raise concern about dengue shock syndrome A history of travel to a dengue-endemic area within 14 days of symptom onset is also helpful for diagnosis
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