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Available prophylactic measures include control of mosquitoes by screening and insect repellents, particularly during early morning and late afternoon exposures A screening program at an airport for persons with fever facilitated the diagnosis of dengue and the implementation of public health measures in Taipei, Taiwan A variety of vaccines, involving attenuated or genetically modified virus, are under study including combinations of attenuated dengue strains
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Treatment
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Treatment entails the appropriate use of volume support (with Ringer s lactate the preferred agent in moderately severe shock), blood products, and pressor agents, and acetaminophen rather than nonsteroidal anti-inflammatory drugs for analgesia Activities are gradually restored during prolonged convalescences Endoscopic therapy is useful in evaluating and managing gastrointestinal hemorrhage although injection therapy with sclerosing agents is not beneficial in most dengue hemorrhagic states Monitoring platelet counts does not usefully predict clinically significant bleeding Monitoring for hemoconcentration, however, may help in anticipating the complications of dengue hemorrhagic fever or shock syndrome
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Fatalities are rare but do occur, especially during epidemic outbreaks, with occasional patients dying from fulminant hepatitis Convalescence for most patients is slow
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Centers for Disease Control and Prevention (CDC): Travelassociated dengue infections United States, 2005 MMWR Morb Mortal Wkly Rep 2006 Jun 30;55(25):700 2 [PMID: 16810147] Wilder-Smith A et al Dengue in Travelers N Engl J Med 2005 Sep 1;353(9):924 32 [PMID: 16135837] Wills BA et al Comparison of three fluid solutions for resuscitation in dengue shock syndrome N Engl J Med 2005 Sep 1;353(9):877 89 [PMID: 16135832]
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Leukopenia is characteristic and elevated transaminases are found frequently in dengue fever Thrombocytopenia, increased fibrinolysis, and hemoconcentration occur more often in the hemorrhagic form of the disease Liver function abnormalities are nearly universal The nonspecific nature of the illness mandates laboratory verification for diagnosis, usually with IgM and IgG ELISAs Virus may be recovered from the blood during the acute phase, and PCR may be diagnostic during the first few days of infection Immunohistochemistry for antigen detection in tissue samples can also be used
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3 Hantaviruses
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Hantaviruses are rodent-borne enveloped RNA bunyaviruses with several distinct serotypes These differ in rodent hosts, geographic distribution, and degree of pathogenicity for humans They cause two major clinical syndromes: hemorrhagic fever (discussed above) and the hantavirus pulmonary syndrome Each year, over 150,000 cases of these two syndromes occur globally Aerosols of virus-contaminated rodent urine and perhaps feces are thought to be the main vehicle for transmission to humans The ubiquity of hantaviruses is becoming recognized, with descriptions of infections from North and South America and additional infections from Europe and Asia The Hantaan serotype viruses cause severe hemorrhagic fever with renal syndrome and are found
Complications
Usual complications include depression, chronic fatigue, pneumonia, bone marrow failure, hepatitis, iritis, orchitis, and oophoritis Neurologic complications such as encephalitis and transverse myelitis are less often reported Dengue
CMDT 2008
Sudden onset of severe headache, aching in legs, and tachycardia Brief (1 day) remission, followed by bradycardia, hypotension, jaundice, hemorrhagic tendency Proteinuria, leukopenia, bilirubinemia, bilirubinuria Rare and potentially fatal reactions to vaccination
primarily in Korea, China, and eastern Russia The Seoul viruses produce a less severe form and are found primarily in Korea and China The Puumala and Dobrava viruses are found in Scandinavia and Europe and are associated with a milder form of the syndrome, nephropathia epidemica, which usually presents with fever, headache, gastrointestinal symptoms, and impaired renal function The Sin Nombre (Muerto Canyon, Four Corners) virus is the most common hantavirus infection in the United States and is one of the viruses responsible for the hantavirus pulmonary syndrome, seen in the southwestern United States Between 1993 and 2006, 438 cases have been reported in 32 states Outbreaks are currently being reported from Central and South America Hantavirus pulmonary syndrome (the mean incubation period for which is 18 days) begins as a nonspecific febrile illness followed by a severe increase in pulmonary vascular permeability, leading to respiratory failure, and rapid progression to a shock-like state Hematologic features include thrombocytopenia, hemoconcentration, and leukocytosis, with abnormal lymphocytes and immature myeloid cells in the peripheral smear Clinical similarities, including a propensity toward renal involvement exist between the New World hantaviruses and their Old World counterparts Diagnosis can be made serologically, with most patients having both IgM and IgG antibodies at the time of presentation; by immunohistochemical staining; or by PCR amplification of viral tissue DNA A viral load assay correlates with severity of disease among patients under intensive care Because infection is thought to occur by inhalation of rodent wastes, prevention is aimed toward eradication of rodents in houses and avoidance of exposure to rodent excreta in rural settings No treatment has been established as definitely effective for hantavirus pulmonary syndrome Intravenous ribavirin has been used with some success in hemorrhagic fever with renal syndrome, and current studies for its use in hantavirus pulmonary syndrome suggest it is not effective
Centers for Disease Control and Prevention (CDC) Hantavirus pulmonary syndrome five states, 2006 MMWR Morb Mortal Wkly Rep 2006 Jun 9;55(22):627 9 [PMID: 16760891] Khaiboullina SF et al Hantaviruses: molecular biology, evolution and pathogenesis Curr Mol Med 2005 Dec;5(8):773 90 [PMID: 16375712] Mertz GJ et al Diagnosis and treatment of new world hantavirus infections Curr Opin Infect Dis 2006 Oct;19(5):437 42 [PMID: 16940866] Vial PA et al Incubation period of hantavirus cardiopulmonary syndrome Emerg Infect Dis 2006 Aug;12(8):1271 3 [PMID: 16965713] Xiao R et al Sin Nombre viral RNA load in patients with hantavirus cardiopulmonary syndrome J Infect Dis 2006 Nov 15;194(10):1403 9 [PMID: 17054070]
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