Page 108 - Journal of Special Operations Medicine - Winter 2015

An Ongoing Series

Crimean-Congo Hemorrhagic Fever

Mark W. Burnett, MD

ABSTRACT

In mid-September 2009, a 22-year-old critically ill Sol- CCHF is caused by a virus, which bears the same name.
dier was medically evacuated from a treatment facility This virus is a member of the Nairovirus genus of the
in southern Afghanistan to Landstuhl Regional Medical Bunyaviridae family of viruses. Its unusual name is
Center in Germany. Despite the efforts of the team at telling regarding its distribution throughout much of
Landstuhl, this patient died and became the US military’s southeastern Europe, the Middle East, Central Asia, and
first known victim of Crimean-Congo hemorrhagic fe- Africa (Figure 1). It was originally recognized during an
ver (CCHF). CCHF is caused by a virus, which bears the outbreak in the Crimean Peninsula during the Second
same name. Because a vaccine is lacking, as well as an World War, and was named Crimean hemorrhagic fever.
effective antiviral treatment, prevention is key. After it was discovered to be the cause of a hemorrhagic
fever in the Congo in 1969, the name of the illness was
Keywords: Crimean­Congo hemorrhagic fever; infectious modified to its present form.
disease
The CCHF virus is found in ixodid (hard) ticks of the re-
gion, especially those of the genus Hyalomma. Infected
ticks can transmit the virus to humans directly through
Introduction
bites or by being crushed. Domestic and wild animals can
In mid-September 2009, a 22-year-old critically ill Sol- serve as “amplifying hosts” for the virus, which can infect
dier was medically evacuated from a treatment facil- humans who come into contact with the infected animal’s
ity outside of Kandahar in southern Afghanistan to blood or tissues. Domesticated cattle, sheep, and goats are
Landstuhl Regional Medical Center in Germany. He among the animals that can become infected (Figure 2). A
had initially sought care less than a week earlier with recent seroprevalence study in western Afghanistan, fol-
a several-day history of hematemesis, fever, abdominal lowing an outbreak of CCHF there, revealed that 75%
pain, and diarrhea, and had been prescribed a course of of 132 domestic animals showed evidence of a past infec-
oral antibiotics. By the time he arrived in Germany, he tion of the disease. Animals may be infected with the virus
was intubated and was in multisystem organ failure with through tick bites, but only humans show signs and symp-
extensive edema of his extremities and widespread pete- toms of the disease. Human-to-human transmission is
chiae. A history obtained early in the course of his illness also possible following exposure to blood or body fluids.
was significant for multiple tick bites and exposure to
undercooked goat meat and blood in the week prior to Clinical Presentation
the onset of his symptoms. Given this history and these The length of incubation differs if the infection is ac-
physical examination findings, a reverse transcription quired via tick bite (usually 1–3 days) or exposure to
polymerase chain reaction (PCR) assay was performed infected blood or tissues, in which case the incubation
on a blood sample; this was done at a German facility is usually twice as long. The onset of disease is abrupt.
with expertise in tropical diseases, and a diagnosis was High fevers, vomiting, and back and joint pain are usual
made. Despite the heroic medical efforts of the team at initial symptoms. A flushed face, red eyes, and pete-
Landstuhl, which included the use of the antiviral drug chiae are also described as being common. As the illness
ribavirin given under an Investigational New Drug (IND) moves into the hemorrhagic stage, for those more se-
protocol, this patient died and became the US military’s verely affected, bleeding from the mouth, nose, and sites
first known victim of Crimean-Congo hemorrhagic fe- of blood draws and intravenous catheter insertion are
ver (CCHF). Two hospital personnel who likely came in characteristic beginning around the fourth day of the
contact with the patient’s blood were infected and were illness. Petechiae can become widespread and worsening
also treated with ribavirin; both survived. bleeding often requires transfusions. Case fatality rates

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