Crimean-Congo hemorrhagic fever and pregnancy: Two cases

Journal of Microbiology and Infectious Diseases / JMID 2015; 5 (1): 29-31 doi: 10.5799/ahinjs.02.2015.01.0171 CASE REPORT Crimean-Congo hemorrhagic fever and pregnancy: Two cases Fazilet Duygu1, Ayşegül Çopur Çiçek2, Turan Kaya3 1 Abdurrahman Yurtaslan Oncology Teaching Hospital, Dept. of Infectious Diseases and Clinical Microbiology, Ankara, Turkey 2 Recep Tayyip Erdoğan University Medical School, Department of Clinical Microbiology, Rize, Turkey 3 Tokat General Hospital, Department of Infectious Diseases and Clinical Microbiology, Tokat, Turkey ABSTRACT Crimean-Congo Hemorrhagic Fever (CCHF) is a viral zoonosis, transmitted to humans by either: the Hyalomma species of ticks; or by direct contact with body fluids or tissues of infected humans or domestic animals. CCHF can result in death through clinical progression of hemorrhagic fever (1). Tokat Province in Turkey is where CCHF cases are seen at the highest rate. In this article, the cases of two pregnant women are discussed. The women applied in Tokat with a fever and were diagnosed with CCHF. Along with symptomatic treatment, thrombocyte and fresh frozen plasma replacement was performed in one of the patient’s cases. Patients were discharged with recovery. The main purpose of this article is to enlighten the progression of CCHF during pregnancy. J Microbiol Infect Dis 2015;5(1): 29-31 Key words: Crimean-Congo hemorrhagic fever, pregnancy, Tokat ÖZET Kırım-Kongo kanamalı ateşi ve gebelik: İki olgu Kırım-Kongo kanamalı ateşi (KKKA) Hyalomma türü kenelerle, enfekte insanlar ya da evcil hayvanların vücut sıvıları veya dokularıyla doğrudan temas sonucu insanlara bulaşan, kanamalı ateş tablosu ile ölüme neden olabilen viral zoonotik bir hastalıktır. Türkiye’de KKKA olguları en fazla Tokat’ta görülmektedir. Bu yazıda, Tokat’ta ateş şikâyetiyle başvuran, KKKA tanısı konan iki gebe hasta değerlendirildi. Hastaların birine semptomatik tedavi olarak trombosit süspansiyonu ve taze donmuş plazma verildi. Her iki hasta da iyileşerek taburcu edildi. Gebelik süresince KKKA gidişatının aydınlatılması amaçlandı. Anahtar kelimeler: Kırım-Kongo kanamalı ateşi, gebelik, Tokat INTRODUCTION Crimean-Congo hemorrhagic fever (CCHF) is a viral zoonosis, which may progress into fatality. The etiological agent is the CCHF virus belonging to Nairovirus family of Bunyaviridae species. It is reported that the rate of incidence of the disease, already encountered in more than 30 countries all over the world, has increased recently, especially in Asia and Europe.1,2 The clinical progression of the disease is the sudden onset of fever, headache, widespread muscle pains, fatigue, nausea, vomiting, and skin and mucosal hemorrhages of various degrees after the 3-7 day incubation period.3,4 Crimean-Congo hemorrhagic fever can be encountered in all age groups. While the disease progresses with a mortality of 5-30% in adults, the progression is milder in children.5 Mortality rate was found to be 5% in the adult CCHF patients in the region of the study. Progression of CCHF in pregnancy is not known definitely, due to an inadequate number of studies of the disease during pregnancy. We believe that discovering the progress and intra-uterine effects of CCHF during pregnancy will be helpful in casting appropriate medical treatment for pregnant patients. We aim to investigate the disease progression in pregnant women diagnosed with CCHF. Correspondence: Ayşegul Çopur Çiçek, Recep Tayyip Erdogan University Faculty of Medicine Deparment of Medical Microbiology, Rize, Turkey Email: Received: 12 September 2013, Accepted: 13 October 2014 Copyright © Journal of Microbiology and Infectious Diseases 2015, All rights reserved 30 Duygu F, et al. CCHF and Pregnancy CASE 1 A 25-year old female patient applied with complaints of high fever, loss of appetite, and nausea. The patient was in the 17th week of her pregnancy. She was dealing with livestock and had no tick contact history. In her physical examination, fever was 39.5°C with hyperemia of face, conjunctiva and oropharynx. CCHF PCR on the serum sample was tested in Refik Saydam Hygiene Center (RSHC), and reported as positive. The patient received symptomatic treatment and the thrombocyte count decreased to 17000/µl after admission to hospital. Obstetrical ultrasonography revealed no pathological finding. She was examined by a gynecology and obstetrics specialist and there was no abnormal finding. The patient was infused with 8 units of random thrombocyte, 2 units of thrombocyte apheresis, and 6 units of fresh frozen plasma. In the follow ups, microscopic and macroscopic hematuria was observed, but there was no vaginal bleeding. The patient complained of nausea during the first 3 days, and her temperature returned to normal on the Day 3. Fatigue and loss of appetite continued until she was discharged. Hyperemia in her face, conjunctiva, and oropharynx decreased in intensity and disappeared on Day 7. While the clinical progression was recovered during her follow ups, she had WBC: 7500/µl, Hb: 9.2 g/dl, and thrombocyte: 143,000/µl. She was discharged on the tenth day of her hospitalization. Patient gave birth to a healthy baby via spontaneous vaginal delivery, after which it was observed that both her physical and mental conditions were normal. CASE 2 A 22-year old female patient admitted to hospital with complaints of high fever and nausea during the 20th week of her pregnancy. She had a tick bite on her arm three days prior to experiencing symptoms. In her physical examination, fever was 39°C with mild hyperemia on her face, conjunctiva, and oropharynx. CCHF PCR in the serum sample tested positive for RSHC. In the follow ups, her fever was persisted; WBC was 3400/µl, and thrombocyte count was 60,000/µL. There were petechial rashes in her legs. Obstetrical ultrasonography findings showed no pathologic finding. Gynecology and obstetrics specialist did not suggest any additional recommendation. The patient was treated symptomatically. Blood and blood product transfusions were J Microbiol Infect Dis not required. During the follow ups, her temperature returned to normal ranges, the clinical progression became totally normal and the patient was discharged with recovery on day 10 of her hospitalization. Patient delivered a healthy baby via spontaneous vaginal birth. After delivery, it was observed that conditions were normal. DISCUSSION Tokat Province in Turkey is an endemic region for CCHF and most cases occur in this area. In 2011, two pregnant women diagnosed with CCHF were followed up in our hospital. CCHF was observed to progress more mildly in these cases. Both patients were fully recovered and discharged. During their follow ups after the discharge, their clinical and laboratory values were all within normal limits. Dizbay et al. presented a case related to clinical progression of the disease during pregnancy. They reported that the 36-week pregnant patient received ribavirin treatment, and she recover (...truncated)