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CASE STUDY

Study case presented by Daniele de Meneghi: UNITO_FMV, Italy; Carla Rosenfeld: UACH, Chile; Ludovina Padre: UEVORA, Portugal; Carolina Pujol: UABC, Mexico, SAPUVETNET III members of group VII.

Haemorrhagic Fever In search of the “culprit”

ANTECEDENTES

There was an outbreak of hemorrhagic leptospirosis, in a Balkan country, a year ago. The epidemiological study identified infected cattle as the probable source. This outbreak in animals was related to the floods that were caused by the heavy seasonal rains. As a precautionary measure all cattle in the area were vaccinated.

ANTECEDENTES

Therefore, the hospital has requested the collaboration of a

veterinarian (you) in assessing the situation. A child with hemorrhagic syndrome has infected other people and the doctors suspect a zoonotic disease but have ruled out leptospirosis, whereby they have requested your help in investigating the cause.

Antecedentes

A child called Pedro presented the following symptoms on May 2: chills, myalgia, cough, nausea, anorexia, vomiting, headache and backache.On May 28 he was taken to the General Practitioner at the local health centre, where he was treated with antibiotics, antipyretics and corticosteroids. On May 29, as he had not improved, Pedro was taken to a private paediatrician. He was prescribed a wide range of antibiotics and it was recommended that he should be hospitalized if he does not respond to the treatment.On May 31, he was hospitalized in the university paediatric clinic of the capital.At this time the child continues to present the same initial symptoms in addition to pain in the legs. Five days later there is massive haemorrhage, hematemesis, melena and petechiae.

The most serious symptoms included :petechiae, epistaxis and haemorrhage.

Discuss and answer (1)FAÇA UMA ANAMNESISincluding:

Individual/time/placeEnvironemental factors

More background (1)The child lives in a cattle breeding

agricultural region in a Balkan country.

More background (1) The area has an altitude of 500 to 1500 m above sea level

with warm climate, fragmented settlements and alternating forest and cultivated lands. The area is mainly used for family farm production (80%), with approximately 2500 inhabitants in the municipality.

The municipality has 2,500 inhabitants, 80% of which are engaged in agriculture.

QUETIONS

According to the information, which laboratory tests would you request?

Discuss and answer (2)


Blood analysis has indicated changes in coagulation parameters, among others.

Toxicological results are negative .

5 days before a tick had been removed from the child’s head.

More background (2)

Two days later the grandfather became sick with similar symptoms.

In a neighbouring area of the same municipality five farmers have shown symptoms similar to those of Pedro.

More background (2)

A week later, the nurse that was attending the child presented similar symptoms.

Neither the farmers nor the breeders have reported diseases in animals.


Which diseases could be considered for differential diagnosis (Dx)?

Is it important to determine if there is a history of any of them in the area?

Which tests are to be carried out and for which infectious agents?

Diseases that cause haemorrhagic syndrome / Dx. differential

Lassa feverMarburgEbola feverYellow feverHantavirus infectionsRift Valley feverOmsk haemorrhagic diseaseKyasanur jungle diseaseCrimea-Congo Haemorrhagic fever (CCHF)Haemorrhagic Dengue

Other diseases:

LeptospirosisShigellosis Recurrent fever

Requested tests:

SerologicalMolecular

Serological test results:

negative


Are the negative results of the serological test conclusive?

Results of molecular tests:PCR tests of blood obtained during paracentesis are

positive for Crimean-Congo haemorrhagic Fever (CCHF).

What kind of common information should be looked for between Pedro and the other individuals who have been affected?Usual means of infection- Relation with the cattle- Increase in the Hyalomma sp. population- Possible direct infection through contact with

infected blood.



-How should the epidemiologic situation be studied / presented?

-Make an epidemiologic questionnaire.

1 Date2 What happend?

3 When did it start?Day, month, year.

4 Where?(City, municipality, region)

5 How many people were affected?

6 Has anyone died? How many?

7 Other information?8 Contact number

Exemple of an epidemiologic questionnaire

No. of cases = No. of deaths= Lethality rate = Population at risk = Mortality rate= Rate of attack =

No. of cases = 7No. of deaths= 1Lethality rate = 1/7 16%Population at risk = 2 000 (farmers)Mortality rate = 0.05% (1/100,000)Rate of attack = 7/2000 = 0.35% or 3 in 1000

- What was the most probable source of infection?

- What studies would you carry out on the animals and the vector population?

- What would be the control and preventive measures for this disease?

- Should the infected cattle be slaughtered?

- Do you think this outbreak is related to environmental and climatic changes?


Assessment questionnaire (ref. WHO, 2008) Yes No

Human Health

Does this incident involve a disease or a syndrome that requires obligatory notification (ex: Diphtheria)

Can this disease lead to an outbreak or create a hub with a high potential for spread?

Is mortality or burden of disease higher than normal?

Is this a rare disease in the community?

Are there other cases of deaths or similar sympotms?

Can this disease be caused by contaminated commercial products? (Ex: food)

Can this disease affect commerce or tourism?

Is it suspected that the infection could be nosocomial?

Animal Health

Does this event have a known consequence for human health?

Is it possible that this event may have consequences for human health?

Case study prepared by members of SAPUVETNET III projectGroup VII

Daniele de Meneghi: UNITO_FMV, ItalyCarla Rosenfeld: UACH, ChileLudovina Padre: UEVORA, PortugalCarolina Pujol: UABC, Mexico