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Updated: Jul 17 2018

Yellow Fever Virus

  • Snapshot
    • A 40-year-old man presents to a hospital after flying from sub-Saharan Africa. He had been on a safari and had sustained multiple mosquito bites. He had not gotten his necessary vaccines, as the trip was planned last-minute. For the past 2 days, he has had fevers, chills, myalgias, and some vomiting. After landing, he had an episode of bloody vomiting. On physical exam, he has a high fever. He also has gingival bleeding, jaundice, and scleral icterus. On abdominal exam, he has hepatosplenomegaly. He is admitted for supportive care and close monitoring.
  • Introduction
    • Classification
      • yellow fever virus
        • a positive-stranded, linear RNA virus
        • a flavivirus and arbovirus with icosahedral capsid
        • transmitted by Aedes mosquito
        • reservoir is human or monkey
    • Epidemiology
      • incidence
        • endemic in South America and Africa
      • risk factors
        • exposure to endemic areas
        • mosquito bites
    • Pathogenesis
      • the virus spreads via blood
      • it infects the liver
        • liver cells die via apoptosis
        • coagulopathy occurs due to loss of hepatic synthesis of clotting factors
    • Associated conditions
      • hemorrhagic fever
    • Prevention
      • live-attenuated virus vaccine
        • given at age 9-12 months in endemic areas
        • given 10 days prior to travel to endemic areas
    • Prognosis
      • most patients recover without complications
      • however, in severe cases, mortality rate is up to 60%
  • Presentation
    • Symptoms
      • most patients are asymptomatic
      • if symptomatic
        • flu-like prodrome
        • headache
        • myalgias
        • nausea
        • black vomitus
    • Physical exam
      • high fever
      • jaundice
      • scleral icterus
      • hepatomegaly
      • minor hemorrhage
        • epistaxis
        • mucosal bleeding
        • melena
  • Studies
    • Labs
      • diagnostic
        • reverse transcriptase-polymerase chain reaction
        • serology with enzyme-linked immunosorbent assay
      • transaminitis (AST > ALT)
      • elevated prothrombin and partial thromboplastin times
      • hyperbilirubinemia
    • Guaiac stool testing
      • occult blood
    • Liver biopsy
      • Councilman bodies
        • eosinophilic apoptotic globules
      • typically found on autopsy
    • Making the diagnosis
      • most cases are clinically diagnosed, especially in those who have recently traveled to an endemic area
  • Differential
    • Dengue fever
      • distinguishing factor
        • may also be hemorrhagic but does not affect the liver
        • will not present with jaundice, scleral icterus, and hepatomegaly
    • Chikungunya
      • distinguishing factor
        • typically does not present with hemorrhage
  • Treatment
    • Conservative
      • supportive care
        • indication
          • all patients
        • modalities
          • rehydration
          • close monitoring
          • pain control
  • Complications
    • Shock
    • Death
    • Prolonged weakness and fatigue
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