First confirmed case of Crimean-Congo haemorrhagic fever in the UK

Abstract

In October, 2012, a 38-year-old Afghan man presented to an emergency department in Glasgow, UK, 2 h after returning on a fl ight from Kabul via Dubai, after a 3 week stay in Afghanistan, where he had attended a wedding in Samangan Province. His symptoms had started 5 days before presentation and included fever, epigastric pain, bloody diarrhoea, and haematemesis. On examination he was languid but orientated, with physical observations within normal limits. Conjunctival suff usion was present and a haematoma rapidly developed at the site of venepuncture. Initial blood results showed transaminitis and thrombocytopenia (appendix). The patient was transferred to the Brownlee Centre for Infectious Diseases, Glasgow, and isolated in a negative-pressure room. Formal viral haemorrhagic fever risk assessment was implemented according to the 2012 guidelines published by the Advisory Committee on Dangerous Pathogens (ACDP); the patient reported no contact with ticks (the vector of Crimean-Congo haemorrhagic fever [CCHF]) or with animals and was therefore classifi ed as “possibility of viral haemorrhagic fever” (appendix). Infection control measures were applied in line with ACDP guidance. He was discussed with the Rare and Imported Pathogens Department (RIPD) of the Health Protection Agency, Greater Glasgow and Clyde Public Health Department, and the High Security Infectious Diseases Unit at the Royal Free Hospital, London. Samples of blood and urine were sent by courier to the RIPD laboratory at Porton Down, UK, for rapid CCHF virus testing by PCR: laboratory con fi rmation of the diagnosis of CCHF was made within 36 h of the patient’s presentation. After diagnosis, the patient’s wife discovered that during the Afghan wedding ceremony her husband had been close to a slaughtered calf, the probable source of infection. Despite intravenous ribavirin, the patient’s condition deteriorated, with fl uctuating Glasgow Coma Scale scores, and rising respiratory rate and pulse. 60 h after initial presentation, in keeping with national guidelines, he was transported to Glasgow International Airport by the Scottish Ambulance Service Special Operations Response Team and a dedicated RAF Air Transport Isolator team, and then transferred to the Royal Free Hospital High Security Infectious Diseases Unit in an RAF Hercules and dedicated ambulance where he was managed in a modi fi ed Trexler isolator (Putlock Chimney Systems Ltd, Whitchurch, UK) which provided a sealed environment and pro tection for the staff caring for him. During the fl ight further clinical deterioration was evident including anuria, vascular leak, and a decerebrate response to pain suggesting an intracerebral haemorrhage. Over the subsequent 24 h, he deteriorated further and developed pulmonary haemorrhage. The patient died 96 h after initial presentation. Viral haemorrhagic fever is a rare diagnosis in nonendemic areas and we report the fi rst confi rmed case of CCHF in the UK. Caused by a tick-borne virus, CCHF virus is endemic to more than 30 countries in Central and south western Asia, south eastern Europe, and Africa. Human beings can be infected from tick bites, contact with body fl uid, or, as suspected in the present case, contact with tissue from viraemic livestock. After a variable incubation period (average 2–7 days), fever and myalgia develop; haemorrhagic features start around the fourth day of illness, with mortality rate up to 30%. With increasing international travel to viral haemorrhagic fever endemic areas, clinicians in all countries must maintain a high index of suspicion for cases. In this instance, following infectious diseases consultant assessment, the possibility of viral haemor rhagic fever was recognised within 6 h of presentation, and the diagnosis of CCHF confi rmed rapidly. Consequently, the patient was promptly isolated. Surveillance has not identifi ed any onward transmission. This situation contrasts with multiple previously reported incidences of CCHF where late diagnosis and gaps in infection control procedure have been associated with nosocomial outbreaks. The case also highlights the value of a collateral history and asking about contact with blood from animal carcasses. Our patient is the fi rst confi rmed case of viral haemorrhagic fever in the UK since the 2012 guidelines for management of human infectious diseases of high consequence were published.