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Yellow Fever

Fevers Yellow

Yellow fever is an acute arbovirus infection. It is transmitted by the bite of the yellow fever mosquito (Aedes aegypti) and other species.


Presentation

Yellow fever has an incubation period of five to six days. In the initial phase that lasts for three to four days, there is mild fever with rigors and chills and yellowing of the skin. The yellowing occurs as the disease affects liver causing hepatitis [7].

The patient also complains of headache, joint and muscle pain, loss of appetite, abdominal pain, back pain, nausea and vomiting, fatigue, weakness and dehydration. The next phase is remission, which lasts for 48 hours. Most patients recover after this phase.

If not treated completely, the disease becomes worse and the sufferers enter a more toxic, third phase of infection. It can lead to a condition called viral hemorrhagic fever with shock, jaundice and abdominal pain [8] [9].

In the toxic phase, there can be bleeding in the mouth, the eyes and the gastrointestinal tract. This will cause vomiting containing blood. It results in damage to the liver, kidneys, and the circulatory system. The World Health Organization estimates that about 50% of people worldwide who reach this severe phase of infection die, while half recover.

Easy Bruising
  • ., nose or gums bleed, easy bruising). During the meeting, some residents told the council they were concerned about the chemicals used in mosquito spraying and sought improved notice of the sprayings. One such spraying is set for 3 to 5 a.m.[pe.com]
  • bruising, unusual bleeding; little or no urination; or vomiting, loss of appetite , jaundice (yellowing of the skin or eyes).[rxlist.com]
  • bruising, unusual bleeding ; little or no urination; or vomiting, loss of appetite, jaundice (yellowing of the skin or eyes).[emedicinehealth.com]
  • In addition to the above symptoms, the following symptoms and signs may also develop: Abdominal pain Prevention Bleeding from the gums, nose, eyes, and/or stomach Blood in the stool and blood in the vomit Easy bruising of the skin Kidney failure Confusion[medicinenet.com]
Fever
  • Yellow fever is an acute arbovirus infection. It is transmitted by the bite of the yellow fever mosquito (Aedes aegypti) and other species. Yellow fever has an incubation period of five to six days.[symptoma.com]
  • Thirty five of the 37 cases of yellow fever were imported from Angola.[ncbi.nlm.nih.gov]
  • […] yellow fever vaccines before travelling to a yellow fever endemic area.[ncbi.nlm.nih.gov]
  • The mother reported 2 days of headache, malaise, and low fever occurring 5 days after receipt of yellow fever vaccine.[ncbi.nlm.nih.gov]
  • Yellow fever virus is a mosquito-borne flavivirus that causes yellow fever, an acute infectious disease that occurs in South America and sub-Saharan Africa.[ncbi.nlm.nih.gov]
Dutch
  • A Dutch traveller returning from Suriname in early March 2017, presented with fever and severe acute liver injury. Yellow fever was diagnosed by (q)RT-PCR and sequencing.[ncbi.nlm.nih.gov]
  • It is surmised that the yellow fever virus was introduced to the Americas by Dutch slave traders during the 17 th century. The first documented epidemic occurred in the Yucatan Peninsula and spread through the Caribbean basin.[emedicine.medscape.com]
Vomiting
  • At one time it was called “Black Vomit” because of the characteristic black putrid vomit it produces. There are approximately 200,000 cases of yellow fever, resulting in 30,000 deaths, each year in tropical endemic areas of Africa and the Americas.[infoplease.com]
  • Symptoms may include: Fever, headache, muscle aches Nausea and vomiting, possibly vomiting blood Red eyes , face, tongue Yellow skin and eyes (jaundice) Decreased urination Delirium Irregular heartbeats (arrhythmias) Bleeding (may progress to hemorrhage[nlm.nih.gov]
  • Famous early American Cotton Mather described it as “turning yellow then vomiting and bleeding every way.” Internal bleeding in the digestive tract causes bloody vomit. Many victims become delirious before dying.[history.com]
Nausea
  • Our patient presented with a clinical syndrome of fever, headache, nausea, and vomiting, which quickly progressed to multiorgan failure and ultimately death on hospital day 4.[ncbi.nlm.nih.gov]
  • The toxic phase develops as the fever returns, with clinical symptoms including high fever, headache, back pain, nausea, vomiting, abdominal pain, and fatigue.[ok.gov]
  • Yellow fever appears with a sudden onset of fever, chills, headache, backache, nausea, and vomiting. The skin and eyes may appear yellow—a condition known as jaundice and a sign that gives rise to the disease’s popular name.[britannica.com]
  • The patient suffered from fever, chills, sweating, headaches, backaches, myalgia, epigastric pains, nausea, vomiting, diarrhea and prostration. He was unvaccinated and had been working in areas where cases of jungle yellow fever had been confirmed.[ncbi.nlm.nih.gov]
  • Symptoms of yellow fever include sudden fever, severe headache, nausea, vomiting and fatigue, according to the Center for Disease Control and Prevention. Reporting by Herculano Coroado; Writing by Mfuneko Toyana[reuters.com]
Loss of Appetite
  • The patient also complains of headache, joint and muscle pain, loss of appetite, abdominal pain, back pain, nausea and vomiting, fatigue, weakness and dehydration. The next phase is remission, which lasts for 48 hours.[symptoma.com]
  • […] of appetite, and nausea or vomiting About 15% of people face a second, more serious phase involving high fever, jaundice, bleeding and deteriorating kidney function Half of those who enter the "toxic" phase usually die within 10 to 14 days Source: WHO[bbc.com]
  • Initial symptoms usually include sudden onset of fever, chills, headache, joint and muscle pain, loss of appetite, abdominal pain, back pain, nausea and vomiting, fatigue, weakness and dehydration. Most patients recover after this stage.[travel.gc.ca]
  • Yellow fever has 3 stages: Stage 1 (infection): Headache, muscle and joint aches, fever, flushing, loss of appetite, vomiting, and jaundice are common. Symptoms often go away briefly after about 3 to 4 days.[nlm.nih.gov]
Black Vomit
  • Bleeding within the stomach produces the so-called “black vomit.” As kidney function deteriorates, patients often die within 10 to 14 days in the “toxic phase.”[infoplease.com]
  • Symptoms of bleeding include black vomit, nose bleed, gum bleeding, and purple pin-point spots (bruising). In the late stages of disease, patients can develop hypotension, shock, kidney and heat complications.[ok.gov]
  • Bleeding in the mouth, the eyes and in the gastrointestinal tract can cause vomits containing blood (giving the name black vomit). Approximately 20% of cases entering the toxic phase end in fatality.[tripadvisor.com]
  • Up to 15 percent of those bitten become severely ill, with symptoms that include black vomit and bleeding from the nose, mouth and eyes. For up to half of those who develop severe symptoms, yellow fever ends in a painful death.[nytimes.com]
Hematemesis
  • Hemorrhage and erosion of the gastric mucosa lead to hematemesis, popularly known as black vomit. Fatty infiltration of the myocardium, including the conduction system, can lead to myocarditis and arrhythmias.[emedicine.medscape.com]
Bleeding Gums
  • Symptoms of bleeding include black vomit, nose bleed, gum bleeding, and purple pin-point spots (bruising). In the late stages of disease, patients can develop hypotension, shock, kidney and heat complications.[ok.gov]
Hypotension
  • In the late stages of disease, patients can develop hypotension, shock, kidney and heat complications. Confusion, seizures, and coma can also occur. When epidemics occur in unvaccinated populations, death rates range from 15% to more than 50%.[ok.gov]
  • In the late stages of yellow fever, patients present with the following: Tachycardia Hypothermia or hyperthermia Hypotension Individuals who are severely hypoperfused appear mottled and cyanotic; they are also often obtunded.[emedicine.medscape.com]
Tachycardia
  • On general physical examination, the findings include tachycardia, yellowness of eyes and skin, coated tongue, state of dehydration and dark colored urine. The laboratory testing helps to confirm the diagnosis.[symptoma.com]
  • In the late stages of yellow fever, patients present with the following: Tachycardia Hypothermia or hyperthermia Hypotension Individuals who are severely hypoperfused appear mottled and cyanotic; they are also often obtunded.[emedicine.medscape.com]
Slow Pulse
  • Often, the high fever is paradoxically accompanied by a slow pulse. After four days, most patients improve and their symptoms disappear.[dermnetnz.org]
  • Often, the high fever is paradoxically associated with a slow pulse. After three to four days most patients improve and their symptoms disappear. However, 15% enter a “toxic phase” within 24 hours.[tmb.ie]
Jaundice
  • For more than 95% of acute febrile jaundice cases identified through surveillance for yellow fever, a reemerging arthropod-borne viral disease, no etiological exploration is ever done.[ncbi.nlm.nih.gov]
  • The majority of patients with acute febrile jaundice ( 95%) identified through a yellow fever surveillance program in the Democratic Republic of Congo (DRC) test negative for antibodies against yellow fever virus.[ncbi.nlm.nih.gov]
  • Yellow fever has 3 stages: Stage 1 (infection): Headache, muscle and joint aches, fever, flushing, loss of appetite, vomiting, and jaundice are common. Symptoms often go away briefly after about 3 to 4 days.[nlm.nih.gov]
  • In most of the cases, symptoms take 3 to 6 days to develop and include fever, chills, jaundice, loss of appetite, nausea, headache, backache, and muscular aches. Vaccination may be effective against yellow fever.[symptoma.com]
Scleral Icterus
  • icterus Jaundice Epigastric tenderness Hepatomegaly The following will also often be apparent: Petechiae Purpura Mucosal bleeding Gastrointestinal bleeding (gross or occult) Organ ischemia, which primarily affects the kidneys and central nervous system[emedicine.medscape.com]
Red Eye
  • Symptoms may include: Fever, headache, muscle aches Nausea and vomiting, possibly vomiting blood Red eyes , face, tongue Yellow skin and eyes (jaundice) Decreased urination Delirium Irregular heartbeats (arrhythmias) Bleeding (may progress to hemorrhage[nlm.nih.gov]
Myalgia
  • The illness was characterized by fever, headache, myalgia, gastrointestinal symptoms, hepatic and renal dysfunction, and (in the fatal case), shock and coagulopathy, compatible with YEL-AVD.[ncbi.nlm.nih.gov]
  • The patient suffered from fever, chills, sweating, headaches, backaches, myalgia, epigastric pains, nausea, vomiting, diarrhea and prostration. He was unvaccinated and had been working in areas where cases of jungle yellow fever had been confirmed.[ncbi.nlm.nih.gov]
  • The clinical presentations were characterised by fever, myalgia, headache, and confusion, followed by severe multisystemic illnesses. Three patients died.[ncbi.nlm.nih.gov]
  • Yellow fever has an incubation period of 3 to 6 days and sudden onset of symptoms with high fever, myalgia, headache, nausea/vomiting and increased transaminases. The disease ranges from asymptomatic to severe forms.[ncbi.nlm.nih.gov]
  • Signs and symptoms History Yellow fever is usually a mild, self-limiting illness consisting of fever, headache, myalgia, and malaise.[emedicine.medscape.com]
Purpura
  • […] of fever (Faget sign) Conjunctival injection Skin flushing As the disease progresses, additional physical findings include the following: Scleral icterus Jaundice Epigastric tenderness Hepatomegaly The following will also often be apparent: Petechiae Purpura[emedicine.medscape.com]
Dark Urine
  • Call your doctor right away if you have signs of liver problems like dark urine, not hungry, stomach pain, light-colored stools, or yellow skin or eyes.[drugs.com]
  • In this phase people are likely to develop jaundice (yellowing of the skin and eyes, hence the name ‘yellow fever’), dark urine and abdominal pain with vomiting. Bleeding can occur from the mouth, nose, eyes or stomach.[who.int]
Oliguria
  • The patient presented with hemorrhagic fever, jaundice and oliguria at day 3 after onset, which rapidly progressed to multisystem organ failure with extremely elevated liver, pancreatic and myocardial enzymes.[ncbi.nlm.nih.gov]
Headache
  • Yellow fever has 3 stages: Stage 1 (infection): Headache, muscle and joint aches, fever, flushing, loss of appetite, vomiting, and jaundice are common. Symptoms often go away briefly after about 3 to 4 days.[nlm.nih.gov]
  • The patients usually present with fever, headache, yellowing of the skin and internal bleeding. Yellow fever can be prevented by a vaccine.[symptoma.com]
  • They include: headaches muscle aches joint aches chills fever Acute Phase This phase usually lasts for three to four days.[healthline.com]

Workup

A diagnosis of yellow fever is established on the basis of complete medical history including history of travel and vaccination status.

On general physical examination, the findings include tachycardia, yellowness of eyes and skin, coated tongue, state of dehydration and dark colored urine.

The laboratory testing helps to confirm the diagnosis. These include:

  • Complete blood count: The findings in a complete blood count for patients with yellow fever include leukopenia, thrombocytopenia, increased hemoglobin and hematocrit levels and initial hemoconcentration.
  • Coagulation studies: These studies reveal reduced fibrinogen and clotting factors II, VI, VII, VIII, XI, and X. It also indicates prolonged clotting time.
  • Urinalysis: It indicates elevated urinary proteins and urobilinogen levels.
  • Liver function tests: These tests reveal elevated serum AST levels, direct bilirubin levels and hypoalbuminemia.
  • Polymerase chain reaction (PCR) assay: It helps in the detection of viral genome in tissue or in blood.
  • Enzyme-linked immunosorbent assay (ELISA): This serologic test aids in making the correct diagnosis. A rise in yellow fever-specific antibody titer confirms a diagnosis.

Treatment

There is no specific treatment for yellow fever. Treatment is supportive and effective treatment involves complete bed rest under mosquito nets.

Antipyretics and analgesics are helpful to control fever and pain respectively. Drugs like antacids and histamine blockers are used to control gastric bleeding. Blood transfusions can be given for severe bleeding.

Oral or intravenous intake of fluids help to maintain dehydration, blood volume, increase blood pressure and correct hypoglycemia. Dialysis may be needed if kidney failure develops.

Prognosis

Mortality due to yellow fever varies according to the severity of the disease. It varies from 50% without medical treatment to about 5% with complete medical care.

Mortality rate is higher with life-threatening hemorrhagic fever, jaundice, liver and kidney failure. Death usually occurs within 7 to 10 days of the toxic phase of yellow fever. Those who recover have life-long immunity. So overall, the prognosis is good if diagnosed and treated properly.

Etiology

Yellow fever is caused by an enveloped RNA virus called yellow fever virus [3]. The individuals who are more at risk of developing yellow fever include travelers to certain parts of South America and Africa. The risk of the disease can increase with various factors like travel to endemic areas, visiting rural areas or participating in outdoor activities such as camping, cycling, hiking or fieldwork.

Epidemiology

Yellow fever is endemic in tropical areas of South America and Africa [4]. About 15% of the cases who develop yellow fever can have serious complications. The World Health Organization estimates that there are 200,000 cases of yellow fever worldwide each year, resulting in 30,000 deaths.

Due to decreased immunity to infection, deforestation, climate changes and increased urbanization, yellow fever appears to be on the rise internationally. Yellow fever transmission with a high risk have been identified in 45 countries, many of them with tropical climates.

Sex distribution
Age distribution

Pathophysiology

Yellow fever virus is transmitted to humans through the bite of an infected mosquito, Aedes aegypti. Some other mosquitoes such as Tiger mosquito can also serve as a vector for this virus. Yellow fever virus is taken up by a female mosquito by feeding on infected humans. The mosquito can then transmit the virus to other humans. Yellow fever virus can also be transmitted by mosquitoes from monkeys to humans by a sylvatic cycle [5]. It mostly occurs in travelers while visiting or working in jungle border areas.

Mosquitoes that spread viruses usually bite during the day time, particularly around sunrise and sunset. Viruses reach the stomach of the infected mosquitoes and then reach the salivary glands via blood stream. When the infected mosquito bites a person, the virus is transmitted to blood system of the person through mosquito’s saliva.

After transmission of the virus from a mosquito to human, the virus replicates in the lymph nodes, particularly the dendritic cells. From there, the viruses reach the hepatocytes in liver. This results in eosinophilic degradation and release of cytokines [6]. If left untreated, it can lead to complications such as cytokine storm, shock, and multiple organ failure, causing fatality.

Prevention

Yellow fever is preventable by vaccination which is valid for ten years. It is effective in ninety five percent of the cases [10]. The vaccination is not recommended for children under 9 months of age and immunocompromised individuals. Immunization should be done in travelers particularly who visit areas where yellow fever exists. The preventive measures should be taken to avoid mosquito bite by wearing full protective clothing, using insect repellant and living in screened areas.

Summary

Yellow fever is a viral infection caused by flavivirus that is transmitted by the bite of an infected mosquito. The virus is found in tropical and subtropical areas in South America and Africa [1][2].

In most of the cases, symptoms take 3 to 6 days to develop and include fever, chills, jaundice, loss of appetite, nausea, headache, backache, and muscular aches.

Vaccination may be effective against yellow fever. Untreated cases can lead to severe complications like bleeding, shock, organ failure, and sometimes death.

Patient Information

Yellow fever is a viral disease which is transmitted by the bite of an infected mosquito. The virus is more common in subtropical areas.

The patients usually present with fever, headache, yellowing of the skin and internal bleeding. Yellow fever can be prevented by a vaccine.

References

Article

  1. Bryan CS, Moss SW, Kahn RJ. Yellow fever in the Americas. Infectious disease clinics of North America. Jun 2004;18(2):275-292, table of contents.
  2. Barnett ED, Wilder-Smith A, Wilson ME. Yellow fever vaccines and international travelers. Expert review of vaccines. Jul 2008;7(5):579-587.
  3. Liceaga E. [The etiology of yellow fever, 1898]. Salud publica de Mexico. Sep-Oct 1989;31(5):708-719.
  4. Barnett ED. Yellow fever: epidemiology and prevention. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. Mar 15 2007;44(6):850-856.
  5. Barrett A, Higgs, S. Yellow fever: A disease that has yet to be conquered. Annu Rev Entomol. 2007;52.
  6. Monath TP, Barrett AD. Pathogenesis and pathophysiology of yellow fever. Advances in virus research. 2003;60:343-395.
  7. Monath TP. Treatment of yellow fever. Antiviral research. Apr 2008;78(1):116-124.
  8. Cleri DJ, Ricketti AJ, Porwancher RB, Ramos-Bonner LS, Vernaleo JR. Viral hemorrhagic fevers: current status of endemic disease and strategies for control. Infectious disease clinics of North America. Jun 2006;20(2):359-393, x.
  9. Quaresma JA, Pagliari C, Medeiros DB, Duarte MI, Vasconcelos PF. Immunity and immune response, pathology and pathologic changes: progress and challenges in the immunopathology of yellow fever. Reviews in medical virology. Sep 2013;23(5):305-318.
  10. Roukens AH, Visser LG. Yellow fever vaccine: past, present and future. Expert opinion on biological therapy. Nov 2008;8(11):1787-1795.

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Last updated: 2018-06-21 12:38