International Journal of Infectious Diseases (2009) 13, e431—e436 http://intl.elsevierhealth.com/journals/ijid An outbreak of Crimean-Congo hemorrhagic fever in western Anatolia, Turkey Bu¨lent Ertugrul a,*, Yavuz Uyar b, Kamil Yavas c, Cetin Turan a, Serkan Oncu a, Ozlem Saylak a, Ahmet Carhan b, Barcin Ozturk a, Nermin Erol c, Serhan Sakarya a a Department of Infectious Diseases and Clinical Microbiology, Adnan Menderes University Medical Faculty, Aydin 09100, Turkey b Refik Saydam National Hygiene Center, Virology Reference and Research Laboratory, Ankara, Turkey c Provincial Health Directorate, Aydin, Turkey Received 18 August 2008; received in revised form 5 February 2009; accepted 20 February 2009 Corresponding Editor: William Cameron, Ottawa, Canada. KEYWORDS Summary Crimean-Congo Objective: Sporadic Crimean-Congo hemorrhagic fever (CCHF) cases were first reported in hemorrhagic fever; Turkey in 2002, arising particularly in northeastern Anatolia. Epidemics have been reported in Western Anatolia; neighboring countries since the 1970s. With the increase in number of CCHF virus infected or Endemic suspected cases in the Aydin region of western Anatolia by 2006, we decided to focus attention on this disease. Methods: Twenty-six patients with an acute febrile syndrome characterized by malaise, bleed- ing, leukopenia, and thrombocytopenia were admitted to various hospitals in Aydin between May 2007 and June 2008. CCHF diagnosis was established by measuring IgM in a blood sample and/or detecting viral genome by real-time polymerase chain reaction (real-time PCR) or by clinical findings of the disease, even if IgM was negative (real-time PCR was not performed). Results: Twenty-five patients (22 of the patients with cases confirmed by laboratory findings) matched the criteria for CCHF defined by the European Network for Diagnostics of ‘Imported’ Viral Diseases (ENIVD); one patient did not match suspected-case criteria, however he was also included in the study as his blood sample was positive according to real-time PCR. The most common signs and symptoms encountered were fever, myalgia, nausea, and vomiting. The overall case-fatality rate was 5.5% (one patient) in 2007. Patients showed hemorrhagic manifestations (35%), while complete blood counts revealed thrombocytopenia and leukopenia in 17 patients (65%), and raised levels of aspartate aminotransferase (77%), alanine aminotransferase (77%), lactate dehydrogenase (69%), and creatinine phosphokinase (42%). Conclusions: To date, western Anatolia has been accepted as a non-endemic area for this disease, with only sporadic cases. These non-endemic CCHF cases in Aydin province of the * Corresponding author. Tel.: +90 532 645 66 21. E-mail address: [email protected] (B. Ertugrul). 1201-9712/$36.00 # 2009 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijid.2009.02.011 e432 B. Ertugrul et al. Aegean region should alert other non-endemic regions of the world to be mindful of this disease. # 2009 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved. Introduction Gu¨mu¨shane, Amasya, Yozgat and Corum provinces; Figure 1).12 Western Anatolia and the Aegean region including 13,14 Crimean-Congo hemorrhagic fever (CCHF) is a potentially Aydin is accepted as a non-endemic area (Figure 1). By fatal viral infection occurring in about 30 countries world- 2006, CCHF cases began to be recorded in Aydin. The cases wide. It has the most extensive geographic range among the reported in Aydin were all residents of the city and surround- significant tick-borne viruses.1,2 The virus belongs to the ings. Since Aydin is an important agricultural and tourism genus Nairovirus in the Bunyaviridae family and causes zone of Turkey showing an increase in CCHF cases, we severe disease in humans, with a reported mortality rate decided to make a detailed analysis of this area. of 5—80%.3 The widespread geographic distribution of CCHF virus and its ability to produce severe human disease with Patients and methods high mortality rates make the virus an important human pathogen. Humans become infected through tick bites or Patients direct contact with body fluids or tissues from viremic 1,2,4,5 patients or viremic livestock. This was a retrospective descriptive study carried out CCHF cases were first reported in Turkey in 2002, although between May 2007 and June 2008. A CCHF case report form, epidemics have been reported from neighboring countries prepared by the MoH of Turkey, was filled out for all patients 1,2,4,6—9 since the 1970 s. Recently, a case report from Greece admitted for tick bites and/or suspicious cases as defined by 10 was published. Between 2002 and 2007, a total of 1820 the European Network for Diagnostics of ‘Imported’ Viral confirmed cases were reported to the Ministry of Health Diseases (ENIVD).15 Admission date, age, gender, address, 11 (MoH) of Turkey. The diagnoses of these cases were per- existing symptoms, epidemiological history, physical exam- formed through virus detection by PCR or IgM and/or IgG ination, and laboratory findings were recorded. Cases positivity on ELISA. All these patients were hospitalized, and admitted for tick bites without any symptoms and normal the fatality rate was calculated as 5.3%. A great majority of laboratory findings were informed about CCHF and its con- the cases were seen in northeastern Anatolia (Tokat, Sivas, sequences. They were advised to follow up their own body Figure 1 Endemic provinces and Aydin on the map of Turkey. An outbreak of CCHF in western Anatolia e433 temperatures and to attend the nearest hospital in the case Table 1 Demographic and clinical characteristics of the of any symptoms related to the disease (i.e., fever over patients 38 8C, petechiae, hemorrhage without history of trauma). Patients (%) (N = 26) These cases were also reached by telephone call from the community health centers. Those with symptoms were hos- Males 15 (58) pitalized immediately in city hospitals. Similar forms were Died 1 (5.5) a filled out for patients who were diagnosed with CCHF at other History of tick bite 19 (73) health centers in the city. Cases positive for CCHF virus IgM and/or positive real-time polymerase chain reaction (real- Living environment time PCR) or cases negative for IgM (real-time PCR not Urban 11 (42) performed) but showing clinical findings of the disease (acute Rural 15 (58) febrile syndrome characterized by malaise, bleeding, leuko- penia, and thrombocytopenia) were included in the study. Cases whose blood samples were unavailable or cases who Symptoms and signs had no clinical and laboratory findings were excluded from Fever 24 (92) the study. Headache 18 (69) Myalgia 15 (58) Laboratory testing Abdominal pain 11 (42) Nausea 18 (69) Patient venous blood samples were stored in optimal condi- Vomiting 12 (46) tions and sent to the Turkish MoH Refik Saydam National Diarrhea 9 (35) Hygiene Center for confirmation of the diagnosis. Hemorrhagic manifestations 9 (35) TaqMan-based real-time PCR was performed as described 16 by Yapar et al. Five microliters of viral RNA were added to Abnormal laboratory results 20 ml of the mixture containing 5 pmol of each primer, 4 pmol AST—ALT elevation 20 (77) of TaqMan probe, 0.2 mM of each dNTP (containing dUTP), LDH elevation 18 (69) and 6 mM MgCl2. The cycle conditions were carried out as Leukopenia 17 (65) follows: a cycle of real time at 42 8C for 40 min, 95 8C for Thrombocytopenia 17 (65) 10 min, followed by 40 PCR cycles of 15 s at 95 8C, 1 min at CK elevation 11 (42) 60 8C . The assay was run on a Perkin—Elmer 7700 Sequence Detection System using the combination of reverse transcrip- AST, aspartate aminotransferase; ALT, alanine aminotransferase; LDH, lactate dehydrogenase; CK, creatinine phosphokinase. tase (MBI Fermentas) and Hot Start Taq DNA polymerase a The percentage is calculated based on 18 patients in 2007. (Bioron GmbH, Germany). The data were analyzed according to Yapar et al.16 CCHF IgM ELISA testing was performed at the Refik Saydam National Hygiene Center, Virology Research and Reference were indigenous—autochthonous with no history of traveling Laboratory following the recommendations of the Centers for to another CCHF endemic area (e.g., eastern Anatolia) in Disease Control and Prevention (CDC, Atlanta, USA). CCHF Turkey. IgM was detected by ELISA prepared with inactivated native Fifteen patients were male and 11 were female. The CCHF viral antigens (Strain IbAr 10200) grown in Vero E6 cells mean Æ SD age was 30.7 Æ 20.6 years (range 2—69 years). on serum samples.17 Three (12%) of the patients were in the pediatric age group (0—15 years old). The most commonly encountered signs and symptoms were fever, headache, myalgia, nausea, and Results vomiting. Hemorrhagic manifestations were seen in nine (35%) patients. Demographic and clinical characteristics Venous blood samples were collected from 61 patients, 49 of of the patients are shown in Table 1.Thetimeperiod them in 2007 and 12 in 2008. Among the samples taken, ELISA between the onset of symptoms and referral to hospital tests for specific CCHF IgM antibodies were positive for eight was3daysonaverage(range1—10days).Elevenpatients patients, and real-time PCR tests for CCHF were positive in (42%) were admitted on the day the symptoms appeared. 14. IgM was negative in four patients and real-time PCR was The mean Æ SD hospitalization was 8.8 Æ 4.2 days (range 2— not performed on the blood samples of these cases; however, 17 days). clinical findings in these patients (acute febrile syndrome Seventeen (65%) of the 26 patients had received ribavirin characterized by malaise, bleeding, leukopenia, and throm- therapy. The overall case-fatality rate was 5.5% (one patient) bocytopenia) were concordant with CCHF. Thus, 26 patients in 2007.