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Infection is usually subclinical; when disease does occur, it generally does so in one of five occasionally overlapping clinical syndromes: fever and myalgia, encephalitis, arthritis and rash, pulmonary disease, or viral hemorrhagic fever (HF).

Fever and Myalgia This is the most common syndrome associated with zoonotic viruses. Typically, pts have an acute onset of fever, chills, severe myalgia, malaise, and headache; true arthritis is not found. Complete recovery after 2-5 days of illness is usual. Important examples include the following:

Encephalitis Depending on the causative virus, the ratio of clinical to subclinical disease, the mortality rate, and residua vary widely. The pt usually presents with a prodrome of nonspecific signs and symptoms (e.g., fever, abdominal pain, sore throat, respiratory signs) that is followed quickly by headache, meningeal signs, photophobia, and vomiting; involvement of deeper structures leads to lethargy, cognitive deficits, focal neurologic signs, and coma. Acute encephalitis usually lasts from a few days to 2-3 weeks, and recovery may be slow and incomplete. Treatable causes of encephalitis (e.g., HSV) should be ruled out promptly. Some important examples of arboviral encephalitides follow.

Arthritis and Rash Alphaviruses are common causes of arthritis accompanied by a febrile illness and maculopapular rash, usually during the summer in temperate climates. Examples include the following:

Pulmonary Disease After a prodrome (e.g., fever, malaise, myalgias, GI disturbances) of ~3-4 days, pts with hantavirus pulmonary syndrome (HPS) enter a cardiopulmonary phase marked by tachycardia, tachypnea, and mild hypotension. Over the next few hours, the illness may rapidly progress to severe hypoxemia and respiratory failure; the mortality rate is ~30-40% with good management. Pts surviving the first 2 days of hospitalization usually recover with no residua.

Viral Hemorrhagic Fever (VHF) The VHF syndrome is a constellation of findings based on vascular instability and decreased vascular integrity. All VHF syndromes begin with the abrupt onset of fever and myalgia and can progress to severe prostration, headache, dizziness, photophobia, abdominal and/or chest pain, anorexia, and GI disturbances. On initial physical examination, there is conjunctival suffusion, muscular or abdominal tenderness to palpation, hypotension, petechiae, and periorbital edema. Laboratory examination usually reveals elevated serum aminotransferase levels, proteinuria, and hemoconcentration. Shock, multifocal bleeding, and CNS involvement (encephalopathy, coma, convulsions) are poor prognostic signs. Early recognition is important; appropriate supportive measures and, in some cases, virus-specific therapy can be instituted.

Outline

Section 7. Infectious Diseases