Pediatric Viral Hemorrhagic Fevers Clinical Presentation

Updated: Aug 17, 2021
  • Author: Martha L Muller, MD, MPH; Chief Editor: Russell W Steele, MD  more...
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Initial symptoms of viral hemorrhagic fevers (VHFs) are nonspecific and follow an incubation period of 2-14 days. Patients experience an insidious or sudden onset of progressive fever (that may be biphasic), chills, malaise, generalized myalgias and arthralgias, headache, anorexia, and cough. Most patients have a severe sore throat and may have epigastric pain, vomiting, and diarrhea.



Typical findings are not distinctive, including nonspecific conjunctival injection, facial and truncal flushing, petechiae, purpura, ecchymoses, icterus, epistaxis, gastrointestinal and genitourinary bleeding, and lymphadenopathy. Severe illness is associated with hypotension and shock, relative bradycardia, pneumonitis, pleural and pericardial effusions, hemorrhage, encephalopathy, seizures, coma, and death.


Patients with one of the South American HFs may present with conjunctivitis, pharyngeal enanthema with petechiae but without exudate, sore throat, or cough. Retrosternal pain is also a major symptom.

The South American HFs may be marked by encephalopathic changes, including intention tremor, cerebellar signs, convulsions, and coma.

Lassa fever often manifests with classic signs of meningitis.

Swollen baby syndrome describes severe Lassa fever in infants and toddlers with anasarca, abdominal distention, and spontaneous bleeding but pediatric disease is otherwise not distinctive from that observed in older patients.


Patients with Rift Valley Fever (RVF) develop retinal vasculitis that may cause permanent blindness.

Cotton wool spots are visible on the macula.

Severe disease is associated with bleeding, shock, anuria, and icterus.

Encephalitis may also occur without overlapping hemorrhagic fever.

The most severe bleeding and ecchymoses among the viral hemorrhagic fevers characterize Crimean-Congo hemorrhagic fever (CCHF). [35]


Ebola virus causes clinically similar but more severe disease than the Marburg agent.

On about the fifth day of illness with Ebola or Marburg virus, a distinct morbilliform rash develops on the trunk and an expressionless ghostlike facies has been described during this stage of illness.

Patients with progressive disease hemorrhage from mucous membranes, venipuncture sites, and body orifices.

Disseminated intravascular coagulation may be a feature of late disease.


Kyasanur Forest disease and Omsk HF are typical biphasic diseases with a febrile or hemorrhagic period that is often followed by CNS involvement, similar to tick-borne encephalitis (Central European encephalitis, Russian spring-summer encephalitis) except that hemorrhagic manifestations are not characteristic of the first phase of the tick-borne encephalitides. Alkhurma HFV typically produces fever, headache, retroorbital pain, joint pain, myalgias, anorexia, vomiting, leukopenia, thrombocytopenia, and elevated serum hepatic transaminases. Hemorrhagic or encephalitic manifestations occur in some patients.



South American HF and Lassa fever arise from inhalation of aerosolized fecal matter or urine of infected rodents and from rodent bites, usually during harvest, with work on small farms, or in newly developed areas. Interhuman transmission usually does not occur but is possible.

RVF is acquired from mosquito bites or contact with the blood of infected domestic livestock. No interhuman transmission has been observed.

CCHF results from tick bites, [36] squashing ticks, or exposure to aerosols or fomites from slaughtered sheep and cattle. Nosocomial epidemics have been observed a number of times.

Ebola and Marburg infections occur from unknown sources, but links to primates and contact with other infected humans are observed.