A 53-year-old male was admitted to the hospital with a history of high fever, abdominal pain, muscle pain, headaches, backaches and chills. The physical examination on admission revealed: temperature was 39.5 ℃, blood pressure was 90/50 mmHg, the pulse rate 110/min, and the respiration 20/min. His sclera was with conjunctivitis. Chest radiography was normal. Abdominal ultrasound examination a few hours after admission revealed minimal ascitic fluid. Laboratory findings were as follows:
Elevated liver enzymes (aspartate aminotransferase [AST] 61 U/L, alanine aminotransferase [ALT] 29 U/L), White blood cell count (WBC) 5100/μL, with segments 76.8%, Hematocrit 52.2% (37.0-50.0), Platelet count 102×103/μL, Erythrocyte sedimentation rate (ESR) 31 mm/h, Creatinin 1.13 mg/dL, Blood urea nitrogen (BUN) 44.9 mg/dL, Glicemia 168 mg/dL (70-110), C Reactive protein 5 mg/L (0-0.5), Amylasemi 33.4 U/L, Lipasemi 85 U/L, Procalcitonin 0.92 ng/mL (0.5-2). Other routine laboratory values within normal range.
The patient was oliguric with urine volumes less than 24-30 mL/h and the urinalysis showed proteinuria, microscopic haematuria and granular casts. On the next day the patient complained about more abdominal pain, nausea and vomiting(Table 1). Elevated serum amylase and lipase levels, in combination with severe abdominal pain, suggested an initial diagnosis of acute pancreatitis. Computed tomography of the thoraco–abdominal region, revealed small pleural effusions, minimal pericardial liquid, increase of peritoneal liquid and edema of the pancreas and peripancreatic tissues. The patient had no history of alcohol abuse, and we excluded infection of the biliary tree, gallbladder stones, microlithiasis, and hypertrigliceridemia(Fig. 1). We asked him where he had been in the last month and he told us that he had made an excursion to a northeastern mountain in Albania, an area where rodents infected by (DOBV) are found. Based on the clinical manifestation, epidemiologic data, and laboratory parameters, HFRS was suspected. On the following day we tested him for HFRS, Crimean-Congo of hemorrhagic fever (CCHF) and Leptospirosis. These gave positive results, detected by enzyme-linked immunosorbent assay (ELISA), for immunoglobulin M(IgM) antibodies and immunoglobulin G (IgM 1.487, cut-off value < 0.8 and IgG 2.215) specific to DOB. An immunofluoreshence assay IFA IgM; IgG was also positive. Screening for CCHF and Leptospira were negative.
Table 1. Laboratory follow up of progress of the disease
The main treatment during hospitalization was supportive therapy: (fresh frozen plasma), manage ment of the patient's fluid (hydration and that use of diuretics) and electrolyte levels (e.g. sodium, potassium, chloride), also treatment with antibiotics. He became polyuric on day 5 after admission, with urine output of 200-250 mL/h and gradual recovery of renal function in the following days. After recovery, the patient was discharged from the hospital on the 15thday of hospitalization. He remained well at the 1.5 month follow-up.