Am. J. Trop. Med. Hyg., 81(4), 2009, pp. 675–678 doi:10.4269/ajtmh.2009.09-0051 Copyright © 2009 by The American Society of Tropical Medicine and Hygiene 675 * Address correspondence to Maryam Keshtkar-Jahromi, Clinical Research and Development Center, Shahid Modarres Hospital, Saa- databad Avenue, Tehran 1998734383, Iran. E-mail: maryam_keshtkar@ yahoo.com Short Report: Crimean-Congo Hemorrhagic Fever Virus as a Nosocomial Pathogen in Iran Masoud Mardani, Maryam Keshtkar-Jahromi,* Behrooz Ataie, and Peyman Adibi Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University, Tehran, Iran; Clinical Research and Development Center, Shahid Modarres Hospital, Tehran, Iran; Infectious Diseases Research Center, and Division of Gastroenterology, Department of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran Abstract. Crimean-Congo hemorrhagic fever (CCHF) is a viral disease with several different modes of transmission. We describe the manifestations, outcome, and likely modes of transmission for three nosocomial cases. All threee cases were healthcare workers (two men and one woman). They had fever, myalgia, and petechia. Disseminated intravascular coagulation resulted in the death occurred in the woman. Because this disease is manifested with non-specific influenza- like symptoms, diagnosis can be difficult. Data for these patients can be used to investigate airborne or sexual transmis- sion of this virus, although neither route was substantiated for these patients. Use of universal precautions and early case detection are the most helpful strategy for preventing nosocomial transmission of CCHF. Crimean-Congo hemorrhagic fever (CCHF) is a tick-borne viral disease that has been reported in more than 30 countries in Africa, Asia, southeastern Europe, and the Middle East. 1 It was first described in the Crimea in 1944. Later, a virus iso- lated from the Congo was identified as the same virus, result- ing in the name Crimean-Congo hemorrhagic fever virus (CCHFV). 2 Infection with CCHFV is manifested as an acute viral disease (fever, myalgia, and arthralgia) and in severe cases, hemorrhagic manifestations may ensue. It is transmitted mainly through tick bite or animal contact but repeatedly has caused nosocomial outbreaks. 3–7 Human-to-human transmis- sion occurs by infected blood or secretions, but airborne trans- mission of the disease has not been documented. 8 We describe the manifestations and outcomes in three con- firmed cases of CCHF in healthcare workers in Iran. The risk factors and routes of transmission in a hospital setting are discussed. INDEX CASE 1 On August 2, 1999, a 55-year-old man (a shepherd) was referred to the emergency room of a hospital with hematem- esis. He had a history of animal contact. Epistaxis developed after a nasogastric tube was inserted in an attempt to con- trol gastrointestinal (GI) bleeding. Unfortunately, he died of intractable GI bleeding and disseminated intravascular coagu- lation (DIC) four days later. SECONDARY CASE 1 On August 16, 1999, a 32 -year -old man (a physician) came to a clinic in Shahrekord in central Iran with severe headache, malaise, fever, vomiting, and diarrhea for one week. Petechiae, epistaxis and gum bleeding then developed, which resulted in his referral to the clinic. He was admitted to a hospital and treated with broad-spectrum antibiotics. There was no his- tory of recent travel or contact with domestic animals. It was later discovered that he had been in contact with index case 1, who had died of severe GI bleeding two weeks before his first symptoms. The index case had coughed and splashed blood on the physician’s face while he was trying to insert a nasogastric tube. Physical examination showed right cervical lymphade- nopathy and a palpable spleen, but the patient was not febrile. Laboratory examinations showed leukopenia, thrombocytope- nia, increased levels of aminotransferases, an increased pro- thrombin time (PT) and partial thromboplastin time (PTT), and hematuria. Bone marrow aspiration and biopsy were per- formed but results were normal. A peripheral blood smear did not show any malignant cells or parasites. During hospi- talization, antibiotics and steroids were administered. After approximately one week, the patient recovered completely, all laboratory test results were normal, and he was discharged. At that time, he was not diagnosed with CCHF, but after the second nosocomial case was identified, he was suspected of having CCHF. He was diagnosed retrospectively after serum IgG and IgM enzyme-linked immunosorbent assay (ELISA) results were positive 3–4 weeks after his discharge. TERTIARY CASE 1 On August 28, 1999, a 26 -year-old woman (a physician) was admitted to the same hospital as secondary case 1. She had undulant fever, vomiting, and diarrhea for two days before admission. Vaginal bleeding developed on the day of admis- sion. She did not have any history of recent travel or contact with domestic animals, but she had close contact with second- ary case 1. This contact involved touching intact skin with- out gloves while trying to gain intravenous access for blood sampling. However, because there was no needlestick injury, this was a considered a low-risk procedure for transmission of CCHF. Sexual contact was likely because she had married sec- ondary case one month earlier. Physical examination showed fever, periorbital edema, and pale mucosa. Laboratory investi- gations showed thrombocytopenia, leukopenia, increased lev- els of aminotransferases, bilirubin, and lactate dehydrogenase, increased PT and PTT, and hematuria. She was treated with broad-spectrum antibiotics, dexamethasone, and other con- servative management, including platelet infusion. Two days after admission, confusion, generalized abdominal pain, and hematemesis developed in this patient. At that time, she was suspected of having viral hemorrhagic fever. Her samples were sent for evaluation to the National Insti- tute for Virology (NIV) in Sandringham, South Africa. After five days, the patient was transferred to a university hospital in Tehran. Coma, nystagmus, left-sided positive Babinski sign, rupture of a right ovarian cyst, and hemorrhagic cyst of the