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INTRODUCTION
Yellow fever is a mosquito-borne viral hemorrhagic fever with a high case-fatality rate. Clinical
manifestations include hepatic dysfunction, renal failure, coagulopathy, and shock. Travelers to
tropical regions of South America and sub-Saharan Africa where the disease is endemic are at
risk for acquisition of infection and require immunization.
Yellow fever is the prototype member of the family Flaviviridae, a group of small (40 to 60 nm),
enveloped, positive-sense, single-stranded RNA viruses that replicate in the cytoplasm of
infected cells. Yellow fever virus is a single serotype and is antigenically conserved, so the
vaccine protects against all strains of the virus. At the nucleotide sequence level, it is possible to
distinguish seven major genotypes representing West Africa (two genotypes), Central-East
Africa and Angola (three genotypes), and South America (two genotypes) [1,2].
The yellow fever virus re-emerged in large outbreaks in Africa (2015 to 2016) and Brazil (2016 to
2018). Phylogenetic studies demonstrated that the 2016 strains were similar to Angola 1971
strains and only three amino acid changes were new to other lineages [3]. In Brazil,
cocirculation of two distinct yellow fever virus clades occurring in humans and nonhuman
primates suggests multiple sylvatic transmission cycles [4].
Humans are highly susceptible to infection and disease. Most nonhuman primate species are
susceptible to infection, and some species of nonhuman primates develop clinical
manifestations.
Yellow fever is characterized by hepatic dysfunction, renal failure, coagulopathy, and shock [5-
8]. The midzone of the liver lobule is principally affected, with sparing of cells bordering the
central vein and portal tracts [9]. Viral antigen localizes to the midzone, indicating that it is the
site of direct viral injury. Very high virus loads have been found in the liver and spleen of fatal
cases [10].
Renal damage is characterized by eosinophilic degeneration and fatty change of renal tubular
epithelium without inflammation. These findings are believed to be a result of both direct viral
injury and nonspecific changes due to hypotension and the hepatorenal syndrome [7].
Focal injury to the myocardium, characterized by cell degeneration and fatty change, is the
result of viral replication.
The hemorrhagic diathesis in yellow fever is due to decreased synthesis of vitamin K-dependent
coagulation factors by the liver, disseminated intravascular coagulation, and platelet
dysfunction.
The late phase of the disease is characterized by circulatory shock. The underlying mechanism
may be cytokine dysregulation, as in the sepsis syndrome. In a series of patients with fatal
yellow fever, levels of proinflammatory cytokines (interleukin [IL]-6, IL-1 receptor antagonist,
tumor necrosis factor [TNF]-alpha, and interferon-inducible protein-10) were elevated compared
with patients with nonfatal yellow fever [13]. Patients dying of yellow fever have cerebral edema
at autopsy, probably the result of microvascular dysfunction. Large amounts of complement-
fixing antigen (presumably NS1) have been found in blood of severely ill yellow fever patients
[14].
Some nonhuman primate species develop fatal infection with features similar to the disease in
humans [7]. A model of yellow fever infection in hamsters has been described [15,16]. Clinical,
immunologic, and pathologic features resemble human infection, suggesting that this model
might serve to increase the understanding of the pathogenesis of infection and to explore
possible treatments. Interferon-alpha/beta receptor-deficient mice are also susceptible to
viscerotropic infection [17].
EPIDEMIOLOGY
The incidence of yellow fever in Africa varies widely, and the disease occurs in epidemics [18]. A
large Aedes aegypti–borne epidemic occurred in Angola and neighboring Democratic Republic of
the Congo in south/central Africa between December 2015 and July 2016 with over 2930
confirmed or suspected cases and 253 deaths and resulting in the emergency distribution of 30
million doses of vaccine [22-24]. Mosquito-borne epidemics in Africa occur where large human
populations reside in high density and immunization coverage is low. The highest number of
outbreaks has occurred in West Africa, but this situation is changing due to a concerted effort
to undertake mass immunization campaigns in that region. Human-to-human transmission in
the absence of the mosquito has not been reported.
Fewer cases occur in South America than in Africa because transmission occurs from enzootic
sources (principally from monkey to human via mosquito vectors), the vector density is
relatively low, and vaccination coverage is relatively high (80 to 90 percent in endemic areas of
South America). In typical years, there are several hundred cases officially notified, but in
epidemic years up to 5000 cases are reported. Between 2016 and 2018, rapid expansion of a
severe sylvatic yellow fever virus outbreak occurred in southeastern Brazil. This outbreak
reached one of the most populated metropolitan areas in Brazil that had been yellow fever-free
for more than 70 years [25]. Between January and March 2018, one report noted 79 patients
with severe yellow fever in Sao Paolo required intensive care [26].
In Africa and South America, only a small proportion of cases is officially recorded because the
disease often occurs in remote areas, recognition of outbreaks is delayed, and diagnostic
facilities are limited. In Africa, reports of outbreaks in the 1980s noted the incidence of yellow
fever infection to be 20 to 40 percent, the incidence of severe disease to be 3 to 5 percent, and
the case-fatality rate to be 20 to 30 percent. In contrast, case-fatality rates in South America are
consistently 50 to 60 percent. It is uncertain whether these disparities reflect reporting artifact,
a real difference in virus strain virulence, and/or differing genetic susceptibility of the human
populations. A racial difference in susceptibility is likely, supported by an analysis of
epidemiologic data from an 1878 epidemic in Tennessee, in which yellow fever attack rates were
similar in the Caucasian and non-Caucasian populations of the city, but the case-fatality rate
was 6.8-fold higher in Caucasians [27].
Yellow fever epidemics have never been reported in Asia, and introduction to that region could
have devastating effects since there is no background of specific immunity, and the urban
vector (Aedes aegypti) is prevalent. In the context of the 2016 yellow fever outbreak in Angola, at
least 11 Chinese workers developed yellow fever upon travel home to China, illustrating the
danger of introduction and potential secondary spread [28].
Prior to the reports among travelers from Angola, yellow fever in expatriates and travelers to
and from Africa and South America had been rare; since the introduction of vaccination after
World War II, ten cases had been recorded up to the time of the 2016 Angolan outbreak [10,29-
33]. During the Angola outbreak, 11 Chinese construction workers were infected while working
in Angola and subsequently exported the virus upon return to China; this was the first
documented exportation of yellow fever into Asia. Subsequent analyses showed that the
majority of Chinese workers in Angola had not been vaccinated [34]. The outbreak in Brazil
resulted in more exportation of yellow fever via travelers than in the previous decades [35]. (See
'Outbreak in South America' below.)
Since January 2018, 10 travel-related cases have been reported in international travelers
returning from Brazil, including four deaths; none of the 10 travelers had received yellow fever
vaccination [35]. In March 2018, the United States Centers for Disease Control and Prevention
issued an advisory which expanded the regions within Brazil for which travelers should receive
yellow fever vaccine [40-42]. In 2018, five countries in the Americas reported confirmed cases of
yellow fever: Bolivia, Brazil, Colombia, French Guiana, and Peru. As of September 2019, three
countries in the Region of the Americas reported yellow fever (Bolivia, Brazil, and Peru) [43].
Transmission cycles — The primary transmission cycle involves monkeys and daytime biting
mosquitoes (Aedes species in Africa, Haemagogus species in South America).
In Africa, a wide array of Aedes vectors is responsible for transmission. During the rainy season,
the virus circulates via mosquitoes in the savanna vegetational zone in proximity to human
settlements. Both humans and nonhuman primates can be hosts in the transmission cycle, and
the rate of virus transmission may accelerate to reach epidemic levels. Aedes aegypti, a common
domestic mosquito that can breed in containers used to store potable water in heavily settled
areas, is capable of serving as an epidemic vector with humans as the intermediate viremic
hosts (so-called "urban yellow fever").
In South America, the larval development of mosquitoes occurs in areas such as tree holes
containing rainwater. Persons entering forested areas are at risk of infection (so-called "jungle
yellow fever"); this accounts for the predominance of cases among young males engaged in
forest clearing and agriculture. In the 1970s, the Aedes aegypti mosquito reinvaded areas of
South America where it previously had been eradicated, increasing the risk that urban yellow
fever may re-emerge. The first well-documented instance of an urban-cycle epidemic since 1942
occurred in Paraguay in 2008 [44].
CLINICAL MANIFESTATIONS
Yellow fever affects all ages, but disease severity and lethality is highest in older adults. The
onset of illness appears abruptly three to six days (median 4.3 days) after the bite of an infected
mosquito [46]. The classical illness is characterized by three stages:
● Period of infection
● Period of remission
● Period of intoxication
Period of infection — The period of infection consists of viremia, which lasts for three to four
days. The patient is febrile and complains of generalized malaise, headache, photophobia,
lumbosacral pain, pain in the lower extremities, myalgia, anorexia, nausea, vomiting,
restlessness, irritability, and dizziness [47]. Symptoms and signs are relatively nonspecific; at
this phase, it is virtually impossible to distinguish yellow fever from other acute infections.
On physical examination, the patient appears acutely ill with flushed skin, reddening of the
conjunctivae and gums, and epigastric tenderness. Enlargement of the liver with tenderness
may be present. The tongue is characteristically red at the tip and sides with a white coating in
the center. The pulse rate is slow relative to the height of the fever (Faget's sign). The
temperature is typically 39ºC but may rise as high as 41ºC.
Laboratory abnormalities include leukopenia (1500 to 2500 per microL) with relative
neutropenia; leukopenia occurs rapidly after the onset of illness. Serum transaminase levels
start to rise 48 and 72 hours after onset of illness, prior to the appearance of jaundice. The
degree of liver enzyme abnormalities at this stage may predict the severity of hepatic
dysfunction later in the illness [48].
Period of remission — A period of remission lasting up to 48 hours may follow the period of
infection, characterized by the abatement of fever and symptoms. Patients with abortive
infections recover at this stage. Approximately 15 percent of individuals infected with yellow
fever virus enter the third stage of the disease.
Period of intoxication (severe yellow fever) — The period of intoxication begins on the third
to sixth day after the onset of infection with return of fever, prostration, nausea, vomiting,
epigastric pain, jaundice, oliguria, and hemorrhagic diathesis. The viremia disappears at this
stage and antibodies appear in the blood, although ongoing viremia has also been reported
[49]. Patients with viral loads of ≥5.1 log copies/mL had an extremely high mortality in the
Brazilian experience [49]. This phase is characterized by variable dysfunction of multiple organs
including the liver, kidneys, and cardiovascular system. Multiorgan failure in yellow fever is
associated with high levels of proinflammatory cytokines similar to that seen in bacterial sepsis
and systemic immune response syndrome (SIRS) [31].
Hepatic dysfunction — Hepatic dysfunction due to yellow fever differs from other viral
hepatitides in that serum aspartate aminotransferase (AST) levels exceed those of alanine
aminotransferase (ALT). This may be due to concomitant viral injury to the myocardium and
skeletal muscle. The levels are proportional to disease severity. In one study, the mean AST and
ALT levels in fatal cases were 2766 and 660 U, respectively, while in surviving patients with
jaundice, the mean levels were 929 and 351 U [50]. Alkaline phosphatase levels are normal or
only slightly elevated. Direct bilirubin levels are typically between 5 and 10 mg/dL, with higher
levels in fatal than in nonfatal cases [51].
Pancreatitis — Among patients with severe yellow fever reported from the 2018 Brazilian
epidemic, the incidence of pancreatitis was 58 percent [26].
Outcome — The outcome is determined during the second week after onset, at which point the
patient either dies or rapidly recovers. Approximately 20 to 50 percent of patients who enter the
period of intoxication succumb to the disease. Poor prognostic signs include anuria, shock,
hypothermia, agitation, delirium, intractable hiccups, seizures, hypoglycemia, hyperkalemia,
metabolic acidosis, Cheyne-Stokes respirations, stupor, and coma. A study in a tertiary hospital
setting in Brazil identified the following predictive factors for progression to severe yellow fever:
older age, male sex, elevated leukocyte and neutrophil counts, elevated alanine
aminotransferase, aspartate transaminase (AST), bilirubin, creatinine, prolonged prothrombin
time, and higher yellow fever virus RNA plasma viral load. In a multivariate regression model,
older age, elevated neutrophil count, increased AST, and higher viral load were independently
associated with death [49].
Convalescence may be associated with fatigue lasting for several weeks. In some cases,
jaundice and serum transaminase elevations may persist for months, although such patients
may have yellow fever superimposed on other hematologic or hepatic diseases. The outcome of
yellow fever appears to be comparable in patients with or without hepatitis B surface
antigenemia.
DIAGNOSIS
Diagnosis is made by serology, detection of viral genome by polymerase chain reaction (PCR),
by viral isolation or histopathology, and immunohistochemistry on postmortem tissues.
Rapid diagnostic tests — Rapid diagnostic tests include PCR to detect viral genome in the
blood or tissue and ELISA for determination of IgM antibody [10]. Next-generation sequencing
of RNA directly amplified from blood has been used to confirm the diagnosis and compare the
patient’s strain to known geographic clades of the virus. These tools are increasingly available in
national and regional laboratories in the endemic areas. A reverse-transcription loop-mediated
isothermal amplification (RT-LAMP) yellow fever diagnostic test, which does not require
thermocycling equipment and can be read visually, has shown promise as a sensitive and rapid
test for use in field conditions [56].
Pathology — Liver biopsy during illness due to yellow fever should never be performed, since
fatal hemorrhage may ensue. Postmortem histopathologic examination of the liver often
demonstrates the typical features of yellow fever including midzonal necrosis. A definitive
postmortem diagnosis may be made by immunocytochemical staining for yellow fever antigen
in the liver, heart, spleen, or kidney [58-60]. (See 'Virology, pathogenesis, and histopathology'
above.)
DIFFERENTIAL DIAGNOSIS
● Dengue – Dengue and yellow fever are similar in that both are associated with fever,
headache and body aches, and hemorrhagic manifestations. Hepatic involvement can
occur in the setting of severe dengue infection [61]. The diagnosis of dengue is established
by serology. (See "Dengue virus infection: Clinical manifestations and diagnosis".)
● Q fever – Q fever occurs as a result of infection with Coxiella burnetii; hepatic involvement
includes elevated transaminases, hepatomegaly without jaundice, and granulomas on liver
biopsy. The diagnosis is established by serology. (See "Clinical manifestations and diagnosis
of Q fever".)
● Hemorrhagic fever – Yellow fever may be distinguished from other viral hemorrhagic fevers
(Lassa fever, Marburg virus, Ebola virus, Bolivian and Argentine hemorrhagic fevers) in that
these other viral hemorrhagic fevers are not usually associated with jaundice. However,
Congo-Crimean hemorrhagic fever may be associated with severe liver damage; Rift Valley
fever and dengue hemorrhagic fever may present with this complication as well. (See
related topics.)
● Mosquito-borne epidemics in Africa occur where human populations reside in high density
and immunization coverage is low (so-called "urban yellow fever"). Fewer cases occur in
South America than in Africa because transmission occurs principally from monkey to
human via mosquito vectors, the vector density is relatively low, and vaccination coverage
is relatively high (so-called "jungle yellow fever"). (See 'Epidemiology' above.)
ACKNOWLEDGMENTS
The editorial staff at UpToDate would like to acknowledge Thomas Monath, MD, FACP, FASTMH,
and Edward T Ryan, MD, DTMH, who contributed to an earlier version of this topic review.
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Contributor Disclosures
Annelies Wilder-Smith, MD, PhD Nothing to disclose Martin S Hirsch, MD Nothing to disclose Elinor L
Baron, MD, DTMH Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
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