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Hemorrhagic fever with renal syndrome - Diagnosis

Alexey Kryvenko, medical expert
Last reviewed: 03.07.2025

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Hemorrhagic fever with renal syndrome is characterized by a combination of acute onset of hemorrhagic fever with renal syndrome with the appearance of fever and symptoms of intoxication, kidney damage with the development of acute liver failure and hemorrhagic syndrome.

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Indications for consultation with other specialists

Consultation with a surgeon to rule out acute surgical diseases of the abdominal organs, if a kidney rupture is suspected. Consultation with a resuscitator in case of infectious toxic shock in acute renal failure to decide on hemodialysis.

Indications for hospitalization

Hemorrhagic fever with renal syndrome requires mandatory early hospitalization in infectious or therapeutic hospitals, regardless of the severity and period of the disease. Outpatient observation and treatment of hemorrhagic fever with renal syndrome is unacceptable. Transportation of the patient should be as gentle as possible, excluding jolts and shaking.

Differential diagnostics

Nosoforms	General symptoms	Differences
OGL	Acute onset, fever, hemorrhagic syndrome	Fever, two-wave hemorrhagic syndrome is weakly expressed, proteinuria is low. ARF does not develop. Abdominal and lumbar pain is absent or insignificant. CNS and lung damage is characteristic. Specific antibodies are detected in RSK and RN
Rickettsioses of the spotted fever group	Acute onset, fever, hemorrhagic syndrome, kidney damage	The fever is prolonged, the central nervous system and cardiovascular system are affected predominantly. The primary effect is a rash, abundant, predominantly roseous-maculopapular, with secondary petechiae, an enlarged spleen, polyadenopathy. In severe cases, nosebleeds. Kidney damage is limited to proteinuria. Specific antibodies are detected in RIF and RSK.
Meningococcemia	Acute onset of fever. Hemorrhagic syndrome. Kidney damage with development of acute renal failure.	During the first day, a hemorrhagic rash appears, acute renal failure hemorrhagic syndrome only against the background of ITS, which develops during the first day of the disease. Most patients (90%) develop purulent meningitis. Leukocytosis is noted. Meningococcus is detected in the blood and CSF bacterioscopically and bacteriologically, positive RLA
Acute surgical diseases of abdominal organs	Abdominal pain and tenderness on palpation, symptom of peritoneal irritation, fever, leukocytosis	Pain syndrome precedes fever and other symptoms. Pain and signs of peritoneal irritation are initially localized. Hemorrhagic syndrome and kidney damage are not typical. Neutrophilic increasing leukocytosis in the blood from the first hours of the disease
Acute diffuse glomerulonephritis	Fever, kidney damage with oliguria, possible acute renal failure, hemorrhagic syndrome	Fever, sore throat, acute respiratory infections precede kidney damage in periods from 3 days to 2 weeks. Characteristic are pale skin, edema, persistent increase in blood pressure. Hemorrhagic syndrome is possible against the background of azotemia, manifested by a positive tourniquet symptom, new bleeding
Leptospirosis	Acute onset, fever, hemorrhagic rash, lesions	The onset is violent, the fever is prolonged, myalgia is pronounced, often meningitis, jaundice from the first day, high leukocytosis. Proteinuria. Moderate or low. Anemia. Detection of leptospira in blood smears, urine, CSF, microneutralization reaction and RAL are positive.

Epidemiological history

Staying in an endemic area, nature of professional activity.

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Seasonality

Cyclic course with a natural change of infectious-toxic symptoms of the initial period (fever, headache, weakness, hyperemia of the face, neck, upper third of the chest, mucous membranes, injection of scleral vessels) signs of increasing renal failure of the oliguric period (pain in the lower back, abdomen; vomiting not associated with food intake; decreased visual acuity against the background of severe headache, dry mouth, thirst; severe hemorrhagic syndrome, decreased diuresis to less than 500 ml / day).

Non-specific laboratory diagnostics of hemorrhagic fever with renal syndrome

The information content of laboratory non-specific (general clinical, biochemical, coagulopathic, electrolyte, immunological) and instrumental (EGDS, ultrasound, CT, ECG, chest radiography, etc.) indicators is relative, since they reflect the severity of non-specific pathophysiological syndromes - acute renal failure, DIC and others, they should be assessed taking into account the period of the disease.

Clinical blood test: in the initial period - leukopenia, an increase in the number of erythrocytes, hemoglobin, a decrease in ESR, thrombocytopenia; at the height of the disease - leukocytosis with a shift in the formula to the left, an increase in ESR to 40 mm/h.

General urine analysis: proteinuria (from 0.3 to 30.0 g/l and higher), micro- and macrohematuria, cylindruria, Dunaevsky cells.

Zimnitsky test: hypoisosthenuria.

Blood biochemistry: increased concentration of urea, creatinine, hyperkalemia, hyponatremia, hypochloremia.

Coagulogram: depending on the period of the disease, signs of hypercoagulation (shortening of thrombin time to 10-15 sec, blood clotting time, increase in fibrinogen concentration to 4.5-8 g/l, prothrombin index to 100-120%) or hypocoagulation (lengthening of thrombin time to 25-50 sec, lengthening of clotting time, decrease in fibrinogen concentration to 1-2 g/l, prothrombin index to 30-60%).

Specific laboratory diagnostics of hemorrhagic fever with renal syndrome

RNIF: studies are conducted in paired sera taken at intervals of 5-7 days. An increase in the antibody titer by 4 times or more is considered diagnostically significant. The method is highly effective, the confirmability of the diagnosis reaches 96-98%. To increase the effectiveness of serodiagnosis of hemorrhagic fever with renal syndrome, it is recommended to collect the first serum before the 4th-7th day of the disease, and the second - no later than the 15th day of the disease. Solid-phase ELISA is also used, which allows determining the concentration of IgM antibodies. For the purpose of early diagnosis, PCR is used to detect fragments of viral RNA in the blood.

Instrumental diagnostics of hemorrhagic fever with renal syndrome

Ultrasound of the kidneys, ECG, chest X-ray.

Severity criteria for hemorrhagic fever with renal syndrome

Mild flow:
- fever (up to 38.0 C);
- oliguria (up to 900 ml/day);
- microproteinuria;
- microhematuria;
- serum urea concentration is normal, creatinine level increased to 130 μmol/l.
Moderate course:
- fever (up to 39.5 C);
- headache, frequent vomiting;
- intense pain in the lumbar region, abdominal pain;
- hemorrhagic rash;
- oliguria (300-900 ml/day);
- moderate azotemia (blood plasma urea up to 18 mmol/l, creatinine up to 300 μmol/l).
Severe course:
- complications in the form of ITS and acute vascular insufficiency;
- hemorrhagic syndrome;
- oliguria (less than 300 ml/day) or anuria;
- uremia (urea concentration above 18.5 mmol/l, creatinine above 300 μmol/l).
Precursors of the development of a severe form (on the 2nd-4th day of illness):
- severe pain in the lower back and abdomen;
- a sharp decrease in visual acuity against the background of severe headache, dry mouth and thirst;
- repeated vomiting not associated with food intake;
- severe hemorrhagic syndrome:
- oliguria (less than 500 ml/day);
- leukocytosis;
- massive proteinuria (3.3 g/l or more);
- a sharp increase in the concentration of urea and creatinine from the 3rd day of illness.

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Differential diagnosis of hemorrhagic fever with renal syndrome

Differential diagnostics of hemorrhagic fever with renal syndrome is carried out with other hemorrhagic fevers, however, the area of their distribution does not coincide with the area of distribution of hemorrhagic fever with renal syndrome, except for OHF. In the initial period of the disease, differential diagnostics are carried out with influenza, rickettsiosis, tick-borne encephalitis, and later with diseases characterized by a triad of symptoms: fever, kidney damage, hemorrhagic syndrome. Differential diagnostics with acute surgical diseases of the abdominal cavity is relevant.

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