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. 2025 Jan 29;10(2):39.
doi: 10.3390/tropicalmed10020039.

Intensive Therapeutic Plasma Exchange-New Approach to Treat and Rescue Patients with Severe Form of Yellow Fever

Yeh-Li Ho  1 , Youko Nukui  2 , Paula Ribeiro Villaça  2 , Erica Okazaki  2 , Nelson Hidekazu Tatsui  2 , Lucas Chaves Netto  1 , Daniel Joelsons  1 , Tania Rubia Flores da Rocha  2 , Fernanda de Mello Malta  3 , João Renato Rebello Pinho  3 , Aluisio Augusto Cotrim Segurado  1 , Vanderson Rocha  2   4   5
Affiliations

Intensive Therapeutic Plasma Exchange-New Approach to Treat and Rescue Patients with Severe Form of Yellow Fever

Yeh-Li Ho et al. Trop Med Infect Dis. .

Abstract

Background: Severe yellow fever (YF) can result in acute liver failure (ALF) and high mortality. The role of therapeutic plasma exchange (TPE) in managing YF-ALF remains unclear. This study evaluated the impact of TPE strategies in severe YF.

Methods: This observational case-series study evaluated three groups of patients classified according to treatment: G1 (standard intensive care support [ICS]), G2 (ICS + high-volume-TPE [HV-TPE]), and G3 (ICS + intensive TPE). HV-TPE was performed during 3 consecutive days with extra sessions of one plasma-volume, if necessary, whereas intensive TPE consisted of one plasma volume/session performed twice daily, with additional fresh frozen plasma infusion. Hemostatic agents, including tranexamic acid, platelets, and cryoprecipitate, were administered as needed. TPE was de-escalated based on clinical and laboratory parameters. The primary outcome was mortality.

Results: Sixty-six patients were included (G1: 41, G2: 11, G3: 14). Groups had similar baseline characteristics. Mortality was significantly lower in G3 (14%) compared to G2 (82%) and G1 (85%) (p < 0.001). Additionally, G3 patients showed a higher frequency of undetectable YF viral load.

Conclusions: Intensive TPE is a feasible and effective intervention for severe YF, achieving an 84% reduction in mortality. The limitations of our results are the small sample size, observational and single-center study. Further studies are warranted to elucidate intensive TPE's role in YF management.

Keywords: acute liver failure; arboviruses; critical care; flaviviruses; plasma exchange; yellow fever.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
Kaplan–Meier survival estimates during the first 30 days of follow-up according to treatment. Group 1 = intensive care support (ICS); Group 2 = ICS plus high-volume therapeutic plasma exchange (TPE) (HV-TPE); Group 3 = ICS plus intensive TPE.
Figure 2
Figure 2
Evolution of median levels of ammonia (A) and factor V (B) during the first seven days according to therapeutic plasma exchange (TPE). Group 2 (G2) = intensive care support (ICS) plus high-volume therapeutic plasma exchange TPE (HV-TPE) and group 3 (G3) = ICS plus intensive TPE. x: median G2 pre, ◦: median G2 post, +: median G3 pre, ∆: median G3 post.
Figure 2
Figure 2
Evolution of median levels of ammonia (A) and factor V (B) during the first seven days according to therapeutic plasma exchange (TPE). Group 2 (G2) = intensive care support (ICS) plus high-volume therapeutic plasma exchange TPE (HV-TPE) and group 3 (G3) = ICS plus intensive TPE. x: median G2 pre, ◦: median G2 post, +: median G3 pre, ∆: median G3 post.
Figure 3
Figure 3
Proportion of undetectable viral load (under 17 copies/mL) during the first five days according to therapeutic plasma exchange (TPE). Group 2 (G2) = ICS plus high-volume therapeutic plasma exchange TPE (HV-TPE); Group 3 (G3) = ICS plus intensive TPE.
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References

    1. Wilder-Smith A., Leong W.Y. Importation of yellow fever into China: Assessing travel patterns. J. Travel Med. 2017;24:tax008. doi: 10.1093/jtm/tax008. - DOI - PubMed
    1. Saúde S.d.V.e., editor. Monitoramento do Período Sazonal da Febre Amarela Brasil–2017/2018. Volume 27 Ministério da Saúde; Brasilia, Brazil: 2017/2018.
    1. Hamer D.H., Angelo K., Caumes E., van Genderen P.J.J., Florescu S.A., Popescu C.P., Perret C., McBride A., Checkley A., Ryan J., et al. Fatal Yellow Fever in Travelers to Brazil, 2018. MMWR Morb. Mortal Wkly. Rep. 2018;67:340–341. doi: 10.15585/mmwr.mm6711e1. - DOI - PMC - PubMed
    1. WHO . A Global Strategy to Eliminate Yellow Fever Epidemics 2017–2026. World Health Organization; Geneva, Switzerland: 2018.
    1. Monath T.P., Barrett A.D. Pathogenesis and pathophysiology of yellow fever. Adv. Virus Res. 2003;60:343–395. - PubMed

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