the disease involves the multi - organ systems ; clinical findings include a rapid progression characterized by hemorrhage , fever , myalgia and liver dysfunction . after first detection of the disease in turkey in 2002 , increasing numbers of patients have been diagnosed with cchf . by the end of june 2008 , a total of 2508 confirmed cases including 133 deaths ( 5.3% ) were reported by the turkish ministry of health . the involvement of the heart in adult patients has been described previously in our center . patients younger than 16 years of age and diagnosed with cchf were enrolled in the study . the diagnosis of cchf infection was based upon typical clinical and epidemiological findings and serological tests with elisa ( anti - cchf igm and igg antibodies ) or of genomic segments of the cchf virus by reverse transcription - polymerase chain reaction ( rt - pcr ) either in the acute and/or convalescent phase of the disease . serum samples of the patients were sent to the virology laboratory of refik saydam hygiene central institute , ankara , turkey for microbiological testing for cchf virus infection . a standard 12-lead electrocardiography was obtained . following this , within 24 hours of hospitalization , all patients underwent a transthoracic echocardiography examination using an appropriate probe ( vivid 7 ge medical system , horten , norway ) , performed by an echocardiographer who was blinded to the study . the same echocardiographer measured the ventricular ( by modified simpson s method ) and valvular functions , wall motions , and presence of pericardial effusion according to the recommendations of recent guidelines . all patients were given general supportive therapy including monitoring of vital signs , replacement of fluid and electrolytes and administration of platelets , and fresh frozen plasma and blood transfusion , depending on their hemostasis . intravenous ribavirin was administered at the dosage recommended by the who ( 30 mg / kg as an initial loading dose , then 15 mg / kg every 6 hours for 4 days , and then 7.5 mg / kg every 8 hours for 6 days ) . the total duration of treatment was 10 days . the local human ethics committee approved the study , and informed consent was obtained from the parents of patients . fifty - two consecutive patients who were hospitalized with a tentative diagnosis of cchf were enrolled in the study . the diagnoses of 23 out of 52 consecutive patients with a tentative diagnosis of cchf were verified . seven of 23 patients ( 30% ) had cchf virus - specific igm antibodies , 5/23 ( 22% ) had a positive rt - pcr test for cchf virus , and 11/23 ( 48% ) were positive in both tests during the acute and/or convalescent phase of the disease . demographic , clinical and laboratory data were shown in table 1 . there was no mortality and all were healed and discharged after a mean of 8 ( 710 ) days . on electrocardiography , all patients were on sinus rhythm , mean heart rate was 949 bpm , the mean interval of pr was 848 msn , the mean of interval of qrs was 908 msn , and the mean of interval of qt was 29322 msn . left ventricular ejection fractions ( lvef ) measured by echocardiography were within normal ranges 575% ( 5066 ) . interestingly , 15 patients ( 65% ) had segmental wall motion abnormalities ( hypokinesia ) ; 10 on interventricular septum ( ivs ) , 1 on anterior wall of lv , and 4 on both ivs and anterior wall . second echocardiography revealed that all wall motion abnormalities had disappeared and pericardial effusion persisted in only 2 of 7 ( 28% ) patients . pericardial effusion and wall motion abnormalities are the major findings defining the cardiac involvement . no valvular lesions or electrocardiographic abnormalities were detected . the other interesting finding of the study was that almost all cardiac abnormalities were completely reversible . according to the turkish ministry of health , cchf most frequently occurs in the 6th decade ( 17.1% ) of life and at a relatively lower frequency in the 1st ( 3.5% ) and 2nd ( 12.6% ) decades . two prior studies included a total of 52 pediatric patients ; 1 patient ( 2% ) died . if added to our 23 patients without mortality , the mortality rate of cchf in children can be considered as 1/75 ( 1.3% ) . given a > 5% mortality rate in adults , the clinical course of cchf among children seems to be milder than in adults . its prognostic value could not be evaluated in this study because no mortality was seen and there is no disease classification such as swanepoel s for pediatric patients . the specific mechanisms underlying the pathogenesis of cchf infection have not been clearly explained [ 79 ] . mononuclear phagocytes , hepatocytes , and endothelial cells are major targets of the cchf virus . endothelial damage contributes to hemostatic failure by stimulating platelet aggregation and degranulation , and , consequently , activation of the intrinsic coagulation cascade . myocarditis and cardiomyopathy can be caused by several viruses ; hemorrhagic fever viruses can also cause cardiac involvement [ 1115 ] . there is insufficient data about cardiac involvement in cchf from postmortem studies , and little is known about the effect of cchf virus on the heart . the observation of cardiac congestion and edema in a fatal cchf case may support cardiac involvement . the wall motion abnormalities of our patients might have been due to involvement of the myocardium by the cchf virus and/or myocardial endothelial injury . a case report of a patient with cchf and pleural effusion defined the fluid as being of a hemorrhagic nature . echocardiographic examination may be helpful in detecting myocardial involvement . a recent study by engin et they investigated 44 patients with cchf , but did not report the electrocardiographic findings of the patients . on echocardiography , they found that 8 ( 18% ) patients had wall motion abnormality ( 3 global and 5 anterior wall ) and 19 patients ( 43% ) had pericardial effusion . pericardial effusion was more frequently seen in severe cases and those in whom lvef was more reduced . in that study , the characteristics of patients who died were compared to surviving patients and it was found that pericardial effusion , reduced lvef and wall motion abnormalities were more frequent in fatal cases . wall motion abnormality was observed in 65% of our patients and pericardial effusion in 30% . pericardial effusion was observed in 14% the non - fatal cases by engin et al . these findings suggest that cardiac involvement is seen more frequently , but more mildly , in children with cchf than in adults . engin et al did not report whether the cardiac findings were reversible . in all of our patients except 2 , all cardiac abnormalities were resolved at discharge . the higher rate of wall motion abnormality and pericardial effusion ( compared to non - fatal cases ) in children could not be explained . for example , although similar data are not available for children , complete recovery is more likely in adults with fulminant compared to acute viral myocarditis . electrocardiographies of our patients revealed no abnormality , suggesting that cchf does not involve the conduction system of children s hearts . cardiac involvement appears to be more frequent in children with cchf disease than in adults , but it is milder and almost completely reversible . however , the course of the disease in children is milder than it is in adults .
summarybackgroundcrimean - congo hemorrhagic fever ( cchf ) involves the multi - organ systems . 
 the involvement of the heart in adult patients has been described previously . 
 we investigated the electrocardiographic and echocardiographic findings of pediatric patients with cchf.material/methodspatients younger than 16 years of age diagnosed with cchf were enrolled in the study . 
 the diagnosis of cchf infection was based upon typical clinical and epidemiological findings and serological tests . 
 all patients underwent a thorough cardiologic evaluation . 
 a standard 12-lead electrocardiography and echocardiography were performed.resultstwenty-three consecutive patients who were hospitalized with diagnosis of cchf were enrolled in the study ( mean age : 122 years , 6 female ) . 
 all electrocardiographic parameters were within normal ranges according to age . 
 seven patients ( 30% ) had minimal ( < 1 cm ) pericardial effusion . 
 fifteen ( 65% ) patients had segmental wall motion abnormalities ( hypokinesia ) . 
 a second echocardiography revealed that all wall motion abnormalities had disappeared ; the pericardial effusion persisted in only 2 of 7 patients ( 28%).conclusionscardiac involvement appears to be more frequent in children with cchf disease than in adults , but it is slighter and almost totally reversible ; however , the course of the disease in children is milder than it is in adults .