Multiple Crimean-Congo hemorrhagic fever virus (CCHFV) variants and strains, associated with CCHF outbreaks, have recently been reported in Alfulah, Western Kordufan  and in Abyei, Southern Kordufan of Sudan . However, CCHF has never been reported in North Kordufan. In this study, a nosocomial transmission of CCHF has been reported in an attending physician in North Kordufan as a result of medical referral of an infected patient from an endemic area in Lagawa District, South Kordufan. In the present study, rapid diagnosis of the disease was achieved using conventional nested RT-PCR. The nested RT-PCR assay could be used for detection of CCHFV in a simple laboratory setting. In addition, the assay detected the multiple CCHFV strains identified, so far, in Sudan. The first RT-PCR round of amplification would be sufficient for detection of CCHFV in sera sampled during acute phase of the disease, as the titer of the virus is usually high during this period, which allows for molecular characterization studies without initial amplification of the virus in cell culture. However, the second round of nested amplification may only be required, at later stage of the disease, when the concentration of the virus in sera or tissue samples is very low. The well characterized primers designed from a highly conserved region of the S-segment RNA would be expected to detect the African CCHFV variants in group III virus lineage and would probably detect the remaining CCHFV from other virus lineages.
The source of the infection of the index patient was considered to be the result of consumption of raw sheep liver. In certain areas of Sudan, the social habit of consumption of raw offals of cattle and raw livers of sheep with bile and spices is not uncommon, which serves as a means of transmission of various communicable diseases  and CCHF is not an exception. It is noteworthy that seasonality for CCHFV infection is quite evident and usually coincides with the influx of sheep from rural areas and villages to towns and major cities on certain religious occasions . Under these circumstances, the animal attendants typically live in close contact with their animals. This will increase the risk of acquiring CCHFV infection through direct contact with infected animals or ticks.
Taking into consideration the identification of multiple virus variants and strains in human cases from Alfulah (2010) and Abyei districts of Kordufan region (2011), in addition to the two CCHF cases mentioned in the present study, it is likely that these CCHFV strains or variants have been actively circulating in Western Sudan, yet undetected for decades. In fact, sporadic cases and outbreaks of acute febrile hemorrhagic illnesses compatible with CCHF have long been observed in Kordufan region for several past decades, but the virus was not identified until very recently . Given the fact that most of CCHF sporadic cases and outbreaks occur in villages and remote areas, together with combined unfamiliarity of the Sudanese physicians with clinical signs and symptoms of CCHFV infections, it is most likely that CCHF cases can easily pass unreported or misdiagnosed. Currently, CCHF is not considered in the differential diagnosis of acute hemorrhagic illness in Sudan.
In Sudan, fever of unknown etiology is not uncommon, but malaria is usually considered to be the primary cause . The first line of treatment in the hospitals focused primarily on prescription of anti-malarial medication but without improvement. Findings of this study illustrate that malaria positive result does not necessarily eliminates the possibility of co-infection with other viral hemorrhagic fever agents. Interestingly enough, both patients were malaria positive as is the case with Alfulah and Abyei CCHF outbreaks [4, 5]. Currently we do not have an explanation for the association of malaria and CCHF positive cases. Therefore, physician should consider CCHF in their differential diagnosis when dealing with malaria cases in CCHF areas of endemicity.
In the present study, we confirmed that cluster of two cases was due to CCHFV as determined by RT-PCR and serology. Clearly, the disease is becoming endemic in most areas of Kordufan region of Sudan. The two CCHFV strains involved are identical and belonged to group III virus lineage as determined by the S segment partial sequences and subsequent phylogenetic analysis . The name Lagawa strain was initially proposed for this CCHFV strain. The partial S segment sequence of Lagawa strain, described in this study, shows 99% homology to Alfulah strain (GenBank accession number GQ862371) previously described by Aradaib et al., . It is suggested that whole genome of this CCHFV strain be sequenced to obtain better information on the virus and the possibility of genetic reassortment and/or recombination events [8, 20, 21].
The CCHFV is susceptible to ribavirin in vitro but there is no controlled study evaluating oral versus intravenous ribavirin in treating infected patients. However, few studies have evaluated oral ribavirin. Oral ribavirin, at a dose rate of 200 mg twice daily for 5 days, is the recommended dosage for post-exposure prophylaxis . In the present study, prescription of oral ribavirin, at a dose rate of 500 mg 4 times a day for 5 days, and administration of platelets concentrate resulted in rapid improvement of the health condition of the physician. Intravenous compensation with blood, platelets concentrate and fluid therapy (dextrose and saline), augmented oral ribavirin therapy as demonstrated by dramatic increase in blood platelets counts. The treatment resulted in improved health condition of the female physician.
In conclusion, this study highlights the need to include CCHF in the differential diagnosis, when fever with hemorrhagic tendencies is observed in clinical centers and hospitals in the Kordufan region, Sudan. The frequent occurrence of sporadic cases and multiple CCHF outbreaks, and the risks these cases pose for medical staff in resource-poor health care facilities, necessitates the need for improved surveillance programs and prevention measures for this important viral disease in Sudan.