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Pulmonary Complications in Fatal Yellow Fever, Brazil, 2017-2019.

Amaro N Duarte-Neto, Katia C Dantas, Suzette C Ferreira

Emerging Infectious Diseases

|February 19, 2026

Summary

Yellow fever (YF) causes severe hepatitis, but this study found significant respiratory tract pathology in fatal cases. Autopsies revealed widespread lung damage, edema, and secondary infections, highlighting the importance of respiratory monitoring in YF.

Keywords:

Brazil autopsy bacteria epidemic fungal infections fungi pneumonia sepsis vector-borne infections viruses yellow fever yellow fever vaccine

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Area of Science:

Pathology
Virology
Public Health

Background:

Yellow fever (YF) is primarily known for causing severe hepatitis.
Data on pulmonary pathology in fatal YF cases are limited.
Understanding YF's full impact is crucial for managing outbreaks.

Purpose of the Study:

To investigate respiratory tract pathology in fatal Yellow Fever cases.
To identify co-pathogens contributing to mortality.
To inform diagnosis and public health strategies for YF.

Main Methods:

Autopsy examination of 73 fatal YF cases from the 2017-2019 São Paulo epidemic.
Histopathological analysis of lung tissue.
Molecular detection of YF virus and co-pathogens (bacterial, fungal).
Electron microscopy in select cases.

Main Results:

All patients had YF-related fulminant hepatitis.
Autopsies showed frequent tracheitis (91%), pulmonary edema/hemorrhage (100%), diffuse alveolar damage (84%), secondary pneumonia (84%), and bronchoaspiration (60%).
YF virus antigens and RNA were detected in most cases; bacterial and fungal pathogens were identified in secondary pneumonias.
Hemorrhage and diffuse alveolar damage were prominent in vaccine-associated viscerotropic disease cases.

Conclusions:

Severe Yellow Fever significantly impacts the respiratory tract, extending beyond hepatitis.
Respiratory complications like edema, pneumonia, and aspiration are common in fatal YF.
Findings support enhanced respiratory monitoring and preparedness for future YF outbreaks.