Hantavirus Pulmonary Syndrome Workup

  • Author: Burke A Cunha, MD; Chief Editor: Michael Stuart Bronze, MD   more...
 
Updated: Jun 21, 2011
 

Laboratory Studies

  • Usually, the patient has leukocytosis with a shift to the left, thrombocytopenia, and an elevated hematocrit value due to hemoconcentration.
  • Atypical lymphocytes are commonly seen in the peripheral smear. The presence of the leukocytosis with a shift to the left combined with the atypical lymphocytosis strongly suggests the presence of a Hantavirus infection.
  • If present, immunoblasts are diagnostic of HPS.
  • Hepatic transaminase values are only mildly elevated, but the serum lactate dehydrogenase level is markedly increased.
  • A mild elevation of the activated partial thromboplastin time occurs in most patients with a normal level of fibrinogen. A clue that disseminated intravascular coagulation has developed is when the concentration of fibrinogen begins to fall.
  • Significant elevation of creatinine and BUN levels is uncommon. Fifty percent of patients exhibit proteinuria, but not to the same degree as patients with hemorrhagic fever with renal failure syndrome (HFRS).
  • A low serum bicarbonate level reflects the degree of acidosis.
  • The serum albumin level is decreased in almost all patients with Hantavirus pulmonary syndrome (HPS). Although this depression represents an acute phase reactant that may be observed in many types of infections, the presence of severe hypoalbuminemia in a previously healthy patient with an acute onset of respiratory distress should suggest HPS.
  • The development of lactic acidoses, combined with rapid respiratory deterioration, usually indicates death within 1-2 days.
  • The serum creatine kinase level is elevated in 50% of patients.
  • Isolation of Hantavirus in tissue culture is not clinically available because of the technical difficulty of achieving this and because of issues related to biosafety.
  • Specific diagnosis may be achieved by serological techniques, polymerase chain reaction (PCR), and immunohistochemistry (IHC) studies.
    • PCR can help detect viral RNA in blood and tissues.
    • IHC can help detect viral RNA in formalin-fixed tissues with specific antibodies.
    • Most commonly, HPS is confirmed by Hantavirus immunoglobulin M (IgM)– and immunoglobulin G (IgG)–specific serology results, usually measured by performing an enzyme-linked immunoassay. Approximately one third of patients with HPS have an elevated IgM titer at the time of clinical presentation. Another one third of patients have elevated titers of IgM and IgG to Hantavirus at the time of presentation. The remaining third develop an increase in IgG titers without an increase in the IgM titer during convalescence.
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Imaging Studies

  • The chest radiographic findings typically show a pattern of noncardiac pulmonary edema.
    • The cardiac silhouette is not enlarged.
    • Perihilar haziness (shaggy heart sign) is characteristic.
    • Virtually all patients have interstitial edema due to pulmonary capillary leak, which manifests radiologically as peribronchial cuffing or Kerley B lines.
    • Pleural effusions are common.
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Other Tests

  • Arterial blood gas evaluation may reveal hypoxemia related to respiratory failure. The patient's concurrent hypocapnia confirms that the respiratory distress is not due to problems in ventilation but to those of gas exchange.
  • Patients with HPS have a normal pulmonary wedge pressure, decreased cardiac index, and elevated systemic vascular resistance.
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Histologic Findings

Histology of lung tissue reveals capillaritis, pulmonary capillary leak syndrome, or both. Hemorrhage is not a feature of HPS in lung sections (see Pathophysiology).

In patients with severe and/or prolonged hypotension, the kidneys may develop histological findings consistent with ATN.

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Contributor Information and Disclosures
Author

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Kenneth C Earhart, MD  Deputy Head, Disease Surveillance Program, United States Naval Medical Research Unit #3

Kenneth C Earhart, MD is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

John L Brusch, MD, FACP  Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD  Professor, Stewart G Wolf Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Association of Professors of Medicine, Association of Program Directors in Internal Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, and Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

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