Hantavirus Cardiopulmonary Syndrome Follow-up

  • Author: Juliet D Caldwell, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Apr 21, 2011
 

Further Inpatient Care

Ventilator management

High positive end-expiratory pressure (PEEP) and high fraction of inspired oxygen (FIO2) are often useful.

Pressure-controlled ventilation and inverse inspiration/expiration (I/E) ratio ventilation are beneficial in select cases.

Hemodynamic management

Careful hemodynamic management optimizes survival.

Maintain mean arterial pressure greater than 70 mm Hg through a measured use of fluids and pressors.

Use pulmonary artery catheterization to avoid fluid overload: Maintain PAOP at 12 mm Hg or below.

Use vasoactive infusions early and liberally. (See Medication.)

Extracorporeal membrane oxygenation (ECMO)

The University of New Mexico Hospital (located in southeast corner of the four corners region) performed extensive research from 1994-2006 to determine the usefulness of ECMO rescue therapy in Hantavirus cardiopulmonary syndrome (HCPS). Given its investigational status, only patients with an estimated 100% mortality rate and with clinical and laboratory evidence of HCPS were eligible to receive ECMO. Qualified patients had to demonstrate a cardiac index of less than 2 L/min, a PaO2/FIO2 ratio of less than 60, as well as refractory shock not responsive to standard medical therapy. Remarkably, among the 38 patients who qualified, approximately two thirds survived to recover completely.[31] The cardiovascular collapse of HCPS is profound but uniquely brief; rescue bridging with ECMO yields complete recovery in many previously determined to be irrecoverable.

ECMO therapy improves survival in a select group of patients with severe disease; an early effort should be made to transfer patients suspected of having HCPS to facilities capable of ECMO.[31, 24, 39] It is possible that earlier institution of ECMO could yield even greater survival benefits.

Patients with prolonged cardiac arrest or prolonged cerebral hypoxia are not candidates for ECMO.

Next

Transfer

Most cases of HCPS occur in rural communities where facilities equipped for aggressive intensive care are often lacking. Given the precipitous nature of this disease:

  • Transport early: A patient who subsequently "rules out" at a tertiary care center is preferable to a patient who deteriorates suddenly and dies en route.
  • Transport quickly: Use the fastest and best-equipped transport, which may be a fixed-wing aircraft, rotor, or ground transportation, depending on proximity.
  • Transport to the highest level care center possible: Again, anticipate the need for intensive care and possibly ECMO.
  • Prepare for clinical decline en route: Anticipate administering aggressive fluid replacement and vasopressors.
Previous
Next

Deterrence/Prevention

The best way to prevent HCPS is to avoid all exposure to rodents, especially deer mice, and their excreta.

Tips on rodent-proofing homes indoors and outdoor may be found at All About Hantaviruses - Prevention Indoors and Outdoors.

Never sweep or vacuum rodent-infested areas as this further aerosolizes the virus. Instead, wet the area thoroughly with disinfectant before cleaning, wearing rubber gloves. Other tips on cleaning infested areas may be viewed at All About Hantaviruses - Clean Up Infested Areas, Using Safety Precautions.

Homes with heavy infestations or homes of patients with confirmed HCPS require special precautions for cleaning. Contact the local health department for guidance. CDC recommendations may be found at All About Hantaviruses - Special Precautions for Homes of Persons with Confirmed Hantavirus Infection or Buildings with Heavy Rodent Infestations.

Persons who frequently handle or are exposed to rodents (eg, mammalogists, pest-control workers) in affected areas are probably at higher risk for Hantavirus infection than the general public because of their frequency of exposure. Therefore, enhanced precautions are warranted to protect them against Hantavirus infection. These precautions may be found at All About Hantaviruses - Precautions for Workers in Affected Areas Who are Regularly Exposed to Rodents.

Vaccines

Presently, no vaccines are approved for use against Hantaviruses in the United States. However, researchers are exploring the efficacy and safety of killed-virus vaccines as well as DNA vector derived antigen vaccines with some promising results in human and animal models.[23, 40, 41, 42, 43]

China and Korea offer a killed-virus vaccine for Hantaan virus and Seoul virus, but cost precludes widespread usage in many affected areas.

Although indirect evidence exists to suggest a role for passive immunization,[38] no regimen has yet been developed.

Previous
Next

Complications

Potential acute complications of Hantavirus cardiopulmonary syndrome (HCPS) include death, cardiovascular collapse, respiratory failure, anoxic brain injury, renal failure, pulseless electrical activity (PEA), ventricular tachycardia, and ventricular fibrillation.

ECMO has its own set of significant and not infrequent complications, including massive hemorrhage, sepsis, renal failure, and limb ischemia.[31] ECMO remains a rescue therapy for patients who are deteriorating despite maximal conventional medical therapy.

Previous
Next

Prognosis

HCPS currently carries a case-mortality rate of 35-40%.[39, 24] Preadolescents seem to experience a milder form of the disease and have had no reported deaths in the United States.

Experiences with HCPS at the University of New Mexico Hospital have identified several factors that resulted in a 100% mortality rate in several patients who do not receive ECMO. These include the following:

  • Cardiac index less than 2.5 L/min/m2
  • Ventricular tachycardia, ventricular fibrillation, or PEA
  • Hypotension despite adequate fluid resuscitation and vasoactive pressors
Previous
Next

Patient Education

Educate patients and their families regarding the following:

  • Prodromal symptoms of HCPS
  • Risk of transmission by contact with rodents or rodent excreta
  • Techniques to safely clean-up infested areas
  • Rodent control measures (See Deterrence/Prevention.)
Previous
 
Contributor Information and Disclosures
Author

Juliet D Caldwell, MD  Assistant Professor, Department of Emergency Medicine, Weill Cornell Medical College; Attending Physician, Department of Emergency Medicine, New York Presbyterian Hospital, Weill-Cornell Medical Center; Attending Physician, Department of Emergency Medicine, Long Island College Hospital

Juliet D Caldwell, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Michelle Ervin, MD  Chair, Department of Emergency Medicine, Howard University Hospital

Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Barry J Sheridan, DO  Chief, Department of Emergency Medical Services, Brooke Army Medical Center

Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD 

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

  1. Sheedy JA, Froeb HF, Batson HA, et al. The clinical course of epidemic hemorrhagic fever. Am J Med. May 1954;16(5):619-28. [Medline].

  2. Lee HW, Baek LJ, Johnson KM. Isolation of Hantaan virus, the etiologic agent of Korean hemorrhagic fever, from wild urban rats. J Infect Dis. Nov 1982;146(5):638-44. [Medline].

  3. Brummer-Korvenkontio M, Vaheri A, Hovi T, et al. Nephropathia epidemica: detection of antigen in bank voles and serologic diagnosis of human infection. J Infect Dis. Feb 1980;141(2):131-4. [Medline].

  4. Avsic-Zupanc T, Xiao SY, Stojanovic R, Gligic A, van der Groen G, LeDuc JW. Characterization of Dobrava virus: a Hantavirus from Slovenia, Yugoslavia. J Med Virol. Oct 1992;38(2):132-7. [Medline].

  5. Tsai TF, Bauer SP, Sasso DR, et al. Serological and virological evidence of a Hantaan virus-related enzootic in the United States. J Infect Dis. Jul 1985;152(1):126-36. [Medline].

  6. Glass GE, Watson AJ, LeDuc JW, Childs JE. Domestic cases of hemorrhagic fever with renal syndrome in the United States. Nephron. 1994;68(1):48-51. [Medline].

  7. Centers for Disease Control and Prevention. From the Centers for Disease Control and Prevention. Infectious diseases update: outbreak, hantavirus infection--southwestern United States, 1993. JAMA. Jul 7 1993;270(1):25. [Medline].

  8. Centers for Disease Control and Prevention. All About Hantavirus Web site. Available at http://www.cdc.gov/ncidod/diseases/hanta/hps.

  9. Klein SL, Calisher CH. Emergence and persistence of hantaviruses. Curr Top Microbiol Immunol. 2007;315:217-52. [Medline].

  10. Hjelle B, Glass GE. Outbreak of hantavirus infection in the Four Corners region of the United States in the wake of the 1997-1998 El Nino-southern oscillation. J Infect Dis. May 2000;181(5):1569-73. [Medline].

  11. Trencseni T, Keleti B. Clinical aspects and epidemiology of haemorrhagic fever with renal syndrome. Budapest. Akademai Kiado. 1971.

  12. Lazaro ME, Cantoni GE, Calanni LM, et al. Clusters of hantavirus infection, southern Argentina. Emerg Infect Dis. Jan 2007;13(1):104-10. [Medline].

  13. Terajima M, Hendershot JD 3rd, Kariwa H, et al. High levels of viremia in patients with the Hantavirus pulmonary syndrome. J Infect Dis. Dec 1999;180(6):2030-4. [Medline].

  14. Xiao R, Yang S, Koster F, Ye C, Stidley C, Hjelle B. Sin Nombre viral RNA load in patients with hantavirus cardiopulmonary syndrome. J Infect Dis. Nov 15 2006;194(10):1403-9. [Medline].

  15. Mertz GJ, Hjelle BL, Bryan RT. Hantavirus infection. Adv Intern Med. 1997;42:369-421. [Medline].

  16. Maes P, Clement J, Gavrilovskaya I, Van Ranst M. Hantaviruses: immunology, treatment, and prevention. Viral Immunol. 2004;17(4):481-97. [Medline].

  17. Peters CJ, Simpson GL, Levy H. Spectrum of hantavirus infection: hemorrhagic fever with renal syndrome and hantavirus pulmonary syndrome. Annu Rev Med. 1999;50:531-45. [Medline].

  18. Nolte KB, Feddersen RM, Foucar K, et al. Hantavirus pulmonary syndrome in the United States: a pathological description of a disease caused by a new agent. Hum Pathol. Jan 1995;26(1):110-20. [Medline].

  19. Hallin GW, Simpson SQ, Crowell RE, et al. Cardiopulmonary manifestations of hantavirus pulmonary syndrome. Crit Care Med. Feb 1996;24(2):252-8. [Medline].

  20. Entwisle G, Hale E. Hemodynamic alterations in hemorrhagic fever. Circulation. Mar 1957;15(3):414-25. [Medline].

  21. Padula PJ, Edelstein A, Miguel SD, Lopez NM, Rossi CM, Rabinovich RD. [Epidemic outbreak of Hantavirus pulmonary syndrome in Argentina. Molecular evidence of person to person transmission of Andes virus]. Medicina (B Aires). 1998;58 Suppl 1:27-36. [Medline].

  22. Young JC, Hansen GR, Graves TK, et al. The incubation period of hantavirus pulmonary syndrome. Am J Trop Med Hyg. Jun 2000;62(6):714-7. [Medline].

  23. Johnson AM, Bowen MD, Ksiazek TG, et al. Laguna Negra virus associated with HPS in western Paraguay and Bolivia. Virology. Nov 10 1997;238(1):115-27. [Medline].

  24. Chang B, Crowley M, Campen M, Koster F. Hantavirus cardiopulmonary syndrome. Semin Respir Crit Care Med. Apr 2007;28(2):193-200. [Medline].

  25. Castillo C, Naranjo J, Sepulveda A, Ossa G, Levy H. Hantavirus pulmonary syndrome due to Andes virus in Temuco, Chile: clinical experience with 16 adults. Chest. Aug 2001;120(2):548-54. [Medline].

  26. Fulhorst CF, Milazzo ML, Armstrong LR, et al. Hantavirus and arenavirus antibodies in persons with occupational rodent exposure. Emerg Infect Dis. Apr 2007;13(4):532-8. [Medline].

  27. Jenison S, Hjelle B, Simpson S, Hallin G, Feddersen R, Koster F. Hantavirus pulmonary syndrome: clinical, diagnostic, and virologic aspects. Semin Respir Infect. Dec 1995;10(4):259-269. [Medline].

  28. Hjelle B. Hantavirus Cardiopulmonary Syndrome. UpToDate. 2008.

  29. Duchin JS, Koster FT, Peters CJ, et al. Hantavirus pulmonary syndrome: a clinical description of 17 patients with a newly recognized disease. The Hantavirus Study Group. N Engl J Med. Apr 7 1994;330(14):949-55. [Medline].

  30. Ketai LH, Williamson MR, Telepak RJ, et al. Hantavirus pulmonary syndrome: radiographic findings in 16 patients. Radiology. Jun 1994;191(3):665-8. [Medline].

  31. Dietl CA, Wernly JA, Pett SB, et al. Extracorporeal membrane oxygenation support improves survival of patients with severe Hantavirus cardiopulmonary syndrome. J Thorac Cardiovasc Surg. Mar 2008;135(3):579-84. [Medline].

  32. Dull SM, Brillman JC, Simpson SQ, Sklar DP. Hantavirus pulmonary syndrome: recognition and emergency department management. Ann Emerg Med. Sep 1994;24(3):530-6. [Medline].

  33. Levy H, Simpson SQ. Hantavirus pulmonary syndrome. Am J Respir Crit Care Med. Jun 1994;149(6):1710-3. [Medline].

  34. Crowley MR, Katz RW, Kessler R, et al. Successful treatment of adults with severe Hantavirus pulmonary syndrome with extracorporeal membrane oxygenation. Crit Care Med. Feb 1998;26(2):409-14. [Medline].

  35. Huggins JW, Hsiang CM, Cosgriff TM, et al. Prospective, double-blind, concurrent, placebo-controlled clinical trial of intravenous ribavirin therapy of hemorrhagic fever with renal syndrome. J Infect Dis. Dec 1991;164(6):1119-27. [Medline].

  36. Chapman LE, Mertz GJ, Peters CJ, et al. Intravenous ribavirin for hantavirus pulmonary syndrome: safety and tolerance during 1 year of open-label experience. Ribavirin Study Group. Antivir Ther. 1999;4(4):211-9. [Medline].

  37. Mertz GJ, Miedzinski L, Goade D, et al. Placebo-controlled, double-blind trial of intravenous ribavirin for the treatment of hantavirus cardiopulmonary syndrome in North America. Clin Infect Dis. Nov 1 2004;39(9):1307-13. [Medline].

  38. Bharadwaj M, Nofchissey R, Goade D, Koster F, Hjelle B. Humoral immune responses in the hantavirus cardiopulmonary syndrome. J Infect Dis. Jul 2000;182(1):43-8. [Medline].

  39. Jonsson CB, Hooper J, Mertz G. Treatment of hantavirus pulmonary syndrome. Antiviral Res. Apr 2008;78(1):162-9. [Medline].

  40. Custer DM, Thompson E, Schmaljohn CS, Ksiazek TG, Hooper JW. Active and passive vaccination against hantavirus pulmonary syndrome with Andes virus M genome segment-based DNA vaccine. J Virol. Sep 2003;77(18):9894-905. [Medline].

  41. Hooper JW, Custer DM, Smith J, Wahl-Jensen V. Hantaan/Andes virus DNA vaccine elicits a broadly cross-reactive neutralizing antibody response in nonhuman primates. Virology. Mar 30 2006;347(1):208-16. [Medline].

  42. Schmaljohn CS, Chu YK, Schmaljohn AL, Dalrymple JM. Antigenic subunits of Hantaan virus expressed by baculovirus and vaccinia virus recombinants. J Virol. Jul 1990;64(7):3162-70. [Medline].

  43. Xu X, Ruo SL, McCormick JB, Fisher-Hoch SP. Immunity to Hantavirus challenge in Meriones unguiculatus induced by vaccinia-vectored viral proteins. Am J Trop Med Hyg. Oct 1992;47(4):397-404. [Medline].

  44. Howard MJ, Doyle TJ, Koster FT, et al. Hantavirus pulmonary syndrome in pregnancy. Clin Infect Dis. Dec 1999;29(6):1538-44. [Medline].

  45. CDC. Hantavirus pulmonary syndrome in five pediatric patients - four states, 2009. MMWR Morb Mortal Wkly Rep. Dec 25 2009;58(50):1409-12. [Medline].

  46. Pergam SA, Schmidt DW, Nofchissey RA, et al. Potential renal sequelae in survivors of hantavirus cardiopulmonary syndrome. Am J Trop Med Hyg. Feb 2009;80(2):279-85. [Medline].

 
Previous
Next
 
Hantavirus cardiopulmonary syndrome (HCPS) precautions during the 1993 outbreak.
Peromyscus maniculatus - The deer mouse.
Geographic distribution and viral cause of Hantavirus cardiopulmonary syndrome (HCPS).
Hantavirus pulmonary syndrome cases by state.
Geographic distribution of Hantavirus cardiopulmonary syndrome (HCPS) and Peromyscus maniculatus.
Hantavirus pulmonary syndrome cases by outcome.
Hantavirus cardiopulmonary syndrome (HCPS) immunoblast.
Chest radiographic progression of Hantavirus cardiopulmonary syndrome (HCPS).
Clinical progression of hantavirus cardiopulmonary syndrome.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.