eMedicine Specialties > Emergency Medicine > Infectious Diseases

Hantavirus Cardiopulmonary Syndrome: Follow-up

Author: Juliet D Caldwell, MD, Assistant Professor, Department of Emergency Medicine, Weill Medical College of Cornell University; Attending Physician, Department of Emergency Medicine, New York Presbyterian Hospital, Weill-Cornell Medical Center
Contributor Information and Disclosures

Updated: Jan 29, 2009

Follow-up

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.
  • 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.

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.

Deterrence/Prevention

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.

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

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.)

Miscellaneous

Special Concerns

  • Five cases of hantavirus in pregnancy were described in 2000. One mother died as a consequence of disease, and 2 fetuses failed to survive. No evidence of vertical transmission or seroconversion was found. It is thought that fetal failure to survive would be similar in any other illness causing acute cardiopulmonary failure.44
  • Sin Nombre virus is found in the breastmilk of infected mothers, but no case of maternal fetal transmission by breastfeeding has been documented.44   
  • The best therapy for the fetus is, as always, good supportive care for the mother.
  • Pediatric Hantavirus cardiopulmonary syndrome (HCPS)  
    • The youngest case of HCPS in the United States was in a child aged 10 years.
    • However, a serologically proven SNV infection has been reported in a child aged 4 years who experienced only mild upper respiratory symptoms and otitis.
    • Preadolescent children in the United States typically experience a milder form of the disease and have not required intubation. This may be due, in part, to an altered immune response in children.
    • In South America, however, cases of HCPS caused by the Andes virus carry a high infant and pediatric mortality rate.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Mana Lumumba Kasongo, MD, MS, Maureen Gang, MD, and Scott Cameron, MD, to the development and writing of this article.



More on Hantavirus Cardiopulmonary Syndrome

Overview: Hantavirus Cardiopulmonary Syndrome
Differential Diagnoses & Workup: Hantavirus Cardiopulmonary Syndrome
Treatment & Medication: Hantavirus Cardiopulmonary Syndrome
Follow-up: Hantavirus Cardiopulmonary Syndrome
Multimedia: Hantavirus Cardiopulmonary Syndrome
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Further Reading

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Keywords

hantavirus, hantavirus pulmonary syndrome, HCPS, hanta, Sin Nombre virus, deer mouse, Peromyscus maniculatus, Muerto Canyon virus, four corners virus, Hantaan virus, hemorrhagic fever with renal syndrome, HFRS, HPS

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Contributor Information and Disclosures

Author

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

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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.

CME Editor

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, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
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

 
 
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