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Hantavirus Cardiopulmonary Syndrome Workup

  • Author: Juliet D Caldwell, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
 
Updated: Apr 01, 2015
 

Laboratory Studies

Laboratory results vary with the phase of disease.

Complete blood cell count (CBC)

The CBC is the most useful test to obtain. It should be checked on arrival as well as 24 hours after presentation.

Platelets

Platelets may initially be normal but a moderate decline in count usually is demonstrated, sometimes as early as the prodromal phase.[26] In patients with Hantavirus cardiopulmonary syndrome (HCPS), 98% present with a platelet count of less than 150 X 109/L. A dramatic fall sometimes heralds the cardiopulmonary phase of HCPS.[32]

White blood cell (WBC) count with peripheral blood smear

Leukocytosis and occasionally leukopenia are the norm. More importantly, a severe clinical course can reliably be predicted by the appearance of a marked leukocytosis (as high as 90,000 cells/microL) and the appearance of immunoblasts (circulating atypical lymphocytes).[33] See the image below.

Hantavirus cardiopulmonary syndrome (HCPS) immunob Hantavirus cardiopulmonary syndrome (HCPS) immunoblast.

Thrombocytopenia, a left shift on peripheral smear, and an immunoblast count that exceeds 10% of the total lymphoid series has been termed the diagnostic triad of HCPS.[34] In experienced centers that see relatively high numbers of HCPS, this triad alerts practitioners to begin preparation for transfer to a center capable of aggressive critical care management and possibly ECMO.

Hematocrit (HCT)

Hemoconcentration is due to massive capillary leak and portends a poor prognosis. Hematocrits >50% in men and >48% in women may occur during the cardiopulmonary phase of HCPS and is a marker of severe disease.[35] This occurs in only 50% of cases.

In the prodromal phase, the CBC may be normal or show slight thrombocytopenia only.

Chemistries

Aspartate aminotransferase (AST), alanine aminotransferase (ALT), and lactate dehydrogenase (LDH) levels are often elevated, sometimes as early as the prodromal phase of HCPS. levels can elevate 2-5 times their reference values.

Creatinine level

SNV rarely causes renal failure; however, the Black Creek Canal, Bayou, and Andes viruses have higher rates of renal insufficiency.

Creatine phosphokinase (CPK) level

SNV rarely causes CPK elevations (again unlike the Bayou, Black Creek Canal, and Andes viruses).

Coagulation studies

Prothrombin time (PT) and activated partial thromboplastin time (aPTT) are usually within the reference range in SNV infection. However, a few cases of disseminated intravascular coagulation (DIC) have been associated with HCPS.

Arterial blood gases (ABGs) measurement

Progressive metabolic acidosis and severe hypoxemia mark the cardiopulmonary phase of HCPS.

Lactate level

levels as high as 9.5 mg/dL have been recorded in severe HCPS. A lactate level greater than 4 has been associated with high mortality rates.

Serologic assays

The preferred method of diagnosis of HCPS is via serologic testing. By the time symptoms have developed, patients have uniformly developed IgM antiviral antibodies, and most, if not all, have developed antibodies of the IgG class. Acute infection can be distinguished from past exposure by the presence of IgM antibodies or by a 4-fold increase in levels of serum IgG antibodies.

Western blot and strip immunoblot assays are the most commonly used serologic assays, but others include enzyme-linked immunosorbent assay (ELISA), indirect immunofluorescence, and compliment fixation, among others. The rapid immunoblot strip assay (RIBA), developed at the University of New Mexico, is a dipstick-type test that detects SNV antibodies in the clinical phase of the disease with 100% sensitivity.

Detection of Hantavirus-specific ribonucleic acid via polymerase chain reaction testing is possible for Hantaviruses that cause fulminant infection, but only in the early stages of disease.

Postmortem assays can be accomplished by using immunohistochemical tests for N-antigens. Viral RNA can also be detected using reverse-transcription polymerase chain reaction.

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Imaging Studies

Radiography

At presentation, approximately one third of patients show radiographic evidence of pulmonary edema. Within 48 hours, virtually all patients demonstrate edema and two thirds have progressed to severe bilateral airspace disease. Although chest radiograph findings on presentation are often normal, onset of the cardiopulmonary phase brings about a characteristic radiologic evolution (see the image below).[36]

Chest radiographic progression of Hantavirus cardi Chest radiographic progression of Hantavirus cardiopulmonary syndrome (HCPS).

Mild interstitial pulmonary edema progresses to severe bilateral alveolar edema in a basilar or perihilar pattern.

Pleural effusions are common.

Heart size is normal (barring concomitant heart disease).

Echocardiography

Occasionally, echocardiography is useful to distinguish cardiogenic pulmonary edema from the noncardiogenic edema typically seen in HCPS.

Global cardiac dysfunction does occur in the later stages of HCPS.

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Procedures

A flow-directed pulmonary artery catheterization (PAC), or Swan-Ganz catheter, can be a useful tool to aid in resuscitative fluid management of HCPS. As HCPS demonstrates a characteristic hemodynamic profile, it can also offer valuable diagnostic and prognostic information. A low pulmonary artery occlusion pressure (consistent with a pulmonary capillary leak) and a low cardiac index characterize early HCPS.

Advanced HCPS yields a severe drop in cardiac index and an increased systemic vascular resistance index (SVRI).

A cardiac index of less than 2 L/min/m2 (one marker used to predict a 100% mortality without further intervention) has been used successfully as criteria to initiate rescue ECMO therapy.[37]

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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, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Barry J Sheridan, DO Chief Warrior in Transition 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.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, South Carolina Medical Association, Columbia Medical Society, South Carolina College of Emergency Physicians, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Chief Editor for Medscape.

Acknowledgements

Scott Cameron, MD Consulting Staff, Department of Emergency Medicine, Regions Hospital

Disclosure: Nothing to disclose.

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.

Maureen Gang, MD Assistant Professor, Department of Emergency Medicine, New York University Medical Center

Disclosure: Nothing to disclose.

Mana Lumumba Kasongo, MD, MS Consulting Staff, Southwest Emergency Physicians

Disclosure: Nothing to disclose.

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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 of exposure.
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.
 
 
 
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