Hantavirus Cardiopulmonary Syndrome Workup

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

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 ultimately at least a moderate decline in count will be demonstrated, sometimes as early as the prodromal phase.[23] In patients with Hantavirus cardiopulmonary syndrome (HCPS), 98% present with a platelet count < 150 X 109/L and all patients eventually develop a platelet count < 100 X 109/L. A dramatic fall sometimes heralds the cardiopulmonary phase of HCPS.

White blood cell (WBC) count with peripheral blood smear

Leukocytosis and occasionally leukopenia are the norm. More importantly, 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).[27] See the image below.

Hantavirus cardiopulmonary syndrome (HCPS) immunobHantavirus 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.[28] 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.[29] 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

Definitive diagnosis of HCPS is made on the basis of 1 of 3 assays.

Western blot and strip blot assays are the most commonly used. They use a nucleocapsid (N) antigen for the detection of Hantavirus antibodies. The rapid immunoblot strip assay (RIBA), developed by UNM, is a dipstick-type test that detects SNV antibodies in the clinical phase of the disease with 100% sensitivity.

Acute infection can be distinguished from past exposure by the presence of IgM antibodies or by a 4-fold increase in serum IgG antibodies.

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

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Imaging Studies

Radiography

At presentation, approximately one third of patients show evidence of pulmonary edema on chest radiograph. Within 48 hours, virtually all patients demonstrate pulmonary edema and two thirds have progressed to severe bilateral airspace disease. Although chest radiographic findings on presentation are often normal, onset of the cardiopulmonary phase brings about a characteristic radiologic evolution (see the image below).[30]

Chest radiographic progression of Hantavirus cardiChest 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 may occur in the later stages of HCPS.

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Procedures

A flow-directed pulmonary artery catheterization (PAC), or Swan-Ganz catheter, is frequently 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.[31]

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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, 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

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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.
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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