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Pediatric Hantavirus Pulmonary Syndrome Workup

  • Author: Vinod K Dhawan, MD, FACP, FRCPC, FIDSA; Chief Editor: Russell W Steele, MD  more...
 
Updated: Nov 26, 2014
 

Laboratory Studies

Diagnosis requires a high index of suspicion. Hantavirus infection should be considered in patients with severe respiratory symptoms with rodent exposure or rural/wilderness travel. Hantavirus cardiopulmonary syndrome presents as a vague prodrome of fever, cough, myalgias, chills, and nausea followed by a rapidly worsening respiratory phase. Presumptive diagnosis can be made based on pulmonary interstitial edema on chest radiographs in association with leukocytosis, thrombocytopenia, and hemoconcentration. Suspected cases should be confirmed with a reference laboratory and reported to the appropriate public health authorities.[40]

  • Several laboratory tests are useful in the diagnosis of Hantavirus pulmonary syndrome (HPS).
    • Thrombocytopenia is noted early in the disease.
    • Leukocytosis is noted with a left shift.
    • Abnormal lymphocytes and immunoblasts are present in the peripheral smear.
    • The hematocrit level is elevated because of the ultrafiltration of fluid into the lungs.
    • Activated partial thromboplastin time (aPTT) is prolonged.
    • Aspartate aminotransferase (AST) and lactic dehydrogenase (LDH) may be mildly elevated.
    • ABG measurement reveals desaturation.
  • The tetrad of thrombocytopenia, leukocytosis (often with left shift), elevated hematocrit levels, and presence of immunoblasts in peripheral blood smear is a sensitive and specific early clue to the underlying disease. These findings in a patient with rapid onset of respiratory insufficiency should suggest the diagnosis.
  • Serologic methods are useful in the diagnosis of Hantavirus infection. Most patients have both immunoglobulin M (IgM) and immunoglobulin G (IgG) enzyme-linked immunosorbent assay (ELISA) antibodies upon admission to the hospital.
  • Hantavirus can be detected in the tissue by the RT-PCR.
  • Immunohistochemical staining of tissue reveals Hantaviral antigen.
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Imaging Studies

See the list below:

  • Chest radiographs usually reveal marked peribronchial cuffing and Kerley B lines early in the disease.
  • Rapid progression of bilateral interstitial and alveolar infiltrates is observed in patients with full-blown Hantavirus pulmonary syndrome.[9]
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Procedures

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  • Catheterization of the pulmonary artery in patients with profound Hantavirus pulmonary syndrome generally reveals decreased stroke volume index (SVI) and a low to low-normal cardiac index (CI).
  • The pulmonary vascular resistance index is elevated.
  • Increased systemic vascular resistance, along with the failure of correction of lowered CI and SVI by volume replacement, distinguishes Hantavirus pulmonary syndrome from septic shock.
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Histologic Findings

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  • Histopathology of the lungs in patients with Hantavirus pulmonary syndrome is depicted in the following image. Under light microscopy, the lungs of these patients reveal interstitial and alveolar edema, alveolar hemorrhage, and a mononuclear interstitial pneumonitis composed of macrophages and T lymphocytes.
    Histopathology of the lung in Hantavirus pulmonaryHistopathology of the lung in Hantavirus pulmonary syndrome. Courtesy of the Centers for Disease Control and Prevention.
  • Unlike the acute respiratory distress syndrome (ARDS) due to other causes, no marked necrosis, polymorphonuclear leukocyte infiltration, type II pneumocyte hyperplasia, or dense hyalinization is observed.
  • Electron microscopy of lung tissue reveals intact and somewhat swollen vascular endothelium. Inflammatory cell infiltration of capillaries, interstitium, and alveoli is evident. The cytoplasm of endothelial cells contains viral inclusions. No evidence of necrosis or a structural cellular defect responsible for the capillary leak is observed.
  • Examination of other tissues may reveal infiltration by immunoblasts, such as in lymph nodes, spleen, liver, and blood vessels of other organs.
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Contributor Information and Disclosures
Author

Vinod K Dhawan, MD, FACP, FRCPC, FIDSA Professor, Department of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Chief, Division of Infectious Diseases, Rancho Los Amigos National Rehabilitation Center

Vinod K Dhawan, MD, FACP, FRCPC, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Pfizer Inc for speaking and teaching.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Mark R Schleiss, MD Minnesota American Legion and Auxiliary Heart Research Foundation Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School

Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Maria A Horga, MD Assistant Professor, Department of Pediatric Infectious Diseases, Bristol-Myers Squibb

Disclosure: Nothing to disclose.

Rosemary Johann-Liang, MD Medical Officer, Infectious Diseases and Pediatrics, Division of Special Pathogens and Immunological Drug Products, Center for Drug Evaluation and Research, Food and Drug Administration

Rosemary Johann-Liang, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Veronica A Mas Casullo, MD Assistant Professor, Department of Pediatric Infectious Diseases, Mount Sinai School of Medicine

Disclosure: Nothing to disclose.

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Deer mouse, Peromyscus maniculatus. Courtesy of the Centers for Disease Control and Prevention.
Transmission electron micrograph of Sin Nombre virus. Courtesy of the Centers for Disease Control and Prevention.
Centers for Disease Control and Prevention: Cumulative case count of Hantavirus pulmonary syndrome in the United States per state, valid as of December 31, 2013. Courtesy of the Centers for Disease Control and Prevention.
Characteristics of 465 Hantavirus pulmonary syndrome cases in the United States, March 26, 2007. Courtesy of the Centers for Disease Control and Prevention.
Histopathology of the lung in Hantavirus pulmonary syndrome. Courtesy of the Centers for Disease Control and Prevention.
Table 1. Hantaviruses That Cause HFRS, Rodent Hosts and Geographic Distribution
Hantavirus TypeRodent HostGeographic Distribution
HantaanApodemus agrarius (striped field mouse)Far East, Russia, Northern Asia, Balkans
DobravaApodemus flavicollis (yellow-necked field mouse)Balkans
SeoulRattus norvegicus (urban rats)Worldwide
PuumalaClathrionomys glariolus (bank vole)Europe, Scandinavia, Western Russia
Table 2. Hantavirus Pulmonary Syndrome Virus Types, Rodent Hosts, and Distribution in the United States
Hantavirus TypeRodent HostGeographic Distribution of the Rodent Host in the United States
Sin Nombre virus, monongahela virusDeer mouse, P maniculatusThroughout the United States, except the Southeast and Atlantic seaboard
Bayou virusRice rat, Oryzomys palustrisSoutheastern United States
Black Creek Canal virusCotton rat, Sigmodon hispidusSoutheastern United States
New York-1 virusWhite-footed mouse, Peromyscus leucopusSouthern New England, mid-Atlantic states, Southern states, and Midwest
Table 3. Hantavirus Types, Rodent Hosts, and Geographic Distribution in the Western Hemisphere (other than the United States)
Hantavirus TypeRodent HostGeographic Distribution
AndesOligoryzomys longicaudatusArgentina and Chile
OranO longicaudatusNorthwest Argentina
LechiguanasOligoryzomys flavescensCentral Argentina
Hu39694UnknownCentral Argentina
Laguna NegraCalomys lauchaParaguay and Bolivia
JuquitibaUnknownBrazil
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