Pediatric Hantavirus Pulmonary Syndrome Workup

  • Author: Vinod K Dhawan, MD, FACP, FRCP(C), FIDSA; Chief Editor: Russell W Steele, MD   more...
 
Updated: May 9, 2012
 

Laboratory Studies

  • 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.
Next

Imaging Studies

  • 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]
Previous
Next

Procedures

  • 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.
Previous
Next

Histologic Findings

  • 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.
Previous
Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Vinod K Dhawan, MD, FACP, FRCP(C), 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, FRCP(C), FIDSA is a member of the following medical societies: American College of Physicians, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and Royal College of Physicians and Surgeons of Canada

Disclosure: Pfizer Inc Honoraria Speaking and teaching

Specialty Editor Board

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.

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  American Legion 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, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: Novartis Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

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, and Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Maria A Horga, MD and Veronica A Mas Casullo, MD to the development and writing of this article.

References

  1. Simpson SQ, Spikes L, Patel S, Faruqi I. Hantavirus pulmonary syndrome. Infect Dis Clin North Am. Mar 2010;24(1):159-73. [Medline].

  2. Vinh DC, Embil JM. Hantavirus Pulmonary Syndrome: A Concise Clinical Review. South Med J. May 7 2009;[Medline].

  3. Figueiredo LT, Moreli ML, de-Sousa RL, Borges AA, de-Figueiredo GG, Machado AM, et al. Hantavirus pulmonary syndrome, central plateau, southeastern, and southern Brazil. Emerg Infect Dis. Apr 2009;15(4):561-7. [Medline].

  4. MacNeil A, Ksiazek TG, Rollin PE. Hantavirus pulmonary syndrome, United States, 1993-2009. Emerg Infect Dis. Jul 2011;17(7):1195-201. [Medline].

  5. Macneil A, Nichol ST, Spiropoulou CF. Hantavirus pulmonary syndrome. Virus Res. Dec 2011;162(1-2):138-47. [Medline].

  6. Mori M, Rothman AL, Kurane I, et al. High levels of cytokine-producing cells in the lung tissues of patients with fatal hantavirus pulmonary syndrome. J Infect Dis. Feb 1999;179(2):295-302. [Medline].

  7. Kilpatrick ED, Terajima M, Koster FT, et al. Role of specific CD8+ T cells in the severity of a fulminant zoonotic viral hemorrhagic fever, hantavirus pulmonary syndrome. J Immunol. Mar 1 2004;172(5):3297-304. [Medline]. [Full Text].

  8. Armstrong LR, Zaki SR, Goldoft MJ, Todd RL, Khan AS, Khabbaz RF. Hantavirus pulmonary syndrome associated with entering or cleaning rarely used, rodent-infested structures. J Infect Dis. Oct 1995;172(4):1166. [Medline].

  9. Ketai LH, Williamson MR, Telepak RJ, Levy H, Koster FT, Nolte KB. Hantavirus pulmonary syndrome: radiographic findings in 16 patients. Radiology. Jun 1994;191(3):665-8. [Medline].

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

  11. 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].

  12. Cho HW, Howard CR. Antibody responses in humans to an inactivated hantavirus vaccine (Hantavax). Vaccine. Jun 4 1999;17(20-21):2569-75. [Medline].

  13. da Rosa Elkhoury M, da Silva Mendes W, Waldman EA, Dias JP, Carmo EH, Fernando da Costa Vasconcelos P. Hantavirus pulmonary syndrome: prognostic factors for death in reported cases in Brazil. Trans R Soc Trop Med Hyg. May 2012;106(5):298-302. [Medline].

  14. Abbott KD, Ksiazek TG, Mills JN. Long-term hantavirus persistence in rodent populations in central Arizona. Emerg Infect Dis. Jan-Feb 1999;5(1):102-12. [Medline].

  15. Abel Borges A, Figueiredo LT. Mechanisms of shock in hantavirus pulmonary syndrome. Curr Opin Infect Dis. Jun 2008;21(3):293-7. [Medline].

  16. Bartholomew DM, Hansen LA, Frank JJ, Farver DK. Case report of hantavirus pulmonary syndrome and review. S D Med. May 2007;60(5):189-91, 193-5. [Medline].

  17. Brillman J, Talan DA, Moran GJ, Pinner R. Update on emerging infections from the Centers for Disease Control and Prevention. Hantavirus pulmonary syndrome--five states, 2006. Ann Emerg Med. Nov 2006;48(5):593-4; discussion 594-5. [Medline].

  18. CDC. Update: hantavirus pulmonary syndrome--United States, 1999. MMWR Morb Mortal Wkly Rep. Jun 25 1999;48(24):521-5. [Medline].

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

  20. Chin C, Chiueh TS, Yang WC, et al. Hantavirus infection in Taiwan: the experience of a geographically unique area. J Med Virol. Feb 2000;60(2):237-47. [Medline].

  21. Douglass RJ, Calisher CH, Bradley KC. State-by-state incidences of hantavirus pulmonary syndrome in the United States, 1993-2004. Vector Borne Zoonotic Dis. Summer 2005;5(2):189-92. [Medline].

  22. Hantavirus pulmonary syndrome--five states, 2006. MMWR Morb Mortal Wkly Rep. Jun 9 2006;55(22):627-9. [Medline].

  23. 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].

  24. Khan AS, Khabbaz RF, Armstrong LR, et al. Hantavirus pulmonary syndrome: the first 100 US cases. J Infect Dis. Jun 1996;173(6):1297-303. [Medline].

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

  26. Koraka P, Avsic-Zupanc T, Osterhaus AD, Groen J. Evaluation of two commercially available immunoassays for the detection of hantavirus antibodies in serum samples. J Clin Virol. Sep 1 2000;17(3):189-96. [Medline].

  27. Maeda K, West K, Toyosaki-Maeda T, et al. Identification and analysis for cross-reactivity among hantaviruses of H-2b-restricted cytotoxic T-lymphocyte epitopes in Sin Nombre virus nucleocapsid protein. J Gen Virol. Jul 2004;85(Pt 7):1909-19. [Medline].

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

  29. Mertz GJ, Hjelle B, Crowley M, Iwamoto G, Tomicic V, Vial PA. Diagnosis and treatment of new world hantavirus infections. Curr Opin Infect Dis. Oct 2006;19(5):437-42. [Medline].

  30. Mills JN, Corneli A, Young JC, et al. Hantavirus pulmonary syndrome--United States: updated recommendations for risk reduction. Centers for Disease Control and Prevention. MMWR Recomm Rep. Jul 26 2002;51(RR-9):1-12. [Medline].

  31. Rivers MN, Alexander JL, Rohde RE, Pierce JR Jr. Hantavirus pulmonary syndrome in Texas: 1993-2006. South Med J. Jan 2009;102(1):36-41. [Medline].

  32. Saggioro FP, Rossi MA, Duarte MI, et al. Hantavirus infection induces a typical myocarditis that may be responsible for myocardial depression and shock in hantavirus pulmonary syndrome. J Infect Dis. May 15 2007;195(10):1541-9. [Medline].

  33. Seitsonen E, Hynninen M, Kolho E, et al. Corticosteroids combined with continuous veno-venous hemodiafiltration for treatment of hantavirus pulmonary syndrome caused by Puumala virus infection. Eur J Clin Microbiol Infect Dis. Mar 21 2006;[Medline].

  34. Terajima M, Hayasaka D, Maeda K, Ennis FA. Immunopathogenesis of hantavirus pulmonary syndrome and hemorrhagic fever with renal syndrome: Do CD8+ T cells trigger capillary leakage in viral hemorrhagic fevers?. Immunol Lett. Nov 15 2007;113(2):117-20. [Medline].

 
Previous
Next
 
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 March 9, 2012.
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
Previous
Next
 
 
 
 
 
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.