Hemorrhagic Fever With Renal Failure Syndrome Clinical Presentation

  • Author: Rajendra Bhimma, MB, ChB, MD, DCH (SA), FCP (Paeds)(SA), MMed (Natal); Chief Editor: Craig B Langman, MD   more...
 
Updated: May 7, 2010
 

History

The clinical features in hemorrhagic fever with renal failure syndrome (HFRS) consist of a triad of fever, hemorrhage, and renal insufficiency. Other common symptoms during the initial phase of the illness include headache, myalgia, abdominal and back pain, nausea, vomiting, and diarrhea. The disease may range from mild to severe. Subclinical infections are especially common in children. The average incubation period varies from 4-42 days. The disease is characterized by fever, hemorrhagic manifestations, and (if severe) hypovolemic shock.

The disease has 5 progressive stages: febrile, hypotensive, oliguric, diuretic, and convalescent.[2] Physicians should be aware of the various presentations during each stage. Individual patients can completely skip stages.

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Physical

Physical examination of the patient is based on the stage of the illness.

  • The febrile stage occurs in all patients and lasts about 4-6 days. The disease is characterized by an abrupt onset of fever with a temperature in the range of 40°C.
    • Patients may complain of headache, chills, abdominal pain, and malaise.
    • Flushing of the face, neck, and chest due to probable vascular dysregulation may be observed.
    • Petechia may occur in the axilla and soft palate.
    • Subconjunctival hemorrhage is noted in one third of patients.
    • Absolute bradycardia may be noted.
    • A normal or mildly elevated hematocrit level caused by hemoconcentration may be observed. Leucocytosis with atypical lymphocytes. The disease is characterized by thrombocytopenia, which also defines prognosis and severity of renal failure.
    • The onset of proteinuria and microhematuria can be observed. Proteinuria due to Hantavirus nephritis is transient and usually resolves within 2 weeks.
  • The hypotensive stage lasts approximately a few hours to 2 days. It occurs in 11% of patients and coincides with defervescence.
    • Patients may have tachycardia, which may indicate impending shock.
    • Patients may have acute abdomen caused by a paralytic ileus.
    • Patients may have convulsions or purposeless movements.
    • The coagulation profile may reveal a prolonged bleeding time, prothrombin time (PT), and activated partial thromboplastin time (aPTT).
  • The oliguric stage occurs in 65% of the patients and lasts about 3-6 days.
    • Oliguria, hypertension, bleeding tendency (caused by uremia), and edema are characteristic of this stage.
    • Patients may develop pulmonary edema.
    • Thrombocytopenia usually resolves in the oliguric stage.
  • The diuretic stage lasts 2-3 weeks.
    • Diuresis in the range of 3-6 L/d occurs after symptoms from the previous stage disappear. Responsiveness of the collecting duct to vasopressin is reduced.
    • Rapid signs of dehydration and severe shock can occur during this stage if fluid replacement is inadequate. The patient's volume status should be closely monitored.
  • The convalescent stage may last for as long as 3-6 months.
    • Clinical recovery usually begins in the middle of the second week, with a gradual resolution of symptoms and azotemia.
    • The concentrating capacity of the renal tubules recovers over many months.
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Causes

The viruses of the genus Hantavirus cause different forms of hemorrhagic fever with renal failure syndrome. The severity of the illness depends on the infecting virus and on the geographic distribution.[3]

  • Korean hemorrhagic fever, a severe type of hemorrhagic fever with renal failure syndrome observed in Asia, is caused by a Hantavirus and is transmitted by the infected A agrarius mouse (striped field mouse).[4]
  • Balkan hemorrhagic fever, a severe type of hemorrhagic fever with renal failure syndrome observed in Balkan countries, is caused by the Dobrava virus and is transmitted by the infected A flavicollis mouse (yellow-necked field mouse).
  • A mild-to-moderate form of hemorrhagic fever with renal failure syndrome is caused by the Seoul virus and is transmitted by the infected Rattus rattus rat (black rat) or the Rattus novergicus rat (urban rat).
  • Nephropathia epidemica, a mild form of hemorrhagic fever with renal failure syndrome observed in Europe, is caused by the Puumala virus and is transmitted by the infected Clethrionomys glariolus vole (European bank vole).
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Contributor Information and Disclosures
Author

Rajendra Bhimma, MB, ChB, MD, DCH (SA), FCP (Paeds)(SA), MMed (Natal)  Associate Professor of Pediatrics, Principal Specialist, Department of Pediatrics and Child Health, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa

Rajendra Bhimma, MB, ChB, MD, DCH (SA), FCP (Paeds)(SA), MMed (Natal) is a member of the following medical societies: American Association for the Advancement of Science, International Pediatric Transplant Association, International Society of Nephrology, South African Medical Association, South African Paediatric Association, and South African Transplant Society

Disclosure: Nothing to disclose.

Coauthor(s)

Vellore K Sairam, MBBS  Assistant Professor, Department of Nephrology, Sri Ramachandra Medical College and Research Institute, India

Disclosure: Nothing to disclose.

Luther Travis, MD  William W Glauser Professor of Pediatrics and Pediatric Nephrology, Department of Pediatrics, Divisions of Nephrology and Diabetes, University of Texas Medical Branch and Children's Hospital

Luther Travis, MD is a member of the following medical societies: Alpha Omega Alpha, American Federation for Medical Research, International Society of Nephrology, and Texas Pediatric Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Deogracias Pena, MD  Medical Director of Dialysis, Department of Pediatrics, Cook Children's Medical Center; Clinical Associate Professor, Texas Tech University School of Medicine

Deogracias Pena, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and American Society of Pediatric Nephrology

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Frederick J Kaskel, MD, PhD  Director of the Division and Training Program in Pediatric Nephrology, Vice Chair, Department of Pediatrics, Montefiore Medical Center and Albert Einstein School of Medicine

Frederick J Kaskel, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American Pediatric Society, American Physiological Society, American Society of Nephrology, American Society of Pediatric Nephrology, American Society of Transplantation, Eastern Society for Pediatric Research, Federation of American Societies for Experimental Biology, International Society of Nephrology, National Kidney Foundation, New York Academy of Sciences, Renal Physicians Association, Sigma Xi, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Howard Trachtman, MD  Program Director, Pediatrics Research, Schneider Children's Hospital, Department of Pediatrics, Division of Nephrology, Professor, Albert Einstein College of Medicine

Howard Trachtman, MD is a member of the following medical societies: American Society of Hypertension, American Society of Nephrology, American Society of Pediatric Nephrology, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Chief Editor

Craig B Langman, MD  The Isaac A Abt, MD, Professor of Kidney Diseases, Feinberg School of Medicine, Northwestern University; Division Head of Kidney Diseases, Children's Memorial Hospital, Chicago

Craig B Langman, MD is a member of the following medical societies: American Academy of Pediatrics, American Society of Nephrology, and International Society of Nephrology

Disclosure: Amgen Grant/research funds None; Genzyme Grant/research funds None; Merck Grant/research funds None; NIH Grant/research funds None; Raptor Pharmaceuticals, Inc Grant/research funds None; Alexion Pharmaceuticals, Inc. Grant/research funds None

References

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Distribution of Hantavirus pulmonary syndrome cases in the United States by virus type. Courtesy of the Centers for Disease Control and Prevention.
 
 
 
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