Hantavirus Pulmonary Syndrome Differential Diagnoses

Sections

DDx

Diagnostic Considerations

Drug-induced noncardiac pulmonary edema

An appropriate ingestion history of medications that are associated with noncardiac pulmonary edema may differentiate drug-induced noncardiac pulmonary edema from Hantavirus pulmonary syndrome (HPS).

Patients with cardiac pulmonary edema usually have a left ventricular S₃ gallop rhythm and often have cardiomegaly upon physical examination, which is not the case with HPS.

Acute respiratory distress syndrome

In contrast to HPS, the distribution of the infiltrates associated with acute respiratory distress syndrome (ARDS) observed on chest radiographs is peripheral rather than central. In addition, pleural effusions are common in HPS but are not a feature of ARDS.

HPS is accompanied by perihilar cuffing, earlier appearance of interstitial edema (Kerley B lines), and pericardiac haziness (fuzzy heart sign), which are characteristic of HPS and are not found with ARDS.

Pneumonic plague

Patients with pneumonic plague are critically ill with hemoptysis, which is not a feature of HPS. Pneumonic plague occurs in the setting of an outbreak of antecedent bubonic plague. Patients with HPS are less ill and have no adenopathy suggesting preceding or concomitant pneumonic plague.

Atypical community-acquired pneumonias

Among the nonzoonotic atypical pneumonias, Legionnaires disease may resemble HPS. Levels of serum transaminases may be mildly elevated in patients with Legionnaires disease and in those with HPS. Relative bradycardia uniformly accompanies Legionnaires disease but not HPS. Gastrointestinal symptoms, particularly diarrhea, may be observed in both. Severe renal insufficiency is uncommon in HPS and is unusual in Legionnaires disease. Cardiopulmonary collapse frequently occurs in HPS and seldom complicates Legionnaires disease, except in the terminal stages.

Tularemia and Q fever are zoonotic atypical pneumonias that are in the differential diagnoses of HPS. However, the vectors are different for these zoonotic infections. Contact with sheep or parturient cats is the usual epidemiological antecedent for Q fever pneumonia. Similarly, contact with deer, rabbits, or deer flies is the usual history suggesting tularemia. Symptoms common to Q fever, tularemia, and HPS are headache and myalgias. Q fever may feature splenomegaly and relative bradycardia, which are findings not observed in HPS. Bilateral hilar adenopathy and bloody pleural effusion characterize tularemic pneumonia and are not associated with HPS.

Viral influenza

Influenza begins abruptly, with patients often recalling the exact minute and/or hour they became acutely ill. A dry nonproductive cough and a sore throat, usually accompanied by rhinorrhea, characterize influenza. These are not features of HPS. Headache and myalgias are common in both infections.

Workup

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David J Cennimo, MD, FAAP, FACP, AAHIVS Assistant Professor of Medicine and Pediatrics, Adult and Pediatric Infectious Diseases, Rutgers New Jersey Medical School; Hospital Epidemiologist and Co-Director of Antimicrobial Stewardship, University Hospital

David J Cennimo, MD, FAAP, FACP, AAHIVS is a member of the following medical societies: American Academy of HIV Medicine, American Academy of Pediatrics, American College of Physicians, American Medical Association, HIV Medicine Association, Infectious Diseases Society of America, Medical Society of New Jersey, Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Coauthor(s)

Zachariah E Hale, MD Resident Physician, Departments of Internal Medicine and Pediatrics, Rutgers New Jersey Medical School

Zachariah E Hale, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association

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.

John L Brusch, MD, FACP Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

Burke A Cunha, MD Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgements

Kenneth C Earhart, MD Deputy Head, Disease Surveillance Program, United States Naval Medical Research Unit #3

Kenneth C Earhart, MD is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Hantavirus Pulmonary Syndrome Differential Diagnoses

Diagnostic Considerations

Drug-induced noncardiac pulmonary edema

Acute respiratory distress syndrome

Pneumonic plague

Atypical community-acquired pneumonias

Viral influenza

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Hantavirus Pulmonary Syndrome Differential Diagnoses

Diagnostic Considerations

Drug-induced noncardiac pulmonary edema

Acute respiratory distress syndrome

Pneumonic plague

Atypical community-acquired pneumonias

Viral influenza

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