Acute hantavirus infection presenting as haemolytic-uraemic syndrome (HUS): the importance of early clinical diagnosis.
Summary (2 min read)
Introduction
- 000 cases/year in West Europe [1]), Puumala hantavirus (PUUV)-induced nephropathia epidemica (NE) and other forms of so-called haemorrhagic fever with renal syndrome (HFRS), are still heavily underdiagnosed in Europe and in the Americas, probably due to insufficient medical awareness and because of the multiple diagnostic pitfalls.
- HFRS and its milder variant NE can mimic other non-tropical infectious illnesses, such as leptospirosis [2, 3] and haemolytic-uraemic syndrome (HUS), which, moreover, can all present in local outbreaks, mostly in summertime [4, 5].
- Misdiagnosis and subsequent invasive treatment for HUS was reported previously [4].
- In the here described case of a flu-like syndrome followed by acute kidney injury (AKI) and thrombocytopaenia, prior contact with bank voles, evoked during anamnesis by the consulted nephrologist, was practically diagnostic from the start.
Case report
- A 58-year-old Belgian male patient developed a flu-like syndrome with respiratory and gastrointestinal complaints.
- Three days post onset of symptoms (POS), his fever reached 40 °C, accompanied by shivers, diaphoresis and oliguria.
- There were no relevant medical antecedents or chronic medication.
- Bone marrow examination showed normocellularity with active trilinear haematopoiesis and an elevated amount of immunoblasts (Fig. 1d), compatible with reactive plasmacytosis.
- Recuperation of the kidney function occurred spontaneously on day 15 POS and the patient was discharged from hospital two days later.
Discussion
- This patient was referred for suspected diarrhoea-associated (D+) Btypical HUS^ because of AKI, concomitant with thrombocytopaenia, schistocytes, raised lactic dehydrogenase (LDH) and coagulopathy, after an episode of gastrointestinal complaints.
- Indicative for hantavirus infection, rather than a possible HUS, was the swift recuperation of thrombocytopaenia and the very rapid spontaneous disappearance of nephrotic-range proteinuria, whilst further renal deterioration occurred.
- This sudden glomerular filtration dysfunction is now explained by a new renal pathological entity, called podocyte injury.
- Of note, lung involvement or acute lung injury (ALI) was also unmistakably present in this case, with coughing and dyspnoea, forthright hypoxaemia and hypocapnia, all hallmarks of HPS.
- Such localisation of the region of infection is only possible when sufficient other sequences of the viral pathogen from different regions are available for comparison [7, 16, 22].
Conclusion
- In summary, European and Russian Puumala virus (PUUV) infections, just because of their relative mildness compared to other, more severe haemorrhagic fever with renal syndrome (HFRS) forms, can constitute a diagnostic challenge, particularly on admission, whereby even the so-called Brenal syndrome^ is hardly or not at all in the foreground [3, 4, 6, 20, 22].
- Increased medical awareness is more than ever warranted for this extremely versatile Bchameleon in internal medicine^, now that HFRS, until recently considered as relevant to the Old World only, has increasingly been recognised in the New World also, this time as the Seoul virus (SEOV)-induced variant.
- SEOV HFRS can lead to isolated acute kidney injury (AKI) and acute lung injury (ALI) forms, generally more severe than the PUUV-induced variant, but is transmitted by the omnipresent wild rat, including pet rats, which is both a global carrier and reservoir of SEOV [2, 3] (Clement et al., 2017, Rat-transmitted hantavirus infection: nil sub sole novum., submitted).
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Cites background from "Acute hantavirus infection presenti..."
...11 plus microhematuria; early (mostly before hospitalization) and rapidly evolving, but cardinal sign, easy, and cheap to assess day-by-day Hyponatremia and hypoalbuminemia, predicting clinical severity‡ (5,8,12,22) Highly increased levels of LDH, and particularly of CRP and PCT, mimicking hemolysis (18,22) or a bacteria, rather than a virus, infection‡ (6–8) Lipid paradox: low acute cholesterolemia (particularly decreased high-density lipoprotein–cholesterol levels), contrasting with fasting hypertriglyceridemia, both transitory (7,18,23,24) Serum creatinine levels might remain initially (18,20) or constantly (4,7,25–27) at standard levels, or barely and briefly increased (28) Slight-to-frank hypokalemia, despite often clearly impeded renal function (8,29) Ultrasound anomalies, reported more for HFRS than for HCPS Third-space, protein-rich fluid effusions‡ (pleuritis, pericarditis, ascites) Longitudinal renal diameter >11 cm¶ (17,18), swollen cortex with echodensity greater than or equal to that for liver....
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...Assays available for the detection of the Hantavirus pathogens are Immunosorbent assays (IgG and IgM ELISA), immunoblotting assays (in house western blot and Microgen blot assays), immunofluorescence assay (IFA), reduction neutralization assay (FRNT) and molecular detection assays (PCRs) (Clement et al., 2018; Mattar et al., 2014)....
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References
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"Acute hantavirus infection presenti..." refers background in this paper
...Despite the increasing incidence of rodent-borne hantavirus infections (approximately 10,000 cases/year in West Europe [1]), Puumala hantavirus (PUUV)-induced nephropathia epidemica (NE) and other forms of so-called haemorrhagic fever with renal syndrome (HFRS), are still heavily underdiagnosed in Europe and in the Americas, probably due to insufficient medical awareness and because of the multiple diagnostic pitfalls....
[...]
...Despite the increasing incidence of rodent-borne hantavirus infections (approximately 10,000 cases/year in West Europe [1]), Puumala hantavirus (PUUV)-induced nephropathia epidemica (NE) and other forms of so-called haemorrhagic fever with renal syndrome (HFRS), are still heavily underdiagnosed in Europe and in the Americas, probably due to insufficient medical awareness and because of the multiple diagnostic pitfalls....
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