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Key Features

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Essentials of Diagnosis
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  • Influenza-like prodrome (fever, myalgia, headache, cough)

  • Rapid onset of unexplained pulmonary edema and myocardiopathy

  • Residence or travel in endemic area; exposure to aerosols from deer mouse droppings or secretions

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General Considerations
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  • First native bunyavirus infection endemic in the United States

  • Distinctly differs in mode of spread (no arthropod vector) and clinical picture from other bunyavirus diseases

  • Has been confirmed in more than 34 states and Canada

  • Epidemics occur when environmental conditions favor large increases in the rodent population and increased prevalence of virus

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Clinical Findings

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Symptoms and Signs
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  • After an incubation period of 1–3 weeks, onset is sudden, with a nonspecific virus-like prodrome

    • Fever, chills

    • Back, hip, and leg pain

    • Headache

    • Nausea and vomiting

  • Abdominal pain may be present

  • Sore throat, conjunctivitis, rash, and adenopathy are absent

  • Respiratory symptoms are absent or limited to a dry cough

  • After 1–10 days (usually 3–7), dyspnea, tachypnea, and evidence of a pulmonary capillary leak syndrome appear and progress rapidly

  • Hypotension is common, not only from hypoxemia but also from myocardial dysfunction

  • Copious, amber-colored, nonpurulent secretions are common

  • Decreased cardiac output due to myocardiopathy and elevated systemic vascular resistance distinguish this disease from early bacterial sepsis

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Differential Diagnosis
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  • Plague

  • Tularemia

  • Q fever

  • Psittacosis

  • Toxin exposure

  • Legionellosis

  • Fungal infections

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Diagnosis

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Laboratory Findings
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  • A serum IgM ELISA test is positive early in the illness

  • Leukocytosis with a prominent left shift and immunoblasts, thrombocytopenia, and hemoconcentration

  • Lactate dehydrogenase is increased

  • Liver function tests are elevated

  • Serum albumin is low

  • Creatinine is elevated in some patients

  • Proteinuria is common

  • Lactic acidosis and low venous bicarbonate are poor prognostic signs

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Imaging
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  • Radiography

    • Initially normal

    • Bilateral interstitial infiltrates with the typical butterfly pattern of acute pulmonary edema, bibasilar airspace disease, or both seen later

    • Significant pleural effusions are often present

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Treatment

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  • Supportive with oxygen therapy and mechanical ventilation as required

  • Venoarterial extracorporeal membrane oxygenation can provide short-term support for selected patients

  • Because of capillary leakage, Swan-Ganz catheterization to monitor cardiac output and inotropic support—rather than fluid therapy—should be used to maintain perfusion

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Outcome

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Prognosis
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  • No isolation is required since transmission is not person to person

  • Case fatality rate is 30–40%

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References

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Knust  B, Rollin  PE: Twenty-year summary of surveillance for human hantavirus infections, United States. Emerg Infect Dis 2013;19(12):1934–1937
[PubMed: 24274585]
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Sargianou  M  et al: Hantavirus infections for the clinician: from case presentation to diagnosis and treatment. Crit Rev Microbiol 2012;38(4):317–329
[PubMed: 22553984]

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