RENAL HISTOPATHOLOGY IN A CASE OF NEPHROPATHIA EPIDEMICA MYHRMAN

[Infection outbreak among German and Finish troups in Eastern Lapland during World War II - First description of hantavirus disease in the German language area]

Eight decades ago, a report on "a swamp fever-like disease in German troups in Lapland" was published in this journal. The disease outbreak had occurred in 1942 and affected more than 1000 soldiers at the Finish front. The published, precise analysis of the clinical picture was obviously the first description of hantavirus disease in the German language area. Nowadays, hantavirus disease - in Central and Northern Europe also known as Nephropathia epidemica - is one of the most frequent notifiable virus diseases in Germany and Finland.

Hantavirus Research in Finland: Highlights and Perspectives

Finland has the highest incidence of hantavirus infections globally, with a significant impact on public health. The large coverage of boreal forests and the cyclic dynamics of the dominant forest rodent species, the bank vole Myodes glareolus, explain most of this. We review the relationships between Puumala hantavirus (PUUV), its host rodent, and the hantavirus disease, nephropathia epidemica (NE), in Finland. We describe the history of NE and its diagnostic research in Finland, the seasonal and multiannual cyclic dynamics of PUUV in bank voles impacting human epidemiology, and we compare our northern epidemiological patterns with those in temperate Europe. The long survival of PUUV outside the host and the life-long shedding of PUUV by the bank voles are highlighted. In humans, the infection has unique features in pathobiology but rarely long-term consequences. NE is affected by specific host genetics and risk behavior (smoking), and certain biomarkers can predict the outcome. Unlike many other hantaviruses, PUUV causes a relatively mild disease and is rarely fatal. Reinfections do not exist. Antiviral therapy is complicated by the fact that when symptoms appear, the patient already has a generalized infection. Blocking vascular leakage measures counteracting pathobiology, offer a real therapeutic approach.

Kidney disease in Puumala hantavirus infection

Acute kidney injury (AKI) remains a predominant clinical expression of nephropathia epidemica (NE). Its pathogenesis is not yet fully understood. Here, we describe the tissue injury comprehensively and present new data aimed to characterize the injury and explain its pathophysiology. When compared to tubulointerstitial nephritis of a wide variety of other aetiologies, a high degree of proteinuria is a distinguished trait of NE, a finding that is also helpful in the clinical suspicion of the disease. Recently, novel biomarkers for the prediction of severe AKI, including neutrophil gelatinase-associated lipocalin (NGAL), have been identified and ultrastructural tissue changes have been more accurately described. A role for soluble urokinase-type plasminogen activator (suPAR) in the pathogenesis of NE has been suggested, and data on gene polymorphisms, in relation to the severity of AKI have been presented. Smoking is a risk factor for NE and smoking is also associated with aggravated AKI in NE. Although no specific treatment is in sight, recent case reports concerning therapy directed against vascular permeability and vasodilation are of interest. In fact, future work trying to explain the pathophysiology of AKI might need concentrated efforts towards the mechanisms of increased vascular permeability and vasodilatation, which irrespective of organ manifestation, are two major determinants of NE.

Electron Microscopy of Nephropathia Epidemica. Glomerular changes

Electron microscopical changes in the glomeruli in 20 kidney biopsies from 18 patients, who were suffering from or had lately suffered from Nephropathia epidemica were studied. Various kinds of deposits were seen. Under the endothelial cells there were collections of light flocculent material. Small dark deposits were seen in the mesangium at the mesangial cell processes, inside the thickened basement membrane, and occasionally on the epithelial side of the membrane. Large deposits were seen around mesangial cells in the mesangium. Deposits were less numerous than in chronic immune complex diseases. The intramembranous or subepithelial deposits were associated with "moon craters", membranous convoluted structures or membrane debris. Granular extracellular mesangial material, round extracellular particles and intraendothelial microtubular inclusions were occasionally seen. In two of our cases occasional capsular epithelial cells showed numerous myelin bodies. Typical viruses were not seen in the glomeruli. The findings are in accord with the short period of scanty immune complex deposition in the glomeruli in the clinically active phase of Nephropathia epidemica.

Angiography in epidemic nephropathy

Nephroangiography has been performed in 35 patients with epidemic nephropathy during the course of the renal lesion phase. In addition to enlarged kidney with thickened cortex, generalized renal vasodilatation was demonstrated in the majority of the cases, frequently combined with rapid circulation. Thus, contrary to previous assumptions, acute oliguric renal insufficiency may also occur in cases with peripheral renal vasodilatation. The angiographic appearance of epidemic nephropathy was characteristic and most evident in the oliguric and anuric phases. Nephroangiography in acute oliguric renal failure may thus be of value for the differential diagnosis and thereby influence the clinical management of the patient.