Acalculous cholecystitis associated with hemorrhagic fever with renal syndrome

Puumala hantavirus: an imaging review

Puumala virus (PUUV) is the most common hantavirus in Europe. It is known to cause nephropathia epidemica, which is considered a mild type of hemorrhagic fever with renal syndrome. However, it does not only involve the kidneys and is rarely accompanied by symptomatic hemorrhage. We review the imaging abnormalities caused by PUUV infection, from head to pelvis, emphasizing the broad spectrum of possible findings and bringing further support to a previously suggested denomination "Hantavirus disease" that would encompass all clinical manifestations. Although non-specific, knowledge of radiological appearances is useful to support clinically suspected PUUV infection, before confirmation by serology.

Flash-Like Albuminuria in Acute Kidney Injury Caused by Puumala Hantavirus Infection

Transient proteinuria and acute kidney injury (AKI) are characteristics of Puumala virus (PUUV) infection. Albuminuria peaks around the fifth day and associates with AKI severity. To evaluate albuminuria disappearance rate, we quantified albumin excretion at different time points after the fever onset. The study included 141 consecutive patients hospitalized due to acute PUUV infection in Tampere University Hospital, Finland. Timed overnight albumin excretion (cU-Alb) was measured during the acute phase in 133 patients, once or twice during the convalescent phase within three months in 94 patients, and at six months in 36 patients. During hospitalization, 30% of the patients had moderately increased albuminuria (cU-Alb 20-200 μg/min), while 57% presented with severely increased albuminuria (cU-Alb >200 μg/min). Median cU-Alb was 311 μg/min (range 2.2-6460) ≤7 days after fever onset, 235 μg/min (range 6.8-5479) at 8-13 days and 2.8 μg/min (range 0.5-18.2) at 14-20 days. After that, only one of the measurements showed albuminuria (35.4 μg/min at day 44). At six months, the median cU-Alb was 2.0 μg/min (range 0.6-14.5). Albuminuria makes a flash-like appearance in PUUV infection and returns rapidly to normal levels within 2-3 weeks after fever onset. In the case of AKI, this is a unique phenomenon.

Acalculous cholecystitis associated with Hantaan virus: A case report

Acute acalculous cholecystitis (AAC) still remains one of the most elusive diagnoses and occurs in various conditions. Although AACs caused by viral infections are rare, various viruses have been revealed to cause AAC. Here we present a case in which a man suffered from AAC caused by a Hantaan virus infection. A 35-year-old man was referred to the emergency room for myalgia and fever that began 4 days ago. He suffered oliguria and abdominal pain for 2 days. At the time of his visit to the emergency room, he experienced a fever that spiked up to 38.3℃. An initial blood sample objectified the following pathologic results: white blood cells - 10260/µl; C-reactive protein – 6.76 mg/dl; total bilirubin – 1.7 mg/dl; AST – 90 IU/L; ALT – 233 IU/L. In the computed tomography, bilateral perirenal fluid collections and bilateral flexural effusion were shown and acute hepatopathy and cholecystopathy were also shown. Because there was no definite tenderness around the patient's right upper quadrant from physical examination and his cholecystopathy looked like it was from secondary change according to acute hepatopathy, we decided to perform conservative care without surgical treatment. The following day, in viral antibody test, Hantaan virus antibody was detected. After conservative management, the patient's condition improved and his laboratory findings were stable. The patient was discharged on the 10^th day at the hospital stay without any symptoms. The Hantaan virus infection should be suspected as a causative agent of AAC, especially when there is abnormal liver function tests and abdominal pain.