Clinical characteristics and outcomes in critical patients with hemorrhagic fever with renal syndrome

Epidemiological and clinical characteristics of death from hemorrhagic fever with renal syndrome: a meta-analysis

Introduction

Hemorrhagic fever with renal syndrome (HFRS) is an acute infectious disease comprising five stages: fever, hypotension, oliguria, diuresis (polyuria), and convalescence. Increased vascular permeability, coagulopathy, and renal injury are typical clinical features of HFRS, which has a case fatality rate of 1-15%. Despite this, a comprehensive meta-analyses of the clinical characteristics of patients who died from HFRS is lacking.

Methods

Eleven Chinese- and English-language research databases were searched, including the China National Knowledge Infrastructure Database, Wanfang Database, SinoMed, VIP Database, PubMed, Embase, Scopus, Cochrane Library, Web of Science, Proquest, and Ovid, up to October 5, 2023. The search focused on clinical features of patients who died from HFRS. The extracted data were analyzed using STATA 14.0.

Results

A total of 37 articles on 140,295 patients with laboratory-confirmed HFRS were included. Categorizing patients into those who died and those who survived, it was found that patients who died were older and more likely to smoke, have hypertension, and have diabetes. Significant differences were also observed in the clinical manifestations of multiple organ dysfunction syndrome, shock, occurrence of overlapping disease courses, cerebral edema, cerebral hemorrhage, toxic encephalopathy, convulsions, arrhythmias, heart failure, dyspnea, acute respiratory distress syndrome, pulmonary infection, liver damage, gastrointestinal bleeding, acute kidney injury, and urine protein levels. Compared to patients who survived, those who died were more likely to demonstrate elevated leukocyte count; decreased platelet count; increased lactate dehydrogenase, alanine aminotransferase, and aspartate aminotransferase levels; prolonged activated partial thromboplastin time and prothrombin time; and low albumin and chloride levels and were more likely to use continuous renal therapy. Interestingly, patients who died received less dialysis and had shorter average length of hospital stay than those who survived.

Conclusion

Older patients and those with histories of smoking, hypertension, diabetes, central nervous system damage, heart damage, liver damage, kidney damage, or multiorgan dysfunction were at a high risk of death. The results can be used to assess patients' clinical presentations and assist with prognostication.Systematic review registration:https://www.crd.york.ac.uk/prospero/, (CRD42023454553).

Levels of peripheral blood routine, biochemical and coagulation parameters in patients with hemorrhagic fever with renal syndrome and their relationship with prognosis: an observational cohort study

BACKGROUND

Hantaan virus (HTNV), Seoul virus (SEOV) and Puumala virus (PUUV) are major serotypes of the Hantavirus, which can cause hemorrhagic fever with renal syndrome (HFRS). The pathophysiology of HFRS in humans is complex and the determinants associated with mortality, especially the coagulation and fibrinolysis disorders, are still not been fully elucidated. Severe patients usually manifest multiple complications except for acute kidney injury (AKI). The aim of this study was to observe the levels of peripheral blood routine, biochemical and coagulation parameters during the early stage, so as to find independent risk factors closely related to the prognosis, which may provide theoretical basis for targeted treatment and evaluation.

METHODS

A total of 395 HFRS patients from December 2015 to December 2018 were retrospectively enrolled. According to prognosis, they were divided into a survival group (n = 368) and a death group (n = 27). The peripheral blood routine, biochemical and coagulation parameters were compared between the two groups on admission. The relationship between the parameters mentioned above and prognosis was analyzed, and the dynamic changes of the coagulation and fibrinolysis parameters during the first week after admission were further observed.

RESULTS

In addition to AKI, liver injury was also common among the enrolled patients. Patients in the death group manifested higher levels of white blood cell counts (WBC) on admission. 27.30% (107/392) of the patients enrolled presented with disseminated intravascular coagulation (DIC) on admission and DIC is more common in the death group; The death patients manifested longer prothrombin time (PT) and activated partial thromboplastin time (APTT), higher D-dimer and fibrinogen degradation product (FDP), and lower levels of platelets (PLT) and fibrinogen (Fib) compared with those of the survival patients. The proportion of D-dimer and FDP abnormalities are higher than PT, APTT and Fib. Prolonged PT, low level of Fib and elevated total bilirubin (TBIL) on admission were considered as independent risk factors for prognosis (death).

CONCLUSIONS

Detection of PT, Fib and TBIL on admission is necessary, which might be benefit to early predicting prognosis. It is also important to pay attention to the dynamic coagulation disorders and hyperfibrinolysis during the early stage in the severe HFRS patients.

Lung ultrasonography versus chest CT for assessing peripheric pulmonary lesions in hemorrhagic fever with renal syndrome: a prospective comparative study in China

OBJECTIVES

To compare the performances of lung ultrasonography (LUS) versus chest CT for assessing peripheric pulmonary lesions in hemorrhagic fever with renal syndrome (HFRS).

METHODS

Paired LUS and chest CT scan were prospectively performed and compared when in diagnosing five pathologies including region with alveolar-interstitial pattern (RAIP), alveolar-interstitial syndrome (AIS), lung consolidation, pleural effusion (PE), and pericardial effusion, in each patient with HFRS.

RESULTS

Forty-four patients (aged 39.9 ± 15.0 years, 35 males) were included, from which 68 paired LUS and chest CT imaging data of 816 lung regions were obtained and analyzed. Compared with chest CT, LUS showed high sensitivity (92.19-100%) and negative predictive value (95.9-100%), but relatively low specificity (39.47-97.21%) and positive predictive value (37.5-76.47%) for diagnosing the above pathologies. McNemer's test showed LUS detected more positive findings than chest CT (all p ≤ 0.002). There was a strong correlation between LUS and chest CT scores (r_s = 0.7141, p < 0.0001) and both scores correlated with the disease severity, hospital days, and partial laboratory profiles in HFRS patients.

CONCLUSIONS

LUS was comparable with chest CT for diagnosing peripheric pulmonary lesions and clinical assessment in patients with HFRS. Given the high sensitivity and negative predictive value compared with chest CT, LUS can be used as an excellent rule-out tool in HFRS, while its use in rule-in still requires more evidence. Considering the obvious advantages of LUS being a bedside, less expansive, and non-radiating exam, future multi-center randomized LUS versus chest CT studies may help to guide the preferred method.

KEY POINTS

• LUS could detect more positive findings than chest CT in assessing peripheric pulmonary lesions in patients with hemorrhagic fever with renal syndrome (HFRS). • Compared with chest CT, LUS showed high sensitivity but relatively low specificity when diagnosing the peripheric pulmonary lesions caused by HFRS. • Both LUS and chest CT scores correlated with the disease severity, hospital days, and partial laboratory profiles in HFRS.

Hantaan virus-induced elevation of plasma osteoprotegerin and its clinical implications in hemorrhagic fever with renal syndrome

OBJECTIVES

The bleeding tendency is a hallmark of hemorrhagic fever with renal syndrome (HFRS) after Hantaan virus (HTNV) infection. Growing reports indicate the importance of osteoprotegerin (OPG) in vascular homeostasis, implying OPG might be involved in the pathogenesis of coagulopathy in patients with HFRS.

METHODS

Acute and convalescence plasmas of 32 patients with HFRS were collected. Enzyme-linked immunosorbent assays (ELISA) were used to detect plasma OPG levels and other parameters. The human umbilical vein endothelial cells were stimulated with HTNV and/or tumor necrosis factor-α (TNF-α) to explore the source of OPG.

RESULTS

Plasma OPG levels of patients with HFRS were elevated and correlated positively with the severity of HFRS and negatively with platelet counts. Abundant OPG was released from endothelial cells in response to TNF-α stimuli, along with HTNV infection, which was in accordance with the findings of positive correlations between plasma OPG and TNF-α or c-reactive protein. Importantly, plasma OPG levels correlated positively with activated partial thromboplastin time and the content of d-dimer.

CONCLUSION

These findings suggested that increased plasma OPG levels induced by HTNV might be an important factor for the severity of HFRS, and was likely involved in endothelium dysfunction and hemorrhagic disorder of HFRS, which might contribute to the pathogenesis of hemorrhage in HFRS.

High levels of exfoliated fragments following glycocalyx destruction in hemorrhagic fever with the renal syndrome are associated with mortality risk

Background

The glycocalyx is a gel-like structure that covers the luminal side of vascular endothelial cells. It plays an important role in maintaining the integrity of the vascular endothelial barrier structure. However, the presence or absence of glycocalyx destruction in hemorrhagic fever with renal syndrome (HFRS) and its specific mechanism and role is still unclear.

Methods

In this study, we detected the levels of exfoliated glycocalyx fragments, namely, heparan sulfate (HS), hyaluronic acid (HA), and chondroitin sulfate (CS), in HFRS patients and investigated their clinical application value on the evaluation of disease severity and prognosis prediction.

Results

The expression of exfoliated glycocalyx fragments in plasma was significantly increased during the acute stage of HFRS. The levels of HS, HA, and CS in HFRS patients during the acute stage were significantly higher than in healthy controls and convalescent stages of the same type. HS and CS during the acute stage gradually increased with the aggravation of HFRS, and both fragments showed a significant association with disease severity. In addition, exfoliated glycocalyx fragments (especially HS and CS) showed a significant correlation with conventional laboratory parameters and hospitalization days. High levels of HS and CS during the acute phase were significantly associated with patient mortality and demonstrated an obvious predictive value for the mortality risk of HFRS.

Conclusion

Glycocalyx destruction and shedding may be closely associated with endothelial hyperpermeability and microvascular leakage in HFRS. The dynamic detection of the exfoliated glycocalyx fragments may be beneficial for the evaluation of disease severity and prognosis prediction in HFRS.

Expert Consensus on the Prevention and Treatment of Hemorrhagic Fever with Renal Syndrome

Abstract

Hemorrhagic fever with renal syndrome (HFRS) is an acute zoonosis with a global distribution. China is one of the countries with a high incidence of HFRS, which has long endangered the lives and health of the Chinese people. The Infectious Disease Branch of the Chinese Preventive Medicine Association and the Infectious Diseases Branch of the Chinese Medical Association organized national multidisciplinary experts, based on domestic and international research results combined with experts’ practical experiences, to reach this consensus after thorough discussion. This consensus contains 17 recommendations aimed at prevention and identification of important clinical issues to further standardize the prevention, diagnosis, and treatment of HFRS.

Hemorrhagic fever with renal syndrome caused by destruction of residential area of rodent in a construction site: epidemiological investigation

BACKGROUND

An outbreak of hemorrhagic fever with renal syndrome (HFRS), caused by a Hantavirus, affected nine adult males in the southwest area of Xi'an in November 2020 was analyzed in this study.

METHODS

Clinical and epidemiological data of HFRS patients in this outbreak were retrospectively analyzed. The whole genome of a hantavirus named 201120HV03xa (hv03xa for short) isolated from Apodemus agrarius captured in the construction site was sequenced and analyzed. In addition, nine HFRS patients were monitored for the IgG antibody against the HV N protein at 6 and 12 months, respectively.

RESULTS

In this study, inhalation of aerosolized excreta and contaminated food may be the main source of infection. Genome analysis and phylogenetic analysis showed that hv03xa is a reassortment strain of HTNV, having an S segment related to A16 of HTN 4, an M segment related to Q37 and Q10 of HTN 4, and an L segment related to prototype strain 76-118 of HTN 7. Potential recombination was detected in the S segment of hv03xa strain. The anti-HV-IgG level of all the patients persist for at least one year after infection.

CONCLUSIONS

This report documented an HFRS outbreak in Xi'an, China, which provided the basic data for epidemiological surveillance of endemic HTNV infection and facilitated to predict disease risk and implement prevention measures.

Hyperamylasemia Caused by the Hantaan Virus: A Retrospective Study of 101 Patients with Hemorrhagic Fever with Renal Syndrome in West China

Background. Hyperamylasemia (HA) is an inconspicuous manifestation of hemorrhagic fever with renal syndrome (HFRS) in Baoji city, West China. Hantaan virus (HTNV) is the only pathogen-caused HFRS in this region, but the knowledge about HA in the local HFRS patients has been limited. The aim of this study was to investigate the characteristics of HA and its predictive risk factors for doctors to engage in timely monitoring and dealing with the possible serious changes prewarned by HA in the early stages of the disease to improve the final outcome. Methods. All HFRS patients with and without HA (HA and nHA groups, respectively) were treated in Baoji People’s Hospital. The clinical characteristics between the two groups were compared by Student’s $\mathit{t}$ -test or Chi-square test. The risk factors for prognosis were measured by the logistic regression analysis. The predictive effects of prognosis in clinical and laboratory parameters were analyzed by the receiver operating characteristic curves. Results. 46.53% of the patients demonstrated HA, among which 71.7% were severe and critical types of HFRS, greater than that in the nHA group (19.57%, $\mathit{P}<\mathbf{0.001}$ ). The hospitalization day and the general incidence of acute pancreatitis (AP) were longer or greater in the HA group than in the nHA group ( $\mathit{P}<\mathbf{0.01}$ ). Age and the time from the onset of the first symptom to the patient being admitted to hospital ( $T_{\text{OA}}$ ) were the predictive risk factors for HA. The best cut-off values were the age of 54 years and $T_{\text{OA}}$ of 5.5 days. Conclusion. HTNV-induced HA is a common clinical presentation of HFRS patients in West China. It can increase the severity, the hospitalization days of patients, and the incidence of AP in HFRS. Age and $T_{\text{OA}}$ constituted independent risk factors for HA caused by HTNV.

Evaluation of Serum Ferritin, Procalcitonin, and C-Reactive Protein for the Prediction of Severity and Mortality in Hemorrhagic Fever With Renal Syndrome

This study aimed to analyze the clinical significance of serum ferritin, procalcitonin (PCT), and C-reactive protein (CRP) in patients with hemorrhagic fever with renal syndrome (HFRS). The demographical, clinical, and laboratory data of 373 patients with HFRS in northeastern China were retrospectively analyzed. The levels of serum ferritin and PCT in severe patients (n = 108) were significantly higher than those in mild patients (n = 265, p < 0.001) and associated with HFRS severity. The area under the receiver operating characteristic curve (AUC) values of serum ferritin and PCT for predicting the severity of HFRS were 0.732 (95% CI 0.678-0.786, p < 0.001) and 0.824 (95% CI 0.773-0.875, p < 0.001), respectively, showing sensitivity and specificity of 0.75 and 0.88 for serum ferritin, and 0.76 and 0.60 for PCT. The CRP level in HFRS with bacterial co-infection (n = 115) was higher than that without bacterial co-infection (n = 258, p < 0.001). The AUC value of CRP for predicting bacterial co-infection was 0.588 (95% CI 0.525-0.652, p < 0.001), showing sensitivity and specificity of 0.43 and 0.76, respectively. The serum ferritin level in non-survivors (n = 14) was significantly higher than in survivors (n = 359, p < 0.001). The AUC value of serum ferritin for predicting mortality was 0.853 (95% CI 0.774-0.933, p < 0.001), showing sensitivity and specificity of 0.933 and 0.739. Serum ferritin and PCT have a robust association with HFRS severity and mortality, which may be promising predictors, and CRP is an effective biomarker to assess bacterial co-infection in HFRS.

Serum superoxide dismutase level is a potential biomarker of disease prognosis in patients with hemorrhagic fever with renal syndrome caused by the Hantaan virus

Background

Hemorrhagic fever with renal syndrome (HFRS) is a disease with increased systemic inflammation and a high fatality rate. Oxidative stress is crucial for inflammation in the pathogeneses of various diseases. We aimed to identify biomarkers of oxidative stress that may assess the severity and disease outcomes of patients with HFRS.

Methods

Between January 2015 and September 2018, we analyzed a retrospective cohort of 149 HFRS patients and 30 healthy individuals. Serum levels of SOD were measured using an ELISA commercial kit, and survival analysis was carried out using the Kaplan–Meier method.

Results

Patients with HFRS had significantly lower serum SOD levels compared with healthy controls (108.40 ± 2.47 U/mL vs 164.23 ± 3.82 U/mL, P < 0.01). SOD levels in patients were lower at acute than at convalescent stage (108.40 ± 2.47 U/mL vs 138.27 ± 2.87 U/mL, P < 0.01), and in severe and critical patients than in moderate and mild patients (89.63 ± 2.38 U/mL vs 122.53 ± 3.18 U/mL, P < 0.01). A serum level of SOD < 88.6 U/mL at admission was associated with a significant increase in mortality risk in HFRS patients.

Conclusion

Our results indicate that serum levels of SOD measured at admission can be used to assess disease severity and assign patients into high- and low-risk groups. SOD can be considered a novel biomarker of severity and outcomes in patients with HFRS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07394-3.

The Clinical Characteristics and Outcomes of Hemorrhagic Fever With Renal Syndrome in Pregnancy

Pregnant women with hemorrhagic fever with renal syndrome (HFRS) are a significant challenge for clinicians. The clinical characteristics of HFRS in pregnant women and its influence on both the pregnant women and fetus have yet to be clarified clearly. To highlight the specific clinical features of HFRS in pregnant women and the outcomes of pregnant women with HFRS and their fetuses, we screened pregnant women with HFRS from inception to May 1^st 2021. We also conducted a comparison with non-pregnant women complicated with HFRS. Twenty-seven pregnant women and 87 non-pregnant women with complete electronic medical records were enrolled for final analyses; 55.6% (15/27) and 21.8% (19/87) were diagnosed as critical type in pregnant women and non-pregnant women, respectively. Compared with non-pregnant patients, there was a significantly higher likelihood of critical status in pregnant patients; the risk was significantly higher in late trimester (p <0.001). In addition, hypoalbuminemia and anemia were also evident in pregnant patients (p = 0.04, p <0.001, respectively). Leukocyte count, especially when higher than 15 × 10⁹/L, was significantly correlated with disease severity (p = 0.009). After comprehensive therapy, 26 pregnant patients recovered without sequelae. Five fetal adverse events were reported during hospitalization. All adverse events were observed in mothers with critical types (p = 0.047, X₂ = 4.909) and occurred in the later trimester. Collectively, our data show that pregnant woman with HFRS during the third trimester presents a more severe condition, especially those with leukocytosis. However, the majority of those pregnant patients could recover with comprehensive treatment and undergo normal labor.

Time series analysis of hemorrhagic fever with renal syndrome in mainland China by using an XGBoost forecasting model

BACKGROUND

Hemorrhagic fever with renal syndrome (HFRS) is still attracting public attention because of its outbreak in various cities in China. Predicting future outbreaks or epidemics disease based on past incidence data can help health departments take targeted measures to prevent diseases in advance. In this study, we propose a multistep prediction strategy based on extreme gradient boosting (XGBoost) for HFRS as an extension of the one-step prediction model. Moreover, the fitting and prediction accuracy of the XGBoost model will be compared with the autoregressive integrated moving average (ARIMA) model by different evaluation indicators.

METHODS

We collected HFRS incidence data from 2004 to 2018 of mainland China. The data from 2004 to 2017 were divided into training sets to establish the seasonal ARIMA model and XGBoost model, while the 2018 data were used to test the prediction performance. In the multistep XGBoost forecasting model, one-hot encoding was used to handle seasonal features. Furthermore, a series of evaluation indices were performed to evaluate the accuracy of the multistep forecast XGBoost model.

RESULTS

There were 200,237 HFRS cases in China from 2004 to 2018. A long-term downward trend and bimodal seasonality were identified in the original time series. According to the minimum corrected akaike information criterion (CAIC) value, the optimal ARIMA (3, 1, 0) × (1, 1, 0)12 model is selected. The index ME, RMSE, MAE, MPE, MAPE, and MASE indices of the XGBoost model were higher than those of the ARIMA model in the fitting part, whereas the RMSE of the XGBoost model was lower. The prediction performance evaluation indicators (MAE, MPE, MAPE, RMSE and MASE) of the one-step prediction and multistep prediction XGBoost model were all notably lower than those of the ARIMA model.

CONCLUSIONS

The multistep XGBoost prediction model showed a much better prediction accuracy and model stability than the multistep ARIMA prediction model. The XGBoost model performed better in predicting complicated and nonlinear data like HFRS. Additionally, Multistep prediction models are more practical than one-step prediction models in forecasting infectious diseases.

Attributable mortality of acute respiratory distress syndrome: a systematic review, meta-analysis and survival analysis using targeted minimum loss-based estimation

BACKGROUND

Although acute respiratory distress syndrome (ARDS) is associated with high mortality, its direct causal link with death is unclear. Clarifying this link is important to justify costly research on prevention of ARDS.

OBJECTIVE

To estimate the attributable mortality, if any, of ARDS.

DESIGN

First, we performed a systematic review and meta-analysis of observational studies reporting mortality of critically ill patients with and without ARDS matched for underlying risk factor. Next, we conducted a survival analysis of prospectively collected patient-level data from subjects enrolled in three intensive care unit (ICU) cohorts to estimate the attributable mortality of critically ill septic patients with and without ARDS using a novel causal inference method.

RESULTS

In the meta-analysis, 44 studies (47 cohorts) involving 56 081 critically ill patients were included. Mortality was higher in patients with versus without ARDS (risk ratio 2.48, 95% CI 1.86 to 3.30; p<0.001) with a numerically stronger association between ARDS and mortality in trauma than sepsis. In the survival analysis of three ICU cohorts enrolling 1203 critically ill patients, 658 septic patients were included. After controlling for confounders, ARDS was found to increase the mortality rate by 15% (95% CI 3% to 26%; p=0.015). Significant increases in mortality were seen for severe (23%, 95% CI 3% to 44%; p=0.028) and moderate (16%, 95% CI 2% to 31%; p=0.031), but not for mild ARDS.

CONCLUSIONS

ARDS has a direct causal link with mortality. Our findings provide information about the extent to which continued funding of ARDS prevention trials has potential to impart survival benefit.

PROSPERO REGISTRATION NUMBER

CRD42017078313.

An evaluation of suspected cases of Hantavirus infection admitted to a tertiary care university hospital in Düzce, Turkey, between 2012 and 2018

Background/aim

Hantavirus is a rodent borne zoonosis caused by the members of the virus family Bunyaviridae, genus Hantavirus . In this study, we aimed to determine the role of peripheral blood leukocyte ratio in differential diagnosis of Hantavirus disease.

Materials and methods

The medical records of patients at the Düzce University Medical Faculty were examined retrospectively. A total of 20 patients diagnosed with hantavirus infection confirmed by serologic tests were included in the study (Group 1). The other group consisted of 30 patients suspected of hantavirus infection but found negative (Group 2). Demographic, clinical and laboratory characteristics, neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and lymphocyte/monocyte (LMR) ratios of both groups were compared.

Results

As a result of the istatistics analysis, no difference was found between the groups’ age, sex, and clinical complaints except lethargy-weakness (P = 0.004) and diarrhea (P < 0.001). Hemogram analysis showed a significant difference between the groups in terms of leukocyte, hemoglobin, hematocrit, platelet, mean platelet volume (P < 0.05) and PLR (P = 0.001) and LMR (P = 0.003) values from peripheral blood leukocyte ratios.

Conclusion

In conclusion, NLR, PLR, and LMR ratios may be useful for clinicians in differential diagnosis of Hantavirus in patients presenting with similar symptoms of Hantavirus disease.

Active Targeted Surveillance to Identify Sites of Emergence of Hantavirus

BACKGROUND

Endemic outbreaks of hantaviruses pose a critical public health threat worldwide. Hantaan orthohantavirus (HTNV) causes hemorrhagic fever with renal syndrome (HFRS) in humans. Using comparative genomic analyses of partial and nearly complete sequences of HTNV from humans and rodents, we were able to localize, with limitations, the putative infection locations for HFRS patients. Partial sequences might not reflect precise phylogenetic positions over the whole-genome sequences; finer granularity of rodent sampling reflects more precisely the circulation of strains.

METHODS

Five HFRS specimens were collected. Epidemiological surveys were conducted with the patients during hospitalization. We conducted active surveillance at suspected HFRS outbreak areas. We performed multiplex polymerase chain reaction-based next-generation sequencing to obtain the genomic sequence of HTNV from patients and rodents. The phylogeny of human- and rodent-derived HTNV was generated using the maximum likelihood method. For phylogeographic analyses, the tracing of HTNV genomes from HFRS patients was defined on the bases of epidemiological interviews, phylogenetic patterns of the viruses, and geographic locations of HTNV-positive rodents.

RESULTS

The phylogeographic analyses demonstrated genetic clusters of HTNV strains from clinical specimens, with HTNV circulating in rodents at suspected sites of patient infections.

CONCLUSIONS

This study demonstrates a major shift in molecular epidemiological surveillance of HTNV. Active targeted surveillance was performed at sites of suspected infections, allowing the high-resolution phylogeographic analysis to reveal the site of emergence of HTNV. We posit that this novel approach will make it possible to identify infectious sources, perform disease risk assessment, and implement preparedness against vector-borne viruses.

Hantavirus diseases pathophysiology, their diagnostic strategies and therapeutic approaches: A review

Hantaviruses are enveloped negative (-) single-stranded RNA viruses belongs to Hantaviridae family, hosted by small rodents and entering into the human body through inhalation, causing haemorrhagic fever with renal syndrome (HFRS) and hantavirus pulmonary syndrome (HPS) also known as hantavirus cardiopulmonary syndrome (HCPS). Hantaviruses infect approximately more than 200 000 people annually all around the world and its mortality rate is about 35%-40%. Hantaviruses play significant role in affecting the target cells as these inhibit the apoptotic factor in these cells. These viruses impair the integrity of endothelial barrier due to an excessive innate immune response that is proposed to be central in the pathogenesis and is a hallmark of hantavirus disease. A wide range of different diagnostic tools including polymerase chain reaction (PCR), focus reduction neutralization test (FRNT), enzyme-linked immunosorbent assay (ELISA), immunoblot assay (IBA), immunofluorescence assay (IFA), and other molecular techniques are used as detection tools for hantavirus in the human body. Now the availability of therapeutic modalities is the major challenge to control this deadly virus because still no FDA approved drug or vaccine is available. Antiviral agents, DNA-based vaccines, polyclonal and monoclonal antibodies neutralized the viruses so these techniques are considered as the hope for the treatment of hantavirus disease. This review has been compiled to provide a comprehensive overview of hantaviruses disease, its pathophysiology, diagnostic tools and the treatment approaches to control the hantavirus infection.

A lateral flow biosensor based on gold nanoparticles detects four hemorrhagic fever viruses

The pathogen of viral hemorrhagic fever (VHF), which is harmful to human health, is a hemorrhagic fever virus. Clinicians have long needed convenient and sensitive point-of-care rapid diagnostic tests (RDTs) for hemorrhagic fever viruses. Commonly used methods for pathogen detection rely on conventional culture-based tests, antibody-based assays and polymerase chain reaction (PCR)-based techniques. However, these methods are costly, laborious and time-consuming. Herein, we present a simple and sensitive biosensor for the rapid detection of hemorrhagic fever viruses. For this assay, we develop lateral flow biosensors (LFBs) based on magnetic beads and nicking enzyme-assisted isothermal strand-displacement amplification (SDA) for the detection of hemorrhagic fever viruses. The detection limit of this assay is 10 fM.

Clinical profiles and factors associated with mortality in adults with yellow fever admitted to an intensive care unit in Minas Gerais, Brazil

BACKGROUND

Yellow fever (YF) is a viral hemorrhagic disease caused by an arbovirus from the Flaviviridae family. Data on the clinical profile of severe YF in intensive care units (ICUs) are scarce. This study aimed to evaluate factors associated with YF mortality in patients admitted to a Brazilian ICU during the YF outbreaks of 2017 and 2018.

METHODS

This was a longitudinal cohort case series study that included YF patients admitted to the ICU. Demographics, clinical and laboratory data were analyzed. Cox regression identified independent predictors of death risk.

RESULTS

A total of 114 patients were studied. The median age was 48 years, and 92.1% were males. In univariate analysis, jaundice, leukopenia, bradycardia, prothrombin time, expressed as a ratio to the international normalized ratio-(PT-INR), alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, lactate, arterial pH and bicarbonate, Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score 3 (SAPS 3) severity scores, transfusion of fresh frozen plasma, acute renal failure (Acute Kidney Injury Network stage III (AKIN III)), hemodialysis, cumulative fluid balance at 72 h of ICU, vasopressor use, seizures and grade IV encephalopathy were significantly associated with mortality. In multivariate analysis, factors independently associated with YF mortality were PT-INR, APACHE II, and grade IV hepatic encephalopathy.

CONCLUSIONS

In the large outbreak in Brazil, factors independently associated with death risk in YF were: PT-INR, APACHE II, and grade IV hepatic encephalopathy. Early identification of patients with YF mortality risk factors may be very useful. Once these patients with a poor prognosis have been identified, proper management should be promptly implemented.

Comparison of autoregressive integrated moving average model and generalised regression neural network model for prediction of haemorrhagic fever with renal syndrome in China: a time-series study

OBJECTIVES

Haemorrhagic fever with renal syndrome (HFRS) is a serious threat to public health in China, accounting for almost 90% cases reported globally. Infectious disease prediction may help in disease prevention despite some uncontrollable influence factors. This study conducted a comparison between a hybrid model and two single models in forecasting the monthly incidence of HFRS in China.

DESIGN

Time-series study.

SETTING

The People's Republic of China.

METHODS

Autoregressive integrated moving average (ARIMA) model, generalised regression neural network (GRNN) model and hybrid ARIMA-GRNN model were constructed by R V.3.4.3 software. The monthly reported incidence of HFRS from January 2011 to May 2018 were adopted to evaluate models' performance. Root mean square error (RMSE), mean absolute error (MAE) and mean absolute percentage error (MAPE) were adopted to evaluate these models' effectiveness. Spatial stratified heterogeneity of the time series was tested by month and another GRNN model was built with a new series.

RESULTS

The monthly incidence of HFRS in the past several years showed a slight downtrend and obvious seasonal variation. A total of four plausible ARIMA models were built and ARIMA(2,1,1) (2,1,1)12 model was selected as the optimal model in HFRS fitting. The smooth factors of the basic GRNN model and the hybrid model were 0.027 and 0.043, respectively. The single ARIMA model was the best in fitting part (MAPE=9.1154, MAE=89.0302, RMSE=138.8356) while the hybrid model was the best in prediction (MAPE=17.8335, MAE=152.3013, RMSE=196.4682). GRNN model was revised by building model with new series and the forecasting performance of revised model (MAPE=17.6095, MAE=163.8000, RMSE=169.4751) was better than original GRNN model (MAPE=19.2029, MAE=177.0356, RMSE=202.1684).

CONCLUSIONS

The hybrid ARIMA-GRNN model was better than single ARIMA and basic GRNN model in forecasting monthly incidence of HFRS in China. It could be considered as a decision-making tool in HFRS prevention and control.

Serum interleukin-18: A novel prognostic indicator for acute respiratory distress syndrome

The aim of this study is to determine the biological function of serum interleukin-18 (IL-18) on prognosis in acute respiratory distress syndrome (ARDS).From October 2016 to September 2017, 150 patients with ARDS in the ICU were enrolled according to the Berlin 2012 definition. The enzyme-linked immunosorbent assay (ELISA) was used to detect the expression level of IL-18 in serum isolated from the patients. Patients were divided into survival group (82 cases) and non-survival group (68 cases) and followed up for at least 2 months. The serum IL-18 expression level on the prognosis was calculated by receiver operating characteristic curve (ROC).The expression level of serum IL-18 was significantly higher in the non-survival group than that in the survival group (P < .05). Based on the ROC curve, the sensitivity and specificity of IL-18 as a predictor of prognosis at a cutoff of 509.5 pg/mL were 88% and 82%, respectively, and the area under the curve (RUC) was 0.84 (P < .05).The expression level of serum IL-18 could be used to evaluate the possible outcomes of patients with ARDS.

Bioclinical Test to Predict Nephropathia Epidemica Severity at Hospital Admission

We conducted a multicenter, retrospective cohort study of hospitalized patients with serologically proven nephropathia epidemica (NE) living in Ardennes Department, France, during 2000-2014 to develop a bioclinical test predictive of severe disease. Among 205 patients, 45 (22.0%) had severe NE. We found the following factors predictive of severe NE: nephrotoxic drug exposure (p = 0.005, point value 10); visual disorders (p = 0.02, point value 8); microscopic or macroscopic hematuria (p = 0.04, point value 7); leukocyte count >10 × 10⁹ cells/L (p = 0.01, point value 9); and thrombocytopenia <90 × 10⁹/L (p = 0.003, point value 11). When point values for each factor were summed, we found a score of <10 identified low-risk patients (3.3% had severe disease), and a score >20 identified high-risk patients (45.3% had severe disease). If validated in future studies, this test could be used to stratify patients by severity in research studies and in clinical practice.

Study on expression of plasma sCD138 in patients with hemorrhagic fever with renal syndrome

BACKGROUND

Until now, there is non-specific treatment, and exploring early and novel biomarkers to determine the disease severity and prognosis of hemorrhagic fever with renal syndrome (HFRS) would be of importance for clinician to take systematic and timely intervention. This study observed the expression of plasma sCD138, a soluble component shedding from the glycocalyx (GCX) to the circulating blood, and evaluated its predictive value on disease severity and prognosis of HFRS.

METHODS

One hundred and seventy-six patients with HFRS who were treated at our center between January 2011 and December 2013 were randomly enrolled in this study. The patients were divided into a mild-type group, a moderate-type group, a severe-type group and a critical-type group according to the HFRS criteria for clinical classification. Thirty-five blood samples from healthy subjects were obtained as the controls. The concentrations of sCD138 were detected using enzyme linked immunosorbent assay (ELISA). The levels of prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (Fib), albumin (ALB), alanine aminotransferase (ALT), aspartate aminotransferase (AST), white blood cells (WBC), platelets (PLT), glucose (GLU), blood urea nitrogen (BUN) and serum creatinine (Scr) in the samples were routinely tested. The levels of sCD138 among the different types were compared; the correlation among sCD138 and the laboratory parameters mentioned above were analyzed. The predictive effectiveness for prognosis of sCD138 was evaluated using the receiver operating characteristic (ROC) curve analysis.

RESULTS

Except for the mild-type, the levels of sCD138 in the moderate-, severe- and critical-type patients during the acute stage were significantly higher than that of the convalescent stage and the control (P<0.05). With the aggravation of the disease, the levels of sCD138 during the acute stage had an increasing tendency, while demonstrated no significant difference among the moderate-, severe- and critical-type patients (P>0.05). sCD138 was negatively correlated with Fib, PLT and ALB, and was positively correlated with WBC and AST (P<0.05). sCD138 demonstrated predictive effectiveness for prognosis with the area under the curve (AUC) of 0.778 (P<0.001).

CONCLUSION

Dynamic detection of plasma sCD138 might be benefit to evaluating the disease severity and prognosis of the patients with HFRS.

Performance assessment of the SAPS II and SOFA scoring systems in Hanta virus Hemorrhagic Fever with Renal Syndrome

BACKGROUND

Hemorrhagic Fever with Renal Syndrome (HFRS), caused by the hantavirus, is a natural infectious disease characterized by fever, hemorrhage and renal damage. China is the most severely endemic area for HFRS in the world. In recent years, critical scoring systems based on quantitative classification have become an important clinical tool for predicting and evaluating the prognosis of critical illness, and provide guidelines for clinical practice.

METHODS

The sample comprised 384 patients with HFRS treated in the Taizhou Hospital from January 2006 to February 2017. The patients were divided into the severe group and the mild group according to their clinical characteristics. By comparing the differences in clinical symptoms, signs and laboratory data between the two groups, the clinically relevant indicators of severe HFRS were explored. According to the previous studies, we incorporated the positive fecal occult blood test (FOBT) into the sepsis-related organ failure assessment (SOFA) tool and formulated a new scoring system specifically for HFRS, named H-SOFA. By comparing the simplified acute physiology score II (SAPS II), SOFA and H-SOFA scores of the two groups, their predictive values for the progression of HFRS were assessed.

RESULTS

Compared to the mild group, patients in the severe group had longer hospital stays; higher frequencies of nausea, vomiting, abdomen pain, signs of congestion and hemorrhage; and more pronounced impairment of liver and renal function. The levels of PLT, PCT, TB, and FOBT were positively correlated with the progression of HFRS (P<0.001). Patients with HFRS in the severe group got significantly higher scores on the SAPS II, SOFA, and H-SOFA scoring systems (P<0.001). The values of SAPS II, SOFA and H-SOFA, were significantly correlated with the severity of HFRS, and the AUC values were 0.90, 0.96, and 0.98, respectively.

CONCLUSION

PLT, PCT, TB, and FOBT were independent predictors of severe HFRS; SAPS II, SOFA, and H-SOFA had high predictive value for the progression of severe HFRS, with H-SOFA being the highest.

Hemorrhagic fever with renal syndrome caused by Hantaan virus infection in four pregnant Chinese women

Hantavirus infection during pregnancy can influence both maternal and fetal outcomes. Here, we describe four cases of hemorrhagic fever with renal syndrome (HFRS) in pregnant Chinese women. The HFRS put these women at increased risk for severe illness, despite the patients' symptomologies in the onset phase were similar to those observed in non-pregnant HFRS patients, such as fever, headache, nausea, and thrombocytopenia. Pregnant women appeared to have a more severe status, presenting with severe complications, such as hypervolemia and pulmonary edema. Nevertheless, with appropriate management, mothers with HFRS may carry to full-term and breastfeeding maybe safe and feasible.

Spatio-Temporal Pattern and Influencing Factors of Hemorrhagic Fever with Renal Syndrome (HFRS) in Hubei Province (China) between 2005 and 2014

Hemorrhagic Fever with Renal Syndrome (HFRS) is considered as a globally distributed infectious disease, which results in many deaths annually in Hubei Province, China. The outbreak of HFRS is usually characterized with spatio-temporal heterogeneity and is seasonally distributed. Further, it might also be impacted by the influencing factors such as socio-economic and geographical environment. To better understand and predict the outbreak of HFRS in the Hubei Province, the spatio-temporal pattern and influencing factors were investigated in this study. Moran's I Index value was adopted in spatial global autocorrelation analysis to identify the overall spatio-temporal pattern of HFRS outbreak. Kulldorff scan statistical analysis was performed to further identify the changing trends of the clustering patterns of HFRS outbreak. Spearman's rank correlation analysis was used to explore the possible influencing factors on HFRS epidemics such as climate and geographic. The results demonstrated that HFRS outbreak in Hubei Province decreased from 2005 to 2012 in general while increasing slightly from 2012 to 2014. The spatial and temporal scan statistical analysis indicated that HFRS epidemic was temporally clustered in summer and autumn from 2005 to 2014 except 2008 and 2011. The seasonal epidemic pattern of HFRS in Hubei Province was characterized by a bimodal pattern (March to May and September to November) while peaks often occurring in the spring time. SEOV-type HFRS was presumed to influence more on the total number of HFRS incidence than HTNV-type HFRS do. The average humidity and human population density were the main influencing factors during these years. HFRS outbreaks were more in plains than in other areas of Hubei Province. We did not find that whether the terrain of the wetland (water system) plays a significant role in the outbreak of HFRS incidence. With a better understanding of rodent infection rate, socio-economic status and ecological environment characteristics, this study may help to reduce the outbreak of HFRS disease.

Changes in Plasma Adiponectin Concentrations in Patients With Hemorrhagic Fever With Renal Syndrome: An Observational Prospective Study

The objective is to observe the changes in plasma adiponectin (APN) and its predictive capacity for disease severity and prognosis of hemorrhagic fever with renal syndrome (HFRS).One hundred and five patients who were treated at our center between October 2011 and December 2012 were randomly enrolled in this study. The patients were divided into a mild-type group, a moderate-type group, a severe-type group, and a critical-type group according to the HFRS criteria for clinical classification. Ninety-three plasma samples from the patients in the acute stage and 78 samples from the patients in the convalescent stage were obtained, and 28 samples from healthy subjects were obtained as controls. The concentrations of APN were detected using the enzyme-linked immunosorbent assay. The levels of white blood cells, platelets, hematocrit, albumin, blood urea nitrogen, serum creatinine, and uric acid in the samples were routinely tested. The levels of APN among the different types were compared; the correlation between APN and the laboratory parameters was analyzed. The predictive effectiveness for prognosis of APN and the laboratory parameters as mentioned above were evaluated using the receiver operating characteristic curve analysis.The levels of APN in the mild- and moderate-type patients in the acute stage were significantly higher than the severe-type and control (P < 0.05) and decreased with the severity of the disease, while there were no obvious difference among severe-, critical-type and control groups. The levels of APN in patients in the convalescent stage were higher than the control group (P < 0.05), and the APN levels of the critical-type group were higher compared with the mild-type groups (P < 0.05). Adiponectin was negatively correlated with white blood cells and hematocrit and positively correlated with platelets, albumin, and uric acid (P < 0.001). Adiponectin showed no statistical significance for predicting prognosis, with the area under the curve equal to 0.609 (95% CI: 0.237-0.745, P = 0.215).Adiponectin can be considered as a novel biomarker for disease severity in patients with HFRS, while it seems to have no predictive capacity for prognosis of HFRS.

Changes of HFRS Incidence Caused by Vaccine Intervention in Yichun City, China, 2005-2013

BACKGROUND

Since 2009, the Hemorrhagic Fever with Renal Syndrome (HFRS) Targeted Expanded Program on Immunization (EPI) has been carried out in the 16-60 age population in Yichun City of Jiangxi Province. However, the annual reported incidences of HFRS in Yichun City Increased significantly from 2009 to 2013.

MATERIAL/METHODS

The information on HFRS reported cases were obtained from the China Information System for Disease Control and Prevention (CISDCP), and demographic data was collected from the Basic Information System. Hantavirus-specific antigen and antibody of rodent specimens were tested by enzyme-linked immunosorbent assay (ELISA) or immune fluorescent assay.

RESULTS

The annual HFRS incidences among all age subgroups presented growth tendencies in non-EPI targeted regions and EPI targeted regions, except for the EPI target population. The annual incidences of EPI target population were stable at around 10 per 100,000 population from 2008 to 2013. HFRS annual incidence was significantly related to rat virus index among all age subgroups in non-EPI targeted regions and >60 age subgroup in EPI targeted regions.

CONCLUSIONS

HFRS vaccine implement has had a notable effect in HFRS prevention and control.

HMGB-1 as a novel predictor of disease severity and prognosis in patients with hemorrhagic fever with renal syndrome

Objective. To examine the predictive capacity of the high mobility group box protein-1 (HMGB-1) for disease severity and prognosis of hemorrhagic fever with renal syndrome (HFRS). Methods. One hundred and five HFRS patients and 28 controls were studied. The concentrations of HMGB-1 in the blood were measured with a commercially available ELISA. The levels of white blood cells (WBC), platelets (PLT), hematocrit (HCT), albumin (ALB), blood urea nitrogen (BUN), serum creatinine (Scr), and uric acid (UA) were routinely tested in the same time frame. Results. The levels of HMGB-1 increased with the severity of the disease (P < 0.001). HMGB-1 was positively correlated with WBC and BUN and negatively correlated with PLT, ALB, and UA (P < 0.001). HMGB-1 showed statistical significance for predicting prognosis (AUC = 0.800, P < 0.001). The sensitivity and specificity of HMGB-1, WBC, PLT, and ALB used in combination for predicting outcome were better than those of single analyses (AUC = 0.892, P < 0.001). Conclusions. HMGB-1 can be considered a novel biomarker for severity and outcome in patients with HFRS. The use of HMGB-1, WBC, PLT, and ALB in combination to predict the outcome in patients with HFRS exhibited an acceptable level of diagnostic capability.

Elevated soluble CD163 plasma levels are associated with disease severity in patients with hemorrhagic fever with renal syndrome

Background

Hantaan virus is a major zoonotic pathogen that causesing hemorrhagic fever with renal syndrome (HFRS). Although HFRS pathogenesis has not been entirely elucidated, the importance of host-related immune responses in HFRS pathogenesis has been widely recognized. CD163, a monocyte and macrophage-specific scavenger receptor that plays a vital function in the hosts can reduce inflammation, is shed during activation as soluble CD163 (sCD163). The aim of this study was to investigate the pathological significance of sCD163 in patients with HFRS.

Methods

Blood samples were collected from 81 hospitalized patients in Tangdu Hospital from October 2011 to January 2014 and from 15 healthy controls. The sCD163 plasma levels were measured using a sandwich ELISA, and the relationship between sCD163 and disease severity was analyzed. Furthermore, CD163 expression in 3 monocytes subset was analyzed by flow cytometry.

Results

The results demonstrated that sCD163 plasma levels during the HFRS acute phase were significantly higher in patients than during the convalescent stage and the levels in the healthy controls (P<0.0001). The sCD163 plasma levels in the severe/critical group were higher than those in the mild/moderate group during the acute (P<0.0001). A Spearman correlation analysis indicated that the sCD163 levels were positively correlated with white blood cell, serum creatine, blood urea nitrogen levels, while they were negatively correlated with blood platelet levels in the HFRS patients. The monocyte subsets were significantly altered during the acute stage. Though the CD163 expression levels within the monocyte subsets were increased during the acute stage, the highest CD163 expression level was observed in the CD14++CD16+ monocytes when compared with the other monocyte subsets.

Conclusion

sCD163 may be correlated with disease severity and the disease progression in HFRS patients; however, the underlying mechanisms should be explored further.