Patient with suspected co-infection of hemorrhagic fever with renal syndrome and malaria: a case report

Background

Hemorrhagic fever with renal syndrome (HFRS) is a natural epidemic disease that can be caused by the Hantaan virus (HTNV). Malaria is caused by plasmodium and can be transmitted by a mosquito bite. The similar manifestations shared by these disorders pose a challenge for clinicians in differential diagnosis, in particular, coupled with a false-positive serological test.

Case presentation

A 46-year-old man was admitted for fever and chills for over 10 days and was suspected of being co-infected with HFRS and malaria due to a history of travel to malaria-endemic areas and a positive HTNV-immunoglobulin M (IgM) test. Although leukocytosis, thrombocytopenia, renal injury, lymphocytosis, overexpression of interleukin-6, and procalcitonin were observed during the hospitalization, the hypotensive, oliguria, and polyuria phases of the HFRS course were not observed. Instead, typical symptoms of malaria were found, including a progressive decrease in erythrocytes and hemoglobin levels with signs of anemia. Furthermore, because the patient had no history of exposure to HFRS endemic areas, exposure to an HTNV-infected rodent, or a positive HTNV-IgG test, and false serological tests of IgM can be caused by various factors, the HFRS coinfection with malaria was ruled out.

Conclusion

Misdiagnosis can be easily induced by a false serological test, in particular the IgM test which can be influenced by various factors. A combination of health history, epidemiology, physical examination, precise application of specific examinations involving tests of conventional laboratory parameters as well as well-accepted methods such as the immunochromatographic (ICG) test, real-time reverse transcription-polymerase chain reaction (PCR), and Western blot (WB), and acquaintance with disorders with similar manifestations will contribute to the precise diagnosis in clinical treatment.

Hantavirus Infections among Military Forces

INTRODUCTION

Hantaviruses cause two kinds of clinical syndromes. Hemorrhagic fever with renal syndrome is caused by Hantaan virus in Asia, Puumala virus (PUUV) and Dobrava virus in Europe, and Seoul virus worldwide. Hantavirus cardiopulmonary syndrome is caused by Sin Nombre virus in North America and Andes virus and related viruses in Latin America. All hantaviruses are carried by rodents and insectivores. Humans are infected via inhaled aerosols of rodent excreta. In the history, there are several epidemics of acute infectious diseases during many wars, which have been suggested or proven to be caused by various hantaviruses.

MATERIALS AND METHODS

Literature review of 41 original publications and reviews published between 1943 and 2022 was performed. Among them, 23 publications handle hantavirus infections among military forces, and the rest 17 hantavirus infections themselves.

RESULTS

A large epidemic during World War II in 1942 among German and Finnish soldiers in Northern Finland with more than 1,000 patients was most probably caused by PUUV. During Korean War in 1951-1954,∼ 3,200 cases occurred among United Nations soldiers in an epidemic caused by Hantaan virus. During Balkan war from 1991 to 1995, numerous soldiers got ill because of hantavirus infection caused by PUUV and Dobrava virus. Several other reports of cases of various hantavirus infections especially among U.S. soldiers acting in South Korea, Germany, Bosnia, and Kosovo have been described in the literature.

CONCLUSIONS

Military maneuvers usually include soil removal, spreading, digging with accompanied dust, and living in field and other harsh conditions, which easily expose soldiers to rodents and their excreta. Therefore, the risks of hantavirus infections in military context are obvious. All military infections have been caused by hantaviruses leading to hemorrhagic fever with renal syndrome.

Medically Significant Vector-Borne Viral Diseases in Iran

Vector-borne viral diseases (VBVDs) continue to pose a considerable public health risk to animals and humans globally. Vectors have integral roles in autochthonous circulation and dissemination of VBVDs worldwide. The interplay of agricultural activities, population expansion, urbanization, host/pathogen evolution, and climate change, all contribute to the continual flux in shaping the epidemiology of VBVDs. In recent decades, VBVDs, once endemic to particular countries, have expanded into new regions such as Iran and its neighbors, increasing the risk of outbreaks and other public health concerns. Both Iran and its neighboring countries are known to host a number of VBVDs that are endemic to these countries or newly circulating. The proximity of Iran to countries hosting regional diseases, along with increased global socioeconomic activities, e.g., international trade and travel, potentially increases the risk for introduction of new VBVDs into Iran. In this review, we examined the epidemiology of numerous VBVDs circulating in Iran, such as Chikungunya virus, Dengue virus, Sindbis virus, West Nile virus, Crimean-Congo hemorrhagic fever virus, Sandfly-borne phleboviruses, and Hantavirus, in relation to their vectors, specifically mosquitoes, ticks, sandflies, and rodents. In addition, we discussed the interplay of factors, e.g., urbanization and climate change on VBVD dissemination patterns and the consequent public health risks in Iran, highlighting the importance of a One Health approach to further surveil and to evolve mitigation strategies.

A framework for understanding and predicting orthohantavirus functional traits

Orthohantaviruses present a global public health threat; there are 58 distinct viruses currently recognized and case fatality of pathogenic orthohantaviruses ranges from <0.1% to 50%. An Old World versus New World dichotomy is frequently applied to distinguish human diseases caused by orthohantaviruses. However, this geographic grouping masks the importance of phylogeny and virus-host ecology in shaping orthohantavirus traits, especially since related arvicoline rodents and their orthohantaviruses are found in both regions. We argue that orthohantaviruses can be separated into three phylogenetically based rodent host groups with differences in key functional traits, including human disease, transmission route, and virus-host fidelity. This framework can help understand and predict traits of under-studied and newly discovered orthohantaviruses and guide public health and biosafety policy.

Time series analyses based on the joint lagged effect analysis of pollution and meteorological factors of hemorrhagic fever with renal syndrome and the construction of prediction model

BACKGROUND

Hemorrhagic fever with renal syndrome (HFRS) is a rodent-related zoonotic disease induced by hantavirus. Previous studies have identified the influence of meteorological factors on the onset of HFRS, but few studies have focused on the stratified analysis of the lagged effects and interactions of pollution and meteorological factors on HFRS.

METHODS

We collected meteorological, contaminant and epidemiological data on cases of HFRS in Shenyang from 2005-2019. A seasonal autoregressive integrated moving average (SARIMA) model was used to predict the incidence of HFRS and compared with Holt-Winters three-parameter exponential smoothing model. A distributed lag nonlinear model (DLNM) with a maximum lag period of 16 weeks was applied to assess the lag, stratification and extreme effects of pollution and meteorological factors on HFRS cases, followed by a generalized additive model (GAM) to explore the interaction of SO2 and two other meteorological factors on HFRS cases.

RESULTS

The SARIMA monthly model has better fit and forecasting power than its own quarterly model and the Holt-Winters model, with an optimal model of (1,1,0) (2,1,0)12. Overall, environmental factors including humidity, wind speed and SO2 were correlated with the onset of HFRS and there was a non-linear exposure-lag-response association. Extremely high SO2 increased the risk of HFRS incidence, with the maximum RR values: 2.583 (95%CI:1.145,5.827). Extremely low windy and low SO2 played a significant protective role on HFRS infection, with the minimum RR values: 0.487 (95%CI:0.260,0.912) and 0.577 (95%CI:0.370,0.898), respectively. Interaction indicated that the risk of HFRS infection reached its highest when increasing daily SO2 and decreasing humidity.

CONCLUSIONS

The SARIMA model may help to enhance the forecast of monthly HFRS incidence based on a long-range dataset. Our study had shown that environmental factors such as humidity and SO2 have a delayed effect on the occurrence of HFRS and that the effect of humidity can be influenced by SO2 and wind speed. Public health professionals should take greater care in controlling HFRS in low humidity, low windy conditions and 2-3 days after SO2 levels above 200 μg/m3.

Atypical Viral Infections in Gastroenterology

Enteric viruses are commonly found obligate parasites in the gastrointestinal (GI) tract. These viruses usually follow a fecal-oral route of transmission and are characterized by their extraordinary stability as well as resistance in high-stress environments. Most of them cause similar symptoms including vomiting, diarrhea, and abdominal pain. In order to come in contract with mucosal surfaces, these viruses need to pass the three main lines of defense: mucus layer, innate immune defenses, and adaptive immune defenses. The following atypical gastrointestinal infections are discussed: SARS-CoV2, hantavirus, herpes simplex virus I, cytomegalovirus, and calicivirus. Dysbiosis represents any modification to the makeup of resident commensal communities from those found in healthy individuals and can cause a patient to become more susceptible to bacterial and viral infections. The interaction between bacteria, viruses, and host physiology is still not completely understood. However, with growing research on viral infections, dysbiosis, and new methods of detection, we are getting closer to understanding the nature of these viruses, their typical and atypical characteristics, long-term effects, and mechanisms of action in different organ systems.

An HFman Probe-Based Multiplex Reverse Transcription Loop-Mediated Isothermal Amplification Assay for Simultaneous Detection of Hantaan and Seoul Viruses

Hantaviruses are zoonotic pathogens that are widely distributed worldwide. Hantaan virus (HTNV) and Seoul virus (SEOV) are two most common hantaviruses that infect humans and cause hemorrhagic fever with renal syndrome (HFRS). Rapid and sensitive detection of HTNV and SEOV are crucial for surveillance, clinical treatment and management of HFRS. This study aimed to develop a rapid HFman probe-based mulstiplex reverse transcription loop-mediated isothermal amplification (RT-LAMP) assay to simultaneously detect HTNV and SEOV. A novel multiplex RT-LAMP assay was developed, and 46 serum samples obtained from clinically suspected patients were used for evaluation. The novel RT-LAMP assay can detect as low as 3 copies/reaction of hantaviruses with a detection limit of 41 and 73 copies per reaction for HTNV and SEOV, respectively. A clinical evaluation showed that the consistencies of the multiplex RT-LAMP with RT-qPCR assay were 100% and 97.8% for HTNV and SEOV, respectively. In view of the high prevalence of HTNV and SEOV in rural areas with high rodent density, a colorimetric visual determination method was also developed for point-of-care testing (POCT) for the diagnosis of the two viruses. The novel multiplex RT-LAMP assay is a sensitive, specific, and efficient method for simultaneously detecting HTNV and SEOV.

Epidemiology, virology and clinical aspects of hantavirus infections: an overview

At the end of 2019 and 2020s, a wave of coronavirus disease 19 (COVID-19) epidemics worldwide has catalyzed a new era of 'communicable infectious diseases'. However, the world is not currently prepared to deal with the growing burden of COVID-19, with the unexpected arrival of Hantavirus infection heading to the next several healthcare emergencies in public. Hantavirus is a significant class of zoonotic pathogens of negative-sense single-stranded ribonucleic acid (RNA). Hemorrhagic renal syndrome (HFRS) and hantavirus cardiopulmonary syndrome (HCPS) are the two major clinical manifestations. Till date, there is no effective treatments or vaccines available, public awareness and precautionary measures can help to reduce the spread of hantavirus disease. In this study, we outline the epidemiology, virology, clinical aspects, and existing HFRS and HCPS management approaches. This review will give an understanding of virus-host interactions and will help for the early preparation and effective handling of further outbreaks in an ever-changing environment.

Clinical and Immunological Predictors of Hemorrhagic Fever with Renal Syndrome Outcome during the Early Phase

The ability to accurately predict the early progression of hemorrhagic fever with renal syndrome (HFRS) is crucial for reducing morbidity and mortality rates in severely affected patients. However, the utility of biomarkers for predicting clinical outcomes remains elusive in HFRS. The aims of the current study were to analyze the serum levels of immune function-related proteins and identify novel biomarkers that may help ascertain clinical outcomes of HFRS. Enzyme-linked immunosorbent assay, Luminex, and bioanalyzer assays were used to quantitatively detect 15 biomarkers in 49 serum samples of 26 patients with HFRS. High hemoglobin (HGB) and low urine output (UO) levels were identified as potential biomarkers associated with the acute HFRS. The serum soluble urokinase plasminogen activator receptor (suPAR) and C-X-C motif chemokine ligand 10 (CXCL10) values increased in the early phase of diseases. Elevated suPAR, interleukin-10 (IL-10), CXCL10, and decreased transforming growth factor-beta 3 (TGF-β3) were representative predictors of the disease severity. Upregulation of the HGB showed a significant correlation with high levels of suPAR and CXCL10. Reduced UO positively correlated with increased suPAR, CXCL10, and TGF-β2, and decreased vascular endothelial growth factor and TGF-β3. The changing HGB and UO criteria, high suPAR, IL-10, CXCL10, and low TGF-β3 of HFRS raise significant awareness for physicians regarding prospective biomarkers for monitoring early warning signs of HFRS. This study provides critical insights into the clinical and immunological biomarkers for disease severity and progression in patients with HFRS to identify early predictions of fatal outcomes.

Hantavirus Induced Kidney Disease

Hantavirus induced hemorrhagic fever with renal syndrome (HFRS) is an emerging viral zoonosis affecting up to 200,000 humans annually worldwide. This review article is focused on recent advances in the mechanism, epidemiology, diagnosis, and treatment of hantavirus induced HFRS. The importance of interactions between viral and host factors in the design of therapeutic strategies is discussed. Hantavirus induced HFRS is characterized by thrombocytopenia and proteinuria of varying severities. The mechanism of kidney injury appears immunopathological with characteristic deterioration of endothelial cell function and compromised barrier functions of the vasculature. Although multidisciplinary research efforts have provided insights about the loss of cellular contact in the endothelium leading to increased permeability, the details of the molecular mechanisms remain poorly understood. The epidemiology of hantavirus induced renal failure is associated with viral species and the geographical location of the natural host of the virus. The development of vaccine and antiviral therapeutics is necessary to avoid potentially severe outbreaks of this zoonotic illness in the future. The recent groundbreaking approach to the SARS-CoV-2 mRNA vaccine has revolutionized the general field of vaccinology and has provided new directions for the use of this promising platform for widespread vaccine development, including the development of hantavirus mRNA vaccine. The combinational therapies specifically targeted to inhibit hantavirus replication and vascular permeability in infected patients will likely improve the disease outcome.

Epidemiological study on the incidence of haemorrhagic fever with renal syndrome in five Western Balkan countries for a 10-year period: 2006-2015

BACKGROUND

Large-scale epidemics of haemorrhagic fever with renal syndrome (HFRS) have been reported mostly in Asia and Europe, with around 100,000 people affected each year. In the Southeast Europe, Balkan region, HFRS is endemic disease with approximately 100 cases per year. Our aim was to describe epidemiological characteristics of HFRS in five Western Balkan (WB) countries and to describe correlation between HFRS incidence and major meteorological event that hit the area in May 2014.

METHODS

National surveillance data of HFRS from Bosnia and Herzegovina, Croatia, Montenegro, North Macedonia and Serbia obtained from 1 January 2006 to 31 December 2015 were collected and analysed.

RESULTS

In a 10-year period, a total of 1,065 HFRS patients were reported in five WB countries. Cumulative incidence rate ranged from 0.05 to 15.80 per 100.000 inhabitants (in North Macedonia and Montenegro respectively). Increasing number of HFRS cases was reported with a peak incidence in three specific years (2008, 2012, and 2014). Average incidence for the entire area was higher in males than females (5.63 and 1.90 per 100.000 inhabitants respectively). Summer was the season with the highest number of cases and an average incidence rate of 1.74/100.000 inhabitants across 10-year period. Haemorrhagic fever with renal syndrome incidence was significantly increased (7.91/100.000 inhabitants) in 2014, when a few months earlier, severe floods affected several WB countries. A strong significant negative correlation (r = -.84, p < .01) between the monthly incidence of HFRS and the number of months after May's floods was demonstrated for the total area of WB.

CONCLUSION

Our findings demonstrate that the HFRS incidence had similar distribution (general, age, sex and seasonality) across majority of the included countries. Summer was the season with the highest recorded incidence. Common epidemic years were detected in all observed countries as well as a negative correlation between the monthly incidence of HFRS and the number of months after May's cyclone.

Global Comprehensive Outlook of Hantavirus Contagion on Humans: A Review

Hantaviruses are rodent viruses that have been identified as etiologic agents of 2 diseases of humans: hemorrhagic fever with renal syndrome (HFRS) and nephropathiaepidemica (NE) in the Old World and Hantavirus pulmonary syndrome (HPS) in the New World. Orthohantavirus is a genus of sin- gle-stranded, enveloped, negative-sense RNA viruses in the family Hantaviridae of the order Bunyavi- rales. The important reservoir of Hantaviruses is rodents. Each virus serotype has its unique rodent host species and is transmitted to human beings with the aid of aerosolized virus, which is shed in urine, fae- ces and saliva and hardly by a bite of the contaminated host. Andes virus is the only Hantavirus identified to be transmitted from human-to-human and its major signs and symptoms include fever, headache, mus- cle aches, lungs filled with fluid etc. In the early 1993, this viral syndrome appeared in the Four Cor- ner location in the south western United States. The only accepted therapeutics for this virus is Ribavirin. Recently, serological examinations to identify Hantavirus antibodies have become most popular for in- vestigation among humans and rodent reservoirs.

OUP accepted manuscript

Hantavirus-induced diseases are emerging zoonoses with endemic appearances and frequent outbreaks in different parts of the world. In humans, hantaviral pathology is characterized by the disruption of the endothelial cell barrier followed by increased capillary permeability, thrombocytopenia due to platelet activation/depletion and an overactive immune response. Genetic vulnerability due to certain human leukocyte antigen haplotypes is associated with disease severity. Typically, two different hantavirus-caused clinical syndromes have been reported: hemorrhagic fever with renal syndrome (HFRS) and hantavirus cardiopulmonary syndrome (HCPS). The primarily affected vascular beds differ in these two entities: renal medullary capillaries in HFRS caused by Old World hantaviruses and pulmonary capillaries in HCPS caused by New World hantaviruses. Disease severity in HFRS ranges from mild, e.g. Puumala virus-associated nephropathia epidemica, to moderate, e.g. Hantaan or Dobrava virus infections. HCPS leads to a severe acute respiratory distress syndrome with high mortality rates. Due to novel insights into organ tropism, hantavirus-associated pathophysiology and overlapping clinical features, HFRS and HCPS are believed to be interconnected syndromes frequently involving the kidneys. As there are no specific antiviral treatments or vaccines approved in Europe or the USA, only preventive measures and public awareness may minimize the risk of hantavirus infection. Treatment remains primarily supportive and, depending on disease severity, more invasive measures (e.g., renal replacement therapy, mechanical ventilation and extracorporeal membrane oxygenation) are needed.

Occupational Hantavirus Infections in Agricultural and Forestry Workers: A Systematic Review and Metanalysis

Hantaviruses are zoonotic pathogens that can cause serious human disorders, including hemorrhagic fever with renal syndrome and hantavirus cardiopulmonary syndrome. As the main risk factor for human infections is the interaction with rodents, occupational groups such as farmers and forestry workers are reportedly at high risk, but no summary evidence has been collected to date. Therefore, we searched two different databases (PubMed and EMBASE), focusing on studies reporting the prevalence of hantaviruses in farmers and forestry workers. Data were extracted using a standardized assessment form, and results of such analyses were systematically reported, summarized and compared. We identified a total of 42 articles, including a total of 28 estimates on farmers, and 22 on forestry workers, with a total workforce of 15,043 cases (821 positive cases, 5.5%). A pooled seroprevalence of 3.7% (95% confidence interval [95% CI] 2.2–6.2) was identified in farmers, compared to 3.8% (95% CI 2.6–5.7) in forestry workers. Compared to the reference population, an increased occurrence was reported for both occupational groups (odds ratio [OR] 1.875, 95% CI 1.438–2.445 and OR 2.892, 95% CI 2.079–4.023 for farmers and forestry workers, respectively). In summary, our analyses stress the actual occurrence of hantaviruses in selected occupational groups. Improved understanding of appropriate preventive measures, as well as further studies on hantavirus infection rates in reservoir host species (rodents, shrews, and bats) and virus transmission to humans, is needed to prevent future outbreaks.

Hantaviruses in Agricultural and Forestry Workers: Knowledge, Attitudes and Practices in Italian Physicians

Hantaviruses are viral pathogens usually endemic in rodent populations. Human exposure follows inhalation of dusts contaminated with rodent excreta, and most individuals have been infected in occupational settings heavily contaminated with rodent droppings, such as agricultural and forestry. To date, knowledge, attitudes and practices of medical professionals, especially occupational physicians (OP), regarding hantavirus disease in at-risk workers have been scarcely investigated. We investigated these topics through a structured questionnaire administered through an online survey of 223 medical professionals (42.2% of them working as OP). Adequate general knowledge of hantavirus disease was found in 48.9% of respondents, with OP exhibiting a better understanding of clinical features of human hantavirus infections. OP aware of the endemic status of hantavirus in North-Eastern Italy exhibited higher risk perception for agricultural workers (odds ratio 21,193, 95% confidence interval 3.666-122.505). On the contrary, a better knowledge of hantaviruses was association with acknowledging an increased risk of hantavirus infection in forestry workers (odds ratio 5.880, 95% confidence interval 1.620-21.343). Hantavirus in Italy represent an often-overlooked biological risk in occupational settings. The lack of preventive immunization, the inappropriate risk perception and the unsatisfying awareness of hantavirus issues collectively stress the importance of appropriate information campaigns among health care providers.

Hantavirus infections in Italy: not reported doesn't mean inexistent

BACKGROUND

Hantaviruses can cause serious human diseases including hemorrhagic fever with renal syndrome (HFRS) and Hantavirus Cardiopulmonary Syndrome (HCPS). European Hantavirus are usually associated with HFRS, and their geographical distribution mirrors the ecology of reservoir host species. Epidemiology of HFRS is well-studied in Western Europe, but data from Italy are fragmentary.

METHODS

We searched into two different databases (PubMed and EMBASE), focusing on studies reporting the prevalence of Hantaviruses in Italy. Data were extracted using a standardized assessment form, and results of the analyses were systematically reported, summarized and compared.

RESULTS

We identified a total of 18 articles, including 12 reports (total population: 5,336 subjects, 1981-2019) and 6 case reports (1984-2019). In total, 200 subjects exhibited some degree of seropositivity, with a pooled seroprevalence of 1.7% (95% confidence interval 0.7%-4.0%) in the general population. Higher occurrence was reported in selected subgroups, i.e. acute (28.7%, 95%CI 22.1-36.2) and chronic (6.6%, 95%CI 4.7-9.1) renal failure, forestry workers (3.0%, 95%CI 1.4-6.5, actual range 0.0 to 10.8%).

CONCLUSIONS

In the last decade, no human cases of hantavirus infection have been officially reported in Italy. However, our analysis stresses the actual occurrence of Hantavirus among general population and in selected population groups. Further studies on hantavirus infection rates in reservoir host species (rodents, shrews, and bats) and virus transmission to humans are needed to prevent outbreaks in the future.

Acute pancreatitis associated with hemorrhagic fever with renal syndrome: a cohort study of 346 patients

Background

To assess the prevalence, risk factors, clinical characteristics, and outcomes of acute pancreatitis (AP) in patients with hemorrhagic fever with renal syndrome (HFRS).

Methods

All patients diagnosed with HFRS admitted to the First Affiliated Hospital of Xi’an Jiaotong University from January 2013 to July 2020 were enrolled. Patients with and without AP were compared by two risk stratification models: (1) a multivariate regression analysis using propensity score to adjust for confounding and (2) a propensity-matched nested case-control study.

Results

A total of 346 patients were enrolled in the cohort study, 29 of whom (8.4%) were diagnosed as AP. There was no significant difference between patients with and without AP with regards to common risk factors and presenting signs/symptoms other than gastrointestinal symptoms (p < 0.01). The patients with AP had a significantly higher 90-day mortality rate (24.1% vs. 3.5%, OR 8.9, 95% CI 1.3 to 103.4, p = 0.045), and significantly shorter duration of therapy free-days to 28 day such as RRT and mechanical ventilation free days (p < 0.05, respectively).

Conclusions

Our study indicated that AP was independently associated with higher mortality in HFRS patients. While considering the difficulty of early recognition of AP among HFRS patients with similar signs and/or symptoms, further laboratory and imaging studies might help identify these patients at risk of poor clinical prognosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-05964-5.

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.

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.

Hantavirus Infections-Treatment and Prevention

Purpose of review

Hantavirus infection is an emerging zoonosis and there are two main clinical presentations, hemorrhagic fever with renal syndrome (HFRS) and Hantavirus pulmonary syndrome (HPS). Although Hantavirus infections have a worldwide distribution with a high mortality rate, a safe and effective vaccine or an antiviral drug against the Hantavirus disease is yet to be available. This review summarizes all the efforts undertaken to develop medical countermeasures in vitro, in vivo, and human clinical trials against Hantavirus infections.

Recent findings

Multiple antivirals are shown to be effective with limited evidence and recent studies on immunotherapy were not very conclusive. There are multiple vaccine candidates with evidence of conferring long protective immunity against Hantaviruses. Some of these had been already trialed on humans.

Summary

At present, severe HPS or HFRS case management is purely based on supportive treatments, often in an intensive care unit. Rodent control and public health education and promotion play a major role in preventing Hantavirus infection.

Heterogeneous Puumala orthohantavirus situation in endemic regions in Germany in summer 2019

Puumala orthohantavirus (PUUV) causes most human hantavirus disease cases in Europe. PUUV disease outbreaks are usually synchronized Germany-wide driven by beech mast-induced irruptions of its host (bank vole, Myodes glareolus). Recent data indicate high vole abundance, high PUUV prevalence and high human incidence in summer 2019 for some regions, but elsewhere values were low to moderate. This significant lack of synchrony among regions in Germany is in contrast to previous studies. Health institutions need to be informed about the heterogeneous distribution of human PUUV infection risk to initiate appropriate actions.

Revisiting the genetic diversity of emerging hantaviruses circulating in Europe using a pan-viral resequencing microarray

Hantaviruses are zoonotic agents transmitted from small mammals, mainly rodents, to humans, where they provoke diseases such as Hemorrhagic fever with Renal Syndrome (HFRS) and its mild form, Nephropathia Epidemica (NE), or Hantavirus Cardio-Pulmonary Syndrome (HCPS). Hantaviruses are spread worldwide and monitoring animal reservoirs is of primary importance to control the zoonotic risk. Here, we describe the development of a pan-viral resequencing microarray (PathogenID v3.0) able to explore the genetic diversity of rodent-borne hantaviruses endemic in Europe. Among about 800 sequences tiled on the microarray, 52 correspond to a tight molecular sieve of hantavirus probes covering a large genetic landscape. RNAs from infected animal tissues or from laboratory strains have been reverse transcribed, amplified, then hybridized to the microarray. A classical BLASTN analysis applied to the sequence delivered through the microarray allows to identify the hantavirus species up to the exact geographical variant present in the tested samples. Geographical variants of the most common European hantaviruses from France, Germany, Slovenia and Finland, such as Puumala virus, Dobrava virus and Tula virus, were genetically discriminated. Furthermore, we precisely characterized geographical variants still unknown when the chip was conceived, such as Seoul virus isolates, recently emerged in France and the United Kingdom.

Phylogeography of Puumala orthohantavirus in Europe

Puumala virus is an RNA virus hosted by the bank vole (Myodes glareolus) and is today present in most European countries. Whilst it is generally accepted that hantaviruses have been tightly co-evolving with their hosts, Puumala virus (PUUV) evolutionary history is still controversial and so far has not been studied at the whole European level. This study attempts to reconstruct the phylogeographical spread of modern PUUV throughout Europe during the last postglacial period in the light of an upgraded dataset of complete PUUV small (S) segment sequences and by using most recent computational approaches. Taking advantage of the knowledge on the past migrations of its host, we identified at least three potential independent dispersal routes of PUUV during postglacial recolonization of Europe by the bank vole. From the Alpe-Adrian region (Balkan, Austria, and Hungary) to Western European countries (Germany, France, Belgium, and Netherland), and South Scandinavia. From the vicinity of Carpathian Mountains to the Baltic countries and to Poland, Russia, and Finland. The dissemination towards Denmark and North Scandinavia is more hypothetical and probably involved several independent streams from south and north Fennoscandia.

Analysis of the integrin β3 receptor for pathogenic orthohantaviruses in rodent host species

Host reservoir specificity of pathogens is complex and may depend on receptor variability. For pathogenic orthohantaviruses, integrin β₃ had been previously identified as entry receptor and the presence of aspartic acid residue at position 39 (D39) in human integrin β₃ was described to be a prerequisite for infection of primate cells with Hantaan virus (HTNV). However, the role of integrin β₃ in orthohantavirus infection of host animals is not completely understood. Therefore, we analyzed the nucleotide sequence of the integrin β₃ gene of Myodes glareolus and Apodemus agrarius, the hosts of Puumala virus (PUUV) and HTNV, respectively. Sequence analysis in tissue samples demonstrated that the amino acid residue D39 is not present in integrin β₃ of these natural orthohantavirus hosts. Furthermore, we analyzed the transcription and protein expression levels of integrin β₃ in the renal cell line BVK168 generated from the PUUV host, bank vole. Transcription level of integrin β₃ was 100-fold lower in BVK168 cells than in Vero E6 cells and integrin β₃ expression was not detectable in BVK168 cells. However, despite the absence of amino acid residue D39 and no detectable integrin β₃ expression, BVK168 cells are susceptible to infection with both PUUV and HTNV. These results indicate that the mechanism of orthohantaviral entry in rodent species does not correspond to the requirements that were described for the entry in primate cells in vitro.

Unique Interferon Pathway Regulation by the Andes Virus Nucleocapsid Protein Is Conferred by Phosphorylation of Serine 386

Andes virus (ANDV) causes hantavirus pulmonary syndrome (HPS) and is the only hantavirus shown to spread person to person and cause a highly lethal HPS-like disease in Syrian hamsters. The unique ability of ANDV N protein to inhibit beta interferon (IFNβ) induction may contribute to its virulence and spread. Here we analyzed IFNβ regulation by ANDV N protein substituted with divergent residues from the nearly identical Maporal virus (MAPV) N protein. We found that MAPV N fails to inhibit IFNβ signaling and that replacing ANDV residues 252 to 296 with a hypervariable domain (HVD) from MAPV N prevents IFNβ regulation. In addition, changing ANDV residue S386 to the histidine present in MAPV N or the alanine present in other hantaviruses prevented ANDV N from regulating IFNβ induction. In contrast, replacing serine with phosphoserine-mimetic aspartic acid (S386D) in ANDV N robustly inhibited interferon regulatory factor 3 (IRF3) phosphorylation and IFNβ induction. Additionally, the MAPV N protein gained the ability to inhibit IRF3 phosphorylation and IFNβ induction when ANDV HVD and H386D replaced MAPV residues. Mass spectroscopy analysis of N protein from ANDV-infected cells revealed that S386 is phosphorylated, newly classifying ANDV N as a phosphoprotein and phosphorylated S386 as a unique determinant of IFN regulation. In this context, the finding that the ANDV HVD is required for IFN regulation by S386 but dispensable for IFN regulation by D386 suggests a role for HVD in kinase recruitment and S386 phosphorylation. These findings delineate elements within the ANDV N protein that can be targeted to attenuate ANDV and suggest targeting cellular kinases as potential ANDV therapeutics.IMPORTANCE ANDV contains virulence determinants that uniquely permit it to spread person to person and cause highly lethal HPS in immunocompetent hamsters. We discovered that ANDV S386 and an ANDV-specific hypervariable domain permit ANDV N to inhibit IFN induction and that IFN regulation is directed by phosphomimetic S386D substitutions in ANDV N. In addition, MAPV N proteins containing D386 and ANDV HVD gained the ability to inhibit IFN induction. Validating these findings, mass spectroscopy analysis revealed that S386 of ANDV N protein is uniquely phosphorylated during ANDV infection. Collectively, these findings reveal new paradigms for ANDV N protein as a phosphoprotein and IFN pathway regulator and suggest new mechanisms for hantavirus regulation of cellular kinases and signaling pathways. Our findings define novel IFN-regulating virulence determinants of ANDV, identify residues that can be modified to attenuate ANDV for vaccine development, and suggest the potential for kinase inhibitors to therapeutically restrict ANDV replication.

Molecular characterization of Dobrava-Belgrade hantavirus in Serbia, 2007-2011

BACKGROUND

Hantaviruses are etiological agents of emerging zoonotic diseases worldwide, including hemorrhagic fever with renal syndrome (HFRS). A number of hantavirus species is known to be present in Europe. In Serbia, existing data on hantavirus presence and prevalence rely in serological findings. In this study, molecular analysis was performed in order to characterize HFRS causing hantaviruses in Serbia.

METHODS

Sixty four serum samples of HFRS cases, previously found seropositive to anti-hantaviral antibodies, were included in the study. Partial hantaviral L and S segments were PCR amplified producing 390nt and 598nt amplicons, respectively, in parallel with human beta-actin mRNA as external reverse transcription positive control. Hantavirus specific PCR products were DNA sequenced in both direction and the obtained sequences phylogenetically confirmed and analyzed.

RESULTS

PCR detection of hantavirus L and S genome segments was positive in 18/64 and 11/64 tested samples, respectively. Positive PCR results involved samples obtained from different locations, mostly from central and southern parts of Serbia. All the obtained sequences were identified as Dobrava-Belgrade virus (DOBV). In the phylogenetic analysis sequences from Serbia tended to cluster in distinctive, geographically related clusters.

CONCLUSIONS

Our findings indicate DOBV as the main HFRS causing hantavirus in Serbia, the site of its initial isolation.

Autochthonous Human Case of Seoul Virus Infection, the Netherlands

Orthohantaviruses are a group of rodentborne viruses with a worldwide distribution. The orthohantavirus Seoul virus (SEOV) can cause hemorrhagic fever with renal syndrome in humans and is distributed worldwide, like its reservoir host, the rat. Cases of SEOV in wild and pet rats have been described in several countries, and human cases have been reported in the United Kingdom, France, Canada, and the United States. In the Netherlands, SEOV has previously been found in wild brown rats. We describe an autochthonous human case of SEOV infection in the Netherlands. This patient had nonspecific clinical symptoms of an orthohantavirus infection (gastrointestinal symptoms and distinct elevation of liver enzymes). Subsequent source investigation revealed 2 potential sources, the patient’s feeder rats and a feeder rat farm. At both sources, a high prevalence of SEOV was found in the rats. The virus closely resembled the Cherwell and Turckheim SEOV strains that were previously found in Europe.

Globally emerging hantaviruses: An overview

Hantaviruses are known to cause haemorrhagic fever with renal syndrome in Eurasia and hantavirus cardiopulmonary syndrome in the Americas. They are globally emerging pathogens as newer serotypes are routinely being reported. This review discusses hantavirus biology, clinical features and pathogenesis of hantavirus disease, its diagnostics, distribution and mammalian hosts. Hantavirus research in India is also summarised.

Spatial and temporal patterns of human Puumala virus (PUUV) infections in Germany

Background

Worldwide, the number of recorded human hantavirus infections as well as the number of affected countries is on the rise. In Europe, most human hantavirus infections are caused by the Puumala virus (PUUV), with bank voles (Myodes glareolus) as reservoir hosts. Generally, infection outbreaks have been related to environmental conditions, particularly climatic conditions, food supply for the reservoir species and land use. However, although attempts have been made, the insufficient availability of environmental data is often hampering accurate temporal and spatially explicit models of human hantavirus infections.

Methods

In the present study, dynamics of human PUUV infections between 2001 and 2015 were explored using ArcGIS in order to identify spatio-temporal patterns.

Results

Percentage cover of forest area was identified as an important factor for the spatial pattern, whereas beech mast was found explaining temporal patterns of human PUUV infections in Germany. High numbers of infections were recorded in 2007, 2010 and 2012 and areas with highest records were located in Baden-Wuerttemberg (southwest Germany) and North Rhine-Westphalia (western Germany).

Conclusion

More reliable data on reservoir host distribution, pathogen verification as well as an increased awareness of physicians are some of the factors that should improve future human infection risk assessments in Germany.

A Binomial Integer-Valued ARCH Model

We present an integer-valued ARCH model which can be used for modeling time series of counts with under-, equi-, or overdispersion. The introduced model has a conditional binomial distribution, and it is shown to be strictly stationary and ergodic. The unknown parameters are estimated by three methods: conditional maximum likelihood, conditional least squares and maximum likelihood type penalty function estimation. The asymptotic distributions of the estimators are derived. A real application of the novel model to epidemic surveillance is briefly discussed. Finally, a generalization of the introduced model is considered by introducing an integer-valued GARCH model.

Companion Animals as a Source of Viruses for Human Beings and Food Production Animals

Companion animals comprise a wide variety of species, including dogs, cats, horses, ferrets, guinea pigs, reptiles, birds and ornamental fish, as well as food production animal species, such as domestic pigs, kept as companion animals. Despite their prominent place in human society, little is known about the role of companion animals as sources of viruses for people and food production animals. Therefore, we reviewed the literature for accounts of infections of companion animals by zoonotic viruses and viruses of food production animals, and prioritized these viruses in terms of human health and economic importance. In total, 138 virus species reportedly capable of infecting companion animals were of concern for human and food production animal health: 59 of these viruses were infectious for human beings, 135 were infectious for food production mammals and birds, and 22 were infectious for food production fishes. Viruses of highest concern for human health included hantaviruses, Tahyna virus, rabies virus, West Nile virus, tick-borne encephalitis virus, Crimean-Congo haemorrhagic fever virus, Aichi virus, European bat lyssavirus, hepatitis E virus, cowpox virus, G5 rotavirus, influenza A virus and lymphocytic choriomeningitis virus. Viruses of highest concern for food production mammals and birds included bluetongue virus, African swine fever virus, foot-and-mouth disease virus, lumpy skin disease virus, Rift Valley fever virus, porcine circovirus, classical swine fever virus, equine herpesvirus 9, peste des petits ruminants virus and equine infectious anaemia virus. Viruses of highest concern for food production fishes included cyprinid herpesvirus 3 (koi herpesvirus), viral haemorrhagic septicaemia virus and infectious pancreatic necrosis virus. Of particular concern as sources of zoonotic or food production animal viruses were domestic carnivores, rodents and food production animals kept as companion animals. The current list of viruses provides an objective basis for more in-depth analysis of the risk of companion animals as sources of viruses for human and food production animal health.

Fugong virus, a novel hantavirus harbored by the small oriental vole (Eothenomys eleusis) in China

BACKGROUND

Rodents are natural reservoirs of hantaviruses, which cause two disease types: hemorrhagic fever with renal syndrome in Eurasia and hantavirus pulmonary syndrome in North America. Hantaviruses related human cases have been observed throughout Asia, Europe, Africa, and North America. To date, 23 distinct species of hantaviruses, hosted by reservoir, have been identified. However, the diversity and number of hantaviruses are likely underestimated in China, and hantavirus species that cause disease in many regions, including Yunnan province, are unknown.

RESULTS

In August 2012, we collected tissue samples from 189 captured animals, including 15 species belonging to 10 genera, 5 families, and 4 orders in Fugong county, Yunnan province, China. Seven species were positive for hantavirus: Eothenomys eleusis (42/94), Apodemus peninsulae (3/25), Niviventer eha (3/27), Cryptotis montivaga (2/8), Anourosorex squamipes (1/1), Sorex araneus (1/1), and Mustela sibirica (1/2). We characterized one full-length genomic sequence of the virus (named fugong virus, FUGV) from a small oriental vole (Eothenomys eleusis). The full-length sequences of the small, medium, and large segments of FUGV were 1813, 3630, and 6531 nt, respectively. FUGV was most closely related to hantavirus LX309, a previously reported species detected in the red-backed vole in Luxi county, Yunnan province, China. However, the amino acid sequences of nucleocapsid (N), glycoprotein (G), and large protein (L) were highly divergent from those of Hantavirus LX309, with amino acid differences of 11.2, 15.3, and 12.7 %, respectively. In phylogenetic trees, FUGV clustered in the lineage corresponding to hantaviruses carried by rodents in the subfamily Arvicolinae.

CONCLUSIONS

High prevalence of hantavirus infection in small mammals was found in Fugong county, Yunnan province, China. A novel hantavirus species FUGV was identified from the small oriental vole. This virus is phylogenetic clustering with another hantavirus LX309, but shows highly genomic divergence.

Two clinical cases of renal syndrome caused by Dobrava/Saaremaa hantaviruses imported to the Netherlands from Poland and Belarus, 2012-2014

We report the rare event of two imported cases in the Netherlands presenting with renal syndrome caused by Dobrava (DOBV)/Saaremaa (SAAV) hantaviruses. DOBV/SAAV hantaviruses are not circulating in the Netherlands and their clinical manifestation is typically more severe than that of the endemic Puumala virus (PUUV). This report aims to increase awareness among healthcare professionals and diagnostic laboratories to consider different hantaviruses as a cause of renal failure.

Clinical course and long-term outcome of hantavirus-associated nephropathia epidemica, Germany

The consequences of associated hematuria may be long-lasting, and hantavirus IgG is detectable years after acute infection.

Human infection with Puumala virus (PUUV), the most common hantavirus in Central Europe, causes nephropathia epidemica (NE), a disease characterized by acute kidney injury and thrombocytopenia. To determine the clinical phenotype of hantavirus-infected patients and their long-term outcome and humoral immunity to PUUV, we conducted a cross-sectional prospective survey of 456 patients in Germany with clinically and serologically confirmed hantavirus-associated NE during 2001–2012. Prominent clinical findings during acute NE were fever and back/limb pain, and 88% of the patients had acute kidney injury. At follow-up (7–35 mo), all patients had detectable hantavirus-specific IgG; 8.5% had persistent IgM; 25% had hematuria; 23% had hypertension (new diagnosis for 67%); and 7% had proteinuria. NE-associated hypertension and proteinuria do not appear to have long-term consequences, but NE-associated hematuria may. All patients in this study had hantavirus-specific IgG up to years after the infection.

Hantavirus infections

Over the past few decades understanding and recognition of hantavirus infection has greatly improved worldwide, but both the amplitude and the magnitude of hantavirus outbreaks have been increasing. Several novel hantaviruses with unknown pathogenic potential have been identified in a variety of insectivore hosts. With the new hosts, new geographical distributions of hantaviruses have also been discovered and several new species were found in Africa. Hantavirus infection in humans can result in two clinical syndromes: haemorrhagic fever with renal syndrome (HFRS) and hantavirus cardiopulmonary syndrome (HCPS) caused by Old World and New World hantaviruses, respectively. The clinical presentation of HFRS varies from subclinical, mild, and moderate to severe, depending in part on the causative agent of the disease. In general, HFRS caused by Hantaan virus, Amur virus and Dobrava virus are more severe with mortality rates from 5 to 15%, whereas Seoul virus causes moderate and Puumala virus and Saaremaa virus cause mild forms of disease with mortality rates <1%. The central phenomena behind the pathogenesis of both HFRS and HCPS are increased vascular permeability and acute thrombocytopenia. The pathogenesis is likely to be a complex multifactorial process that includes contributions from immune responses, platelet dysfunction and the deregulation of endothelial cell barrier functions. Also a genetic predisposition, related to HLA type, seems to be important for the severity of the disease. As there is no effective treatment or vaccine approved for use in the USA and Europe, public awareness and precautionary measures are the only ways to minimize the risk of hantavirus disease.

Increasing incidence of hemorrhagic fever with renal syndrome could be associated with livestock husbandry in Changchun, northeastern China

BACKGROUND

Since the end of the 1990s, the incidence of hemorrhagic fever with renal syndrome (HFRS) has been increasing dramatically in Changchun, northeastern China. However, it is unknown which, and how, underlying risk factors have been involved in the reemergence of the disease.

METHODS

Data on HFRS cases at the county scale were collected from 1998 to 2012. Data on livestock husbandry including the numbers of large animals (cattle, horses, donkeys and mules), sheep, and deer, and on climatic and land cover variables were also collected. Epidemiological features, including the spatial, temporal and human patterns of disease were characterized. The potential factors related to spatial heterogeneity and temporal trends were analyzed using standard and time-series Poisson regression analysis, respectively.

RESULTS

Annual incidence varied among the 10 counties. Shuangyang County in southeastern Changchun had the highest number of cases (1,525 cases; 35.9% of all cases), but its population only accounted for 5.6% of the total population. Based on seasonal pattern in HFRS incidence, two epidemic phases were identified. One was a single epidemic peak at the end of each year from 1988 to 1997 and the other consisted of dual epidemic peaks at both the end and the beginning of each year from 1998 to the end of the study period. HFRS incidence was higher in males compared to females, and most of the HFRS cases occurred in peasant populations. The results of the Poisson regression analysis indicated that the spatial distribution and the increasing incidence of HFRS were significantly associated with livestock husbandry and climate factors, particularly with deer cultivation.

CONCLUSIONS

Our results indicate that the re-emergence of HFRS in Changchun has been accompanied by changing seasonal patterns over the past 25 years. Integrated measures focusing on areas related to local livestock husbandry could be helpful for the prevention and control of HFRS.

Were the English sweating sickness and the Picardy sweat caused by hantaviruses?

The English sweating sickness caused five devastating epidemics between 1485 and 1551, England was hit hardest, but on one occasion also mainland Europe, with mortality rates between 30% and 50%. The Picardy sweat emerged about 150 years after the English sweat disappeared, in 1718, in France. It caused 196 localized outbreaks and apparently in its turn disappeared in 1861. Both diseases have been the subject of numerous attempts to define their origin, but so far all efforts were in vain. Although both diseases occurred in different time frames and were geographically not overlapping, a common denominator could be what we know today as hantavirus infections. This review aims to shed light on the characteristics of both diseases from contemporary as well as current knowledge and suggests hantavirus infection as the most likely cause for the English sweating sickness as well as for the Picardy sweat.

Seroprevalence of hantavirus infections in Switzerland in 2009: difficulties in determining prevalence in a country with low endemicity

Binary file ES_Abstracts_Final_ECDC.txt matches

The role of behavioural heterogeneity on infection patterns: implications for pathogen transmission

Animals infected with pathogens often differ in behaviour from their uninfected counterparts, and these differences may be key to understanding zoonotic pathogen transmission. To explore behavioural heterogeneity and its role in pathogen transmission, we studied deer mice, Peromyscus maniculatus, under field conditions. Deer mice are the natural host of Sin Nombre virus (SNV), a zoonotic pathogen with high human mortality. We live-trapped mice in May, July and September of 2009 and 2010, marked captures with passive integrated transponder (PIT) tags, recorded physical characteristics and collected blood samples for SNV analysis. For 4 nights after each trapping session, we observed behaviour with a novel surveillance system of nine camera stations, each consisting of a foraging tray, infrared camera, PIT antenna and data logger. We found that deer mice infected with SNV (30.0%) engaged more frequently in behaviours that increased the probability of intraspecific encounters and SNV transmission than did uninfected deer mice. When deer mice were categorized as bold (31.7%) or shy (68.3%) based on these behaviours, bold behaviour was predictive of positive SNV status. Bold deer mice were three times more likely to be infected with SNV than were shy deer mice. These results suggest that a small percentage of bold individuals are responsible for a majority of SNV transmission events, and that behavioural phenotype is an important consideration in transmission dynamics of zoonotic diseases.

Role of vascular and lymphatic endothelial cells in hantavirus pulmonary syndrome suggests targeted therapeutic approaches

BACKGROUND

Hantaviruses in the Americas cause a highly lethal acute pulmonary edema termed hantavirus pulmonary syndrome (HPS). Hantaviruses nonlytically infect microvascular and lymphatic endothelial cells and cause dramatic changes in barrier functions without disrupting the endothelium. Hantaviruses cause changes in the function of infected endothelial cells that normally regulate fluid barrier functions. The endothelium of arteries, veins, and lymphatic vessels are unique and central to the function of vast pulmonary capillary beds that regulate pulmonary fluid accumulation.

RESULTS

We have found that HPS-causing hantaviruses alter vascular barrier functions of microvascular and lymphatic endothelial cells by altering receptor and signaling pathway responses that serve to permit fluid tissue influx and clear tissue edema. Infection of the endothelium provides several mechanisms for hantaviruses to cause acute pulmonary edema, as well as potential therapeutic targets for reducing the severity of HPS disease.

CONCLUSIONS

Here we discuss interactions of HPS-causing hantaviruses with the endothelium, roles for unique lymphatic endothelial responses in HPS, and therapeutic targeting of the endothelium as a means of reducing the severity of HPS disease.

Can hantavirus infections be predicted on admission to hospital?

The aim of this study was to investigate the predictive factors which contribute to diagnosis of hantavirus infection. One hundred patients from rural areas hospitalized with a preliminary diagnosis of hantavirus infection from different hospitals in Turkey were investigated. Hantavirus infection was confirmed in 20 patients (Group 1) using immunofluorescence and immunoblot assays at the Refik Saydam National Public Health Agency. Hantaviruses were not detected in the serum of the remaining 80 patients, other infectious and non-infectious diseases being diagnosed in this group (Group 2). Patients' demographic characteristics and clinical and laboratory data on admission were examined and compared between the two groups. Fever, proteinuria, hematuria, lethargy-weakness, and nausea-vomiting were the most frequent symptoms and findings in Group 1, seen in almost all patients. Proteinuria, hematuria, muscle pain, diarrhea/abdominal pain, hypotension, shock, and sweating were observed at significantly higher levels in Group 1 compared to Group 2. Serum urea, creatinine, uric acid, lactate dehydrogenase (LDH), aspartate transaminase (AST), alkaline phosphatase (ALP), and C-reactive protein (CRP) were significantly higher, but serum platelet counts were lower in Group 1 patients. Area beneath the receiver operating characteristics (ROC) curve analysis was used to calculate the discriminative ability of various laboratory values to identify patients with hantavirus infection. This analysis revealed that, serum CRP had a 100% negative predictive value, whilst, platelet, and creatinine had 75% and 70% positive predictive values for the diagnosis of hantavirus infection. In summary, laboratory markers used in clinical practice are of great importance predicting hantavirus infections.

[Systemic hantavirus-infection in a comatose HIV patient]

Klinik

Ein 40 jähriger, desorientierter, HIV- und Hepatitis B positiver Patient wurde mit 40,3°C vorstellig. Es lag eine Sinustachykardie (160/min) mit arterieller Hypotonie (70/60 mmHg) vor.

Untersuchungen

Erhöhte Entzündungsparameter, Retentionsparameter, sowie Proteinurie, Thrombopenie. CD⁴⁺ T-Helferzahl: 320/µl (32 %), HIV RNA: < 40 Kopien/ml, Hepatitis B DNA: 20800 Kopien/ml. Hantavirus-Serologie (Immunfluoreszenz-Antikörper-Test): 1:2048; Serotyp Puumala.

Verlauf

Es wurde eine leitliniengerechte Sepsistherapie und Antibiose mit Piperacillin und Tazobactam eingeleitet. Bei respiratorischer Insuffizienz bei Acute Respiratory Distress Syndrome (ARDS ) mit bipulmonalem Infiltrat erfolgte die Intubation. Bei akutem intrarenalem Nierenversagen bei Aufnahme bestand keine Indikation zur Dialysebehandlung.

Bei paralleler HIV Erkrankung und Hepatitis B wurde eine antiretrovirale Therapie begonnen. Bei Fieber, konjunktivalen und petechialen Einblutungen sowie subkutanen Einblutungen und Nierenversagen wurde eine Hantavirus-Infektion (Serotyp Puumala) festgestellt.

Schlussfolgerung

Anhand dieses Fallberichtes zeigt sich der potentiell fulminante Verlauf der Puumala Infektion. Dies ist untypisch für diese oft blande verlaufende Infektionskrankheit.

Human puumala and dobrava hantavirus infections in the Black Sea region of Turkey: a cross-sectional study

This study was carried out to better understand the epidemiology of hantaviruses in a province of Turkey (Giresun) where human hantavirus disease has recently been detected. In this cross-sectional study, a total of 626 blood samples from healthy people aged 15 and 84 years old were collected both in urban and rural areas in 2009. The sera were tested by enzyme-linked immunosorbent assay (ELISA), immunoblotting assay, and the focus reduction neutralization test (FRNT). We screened the samples by an ELISA and found that 65/626 samples reacted positively for the presence of hantavirus-reactive immunoglobulin G (IgG). Twenty of the 65 ELISA-positive samples could be confirmed by an immunobloting assay, and the overall seroprevalence was thereby calculated to 3.2% (20/626). The seroprevalence of the people living in wood areas or adobe houses 9/17 (52.9%) was significantly higher than among people living in concrete houses 10/47 (21.3%) (p=0.014). Finally, 3 of the 20 immunoblot-positive sera were confirmed as specific for the Puumala hantavirus serotype by FRNT, 1 serum was confirmed as Dobrava virus-specific, whereas 1 serum was found to be equally reactive to Dobrava and Saaremaa viruses. We will now focus on further investigations of the ecology and epidemiology of hantaviruses in humans and their carrier animals in Turkey, studies that have already been started and will be further intensified.

Hantavirus infection prevalence in wild rodents and human anti-hantavirus serological profiles from different geographic areas of South Brazil

Paraná state presents the fourth highest number of accumulated cases of hantavirus pulmonary syndrome in Brazil. To map the risk areas for hantavirus transmission we carried out a study based on rodent trapping and determined the anti-hantavirus seroprevalence in these animals and in the inhabitants of these localities. Overall seroprevalence in rodents and humans were 2.5% and 2.4%, respectively. Eighty-two percent of the seropositive rodents were genetically analyzed. Phylogenetic analyses revealed that hantaviruses from rodent samples cluster with Araucária (Juquitiba-like) or Jaborá hantavirus genotypes. The Jaborá strain was identified in Akodon serrensis and Akodon montensis, whereas the Araucária strain was detected in Oligoryzomys nigripes, Oxymycterus judex, A. montensis, and Akodon paranaensis, with the latter species being identified for the first time as a natural host. These findings expose the complex relationships between virus and reservoirs in Brazil, which could have an impact on hantavirus transmission dynamics in nature and human epidemiology.