The presence of intraperitoneal, retroperitoneal and pleural fluid in acute Puumala hantavirus infection

BACKGROUND

Puumala hantavirus (PUUV) causes most cases of haemorrhagic fever with renal syndrome (HFRS) in Europe. PUUV infection is characterised by acute kidney injury, thrombocytopenia and increased capillary leakage. Typical symptoms are fever, headache, nausea, abdominal and back pain. This study aimed to evaluate the amount and distribution of intraperitoneal, retroperitoneal and pleural fluid and the association of fluid collections to the symptoms and clinical findings in patients with acute PUUV infection.

METHODS

Abdominal magnetic resonance imaging (MRI) was performed on 27 hospitalised patients with acute PUUV infection. The clinical and laboratory findings and patients' symptoms were analysed in relation to the imaging findings. The thickness of the fluid collections was measured in millimetres (mm) from axial images.

RESULTS

Fluid collections were found in all patients. The amount of intraperitoneal fluid correlated positively with plasma C-reactive protein (CRP) level (r = 0.586, p = .001), while it had an inverse correlation with serum creatinine concentration (r = -0.418, p = .030). Retroperitoneal fluid also correlated inversely with serum creatinine and cystatin C concentrations (r = -0.501, p = .008 and r = -0.383, p = .048, respectively). The amount of fluid was not greater in patients with abdominal or back pain. Patients with back pain had higher serum creatinine compared with patients without back pain, 452 µmol/L (range 88-1071) vs. 83 µmol/L (range 60-679), p = .004.

CONCLUSIONS

Fluid collections were found in all patients. A greater amount of intraperitoneal fluid associates with higher CRP concentrations but not with higher serum creatinine levels. Back pain associates with higher creatinine level but not with the presence of fluids.

Arthroscopic Anterior Cruciate Ligament Reconstruction Using a Hamstring Graft with Interference Screw Fixation

Background and Aims:

This study assessed the clinical and radiographic results 3 to 8 years after an arthroscopic ACL reconstruction using a hamstring graft with interference screw fxation on femoral and tibial sites.

Material and Methods:

Seventy-six of 100 patients, who underwent an arthroscopic ACL reconstruction, could be re-examined with a mean follow-up of 5 years.

Results:

The mean Tegner activity score was 4 (scale: 0 to 10) before surgery, and 5 at the follow-up. Fifty-four patients (78%) achieved a satisfactory result in the IKDC rating. The mean Lysholm score was 85 (scale: 0 to 100), the score being better in patients without meniscal resection than those with (P = 0.04). The mean side-to-side difference in anterior-posterior knee laxity was 1.8 mm, and 62 patients (90%) had good stability. Sixty-four patients (93%) had normal range of motion of the knee. Twelve patients (46 %) with meniscal resection had osteoarthritic changes, compared with only 8 of those (20 %) without meniscal resection (P = 0.03).

Conclusions:

This medium-term follow-up study showed that good stability and function and normal range of motion of the knee can be achieved in majority of the patients who have undergone an ACL reconstruction with a hamstring graft and interference screw fixation.

The use of a biodegradable mesh plate to augment grafting of an acetabular defect: Laboratory investigation and clinical pilot study

We used a biodegradable mesh to convert an acetabular defect into a contained defect in six patients at total hip replacement. Their mean age was 61 years (46 to 69). The mean follow-up was 32 months (19 to 50). Before clinical use, the strength retention and hydrolytic in vitro degradation properties of the implants were studied in the laboratory over a two-year period. A successful clinical outcome was determined by the radiological findings and the Harris hip score. All the patients had a satisfactory outcome and no mechanical failures or other complications were observed. No protrusion of any of the impacted grafts was observed beyond the mesh. According to our preliminary laboratory and clinical results the biodegradable mesh is suitable for augmenting uncontained acetabular defects in which the primary stability of the implanted acetabular component is provided by the host bone. In the case of defects of the acetabular floor this new application provides a safe method of preventing graft material from protruding excessively into the pelvis and the mesh seems to tolerate bone-impaction grafting in selected patients with primary and revision total hip replacement.

Radiological findings and their clinical correlations in nephropathia epidemica

Nephropathia epidemica (NE) is a mild form of hemorrhagic fever with renal syndrome (HFRS). Its course varies from asymptomatic to fatal. The etiologic agent, Puumala virus, belongs to the Hantavirus genus of the Bunyaviridae family. Respiratory symptoms, from common cold to respiratory distress, occur in NE. Acute renal failure (ARF) is evident in over 90% of hospital-treated NE patients. In this review article, special attention is paid to radiological lung and renal involvement to investigate the occurrence and type of manifestations during the acute phase of infection and recovery.

Magnetic resonance renography findings and their clinical associations in nephropathia epidemica

PURPOSE

To evaluate, with magnetic resonance renography (MRR), the dynamics of renal function in patients with nephropathia epidemica (NE) and to correlate the findings with the clinical course of NE.

MATERIAL AND METHODS

MRR was performed on 20 hospitalized NE patients during the acute phase of the disease. A repeat MRR study was done 5-8 months later. Primary and repeat MRR studies were compared and functional findings evaluated.

RESULTS

The uptake slope of the contrast enhancement curve was abnormal in the primary study in 14 patients, maximum level of enhancement in 11, decreasing slope of contrast enhancement curve in 14, and signal drop at time in 10 patients when the primary and repeat studies were compared. The greater change in the uptake slope of contrast enhancement, maximum level of enhancement, decreasing slope of enhancement, and signal drop at time between primary and repeat MRR studies evinced a mild association with the severity of clinical renal insufficiency and fluid volume overload.

CONCLUSION

Measurable functional MRR findings were recorded in 14/20 NE patients. The severity of the findings was mildly associated with the degree of clinical renal insufficiency and fluid volume overload.

Value of ultrasonography in acute renal failure: analysis of qualitative features in patients with nephropathia epidemica

PURPOSE

To assess the value of renal ultrasonography (US) and the frequency of qualitative pathology in patients with nephropathia epidemica (NE) and to determine whether these features are related to the clinical course of NE.

MATERIAL AND METHODS

Renal US was undertaken in 23 hospital-treated NE cases during the acute phase of the disease (first study). A second US study was performed 3-6 months later. Captured US images were used in the analysis.

RESULTS

From acute to control phase the overall rating of kidney status improved in 20 patients, parenchymal swelling decreased and corticomedullary border differentiation improved in 21, echogenicity decreased in 18, and patchy pattern in parenchymal echo-texture decreased in 15. The severity of findings in US evinced some association with fluid volume overload, high blood pressure level and blood leukocyte count, and severe clinical renal insufficiency. The degree of parenchymal swelling had more statistically significant associations with clinical course than other US features.

CONCLUSION

Qualitative US features are as sensitive as quantitative US parameters in assessment of NE patients' clinical course and recovery, assuming that a comparative study is available. US using only qualitative features is fairly limited in evaluating NE patients' clinical situation.

Renal MRI findings and their clinical associations in nephropathia epidemica: analysis of quantitative findings

Morphologic renal magnetic resonance imaging (MRI) findings in patients with nephropathia epidemica (NE) were evaluated, and these findings were correlated with the clinical course of NE. Renal MRI was performed in 20 hospitalized NE patients during the acute phase of their disease. A repeat MRI study was made 5-8 months later. Renal parenchymal volume, renal length and parenchymal thickness were decreased in all patients in the repeat study. Edema/fluid collections were found bilaterally in 16 patients in the primary MRI study. Greater change in parenchymal volume, renal length and parenchymal thickness between the primary and the repeat MRI study as well as the presence of edema/fluid collections in the primary study evinced mild association with clinical fluid volume overload, high blood pressure level, inflammation, thrombocytopenia and severe clinical renal insufficiency. Change in parenchymal volume was associated with a severe clinical course more markedly than the other MRI findings. Measurable renal MRI changes occurred in every NE patient. The severity of the findings in MRI evinced mild association with clinical fluid volume overload, high blood pressure level, inflammation, thrombocytopenia and severe clinical renal insufficiency. Based on this study and our previous ultrasound (US) findings, we prefer US as the primary examination mode in NE patients.

Renal ultrasound findings and their clinical associations in nephropathia epidemica. Analysis of quantitative parameters

PURPOSE

To evaluate renal US findings in patients with nephropathia epidemica (NE) and to determine whether changes in these findings are related to the clinical course of NE.

MATERIAL AND METHODS

Renal US was undertaken in 23 hospital-treated NE patients during the acute phase of their disease (first study). The second US study was performed 3-6 months later.

RESULTS

The resistive index (RI) was abnormal in 12 patients and fluid collections (perirenal, pleural, pericardial, ascites) were found in 13 patients in the first study. Renal length decreased in every patient, cortical parenchymal thickness in 19 patients and RI in 18 patients from the first to the second studies. The mean change was significant in all parameters. Increased RI and presence of fluid collections in the first study as well as a greater change in length and RI between the first and the second studies were associated with high maximum daily urine excretion, substantial change in body weight between the anuric and polyuric phases, high maximum serum creatinine and urea concentration, high blood leukocyte count and low hematocrit value.

CONCLUSION

Renal US changes occurred in every patient with NE. The severity of the findings was associated with fluid volume overload and degree of clinical renal insufficiency.

Complement activation in nephropathia epidemica caused by Puumala hantavirus

BACKGROUND AND AIM

Nephropathia epidemica (NE) is a hemorrhagic fever with renal syndrome caused by Puumala hantavirus. There is considerable variability in the clinical severity of NE. Its pathogenesis is largely unknown and data on complement activation in NE are scant. We sought here to establish how the complement system behaves during NE and whether the variation in the clinical outcome is related to the activation of complement.

PATIENTS AND METHODS

The complement component levels and complement activation products and the clinical course of 25 hospital-treated acutely ill NE patients were studied.

RESULTS

Complement activation was observed in 23 patients. In 10 patients the complement system was activated mainly through the alternative route, in 6 mainly through the classical route and in 5 through both the alternative and the classical route. An elevated soluble terminal complex SC5b-9 was the most sensitive indicator of complement activation (17 out of 25 patients). Two patients had only an elevated SC5b-9 value and 2 had no complement activation. The C4d/C4 maximal ratio was significantly higher in patients with clinically severe NE compared to the mild or moderate disease groups.

CONCLUSION

Our results show that complement activation is common in NE. Although both pathways are usually activated, the classical pathway activation by immune complexes or directly by viral components is associated with a severe clinical course of NE.

Pulmonary involvement in nephropathia epidemica: radiological findings and their clinical correlations

Nephropathia epidemica (NE) is a hemorrhagic fever with renal syndrome (HFRS) normally taking a benign clinical course. The etiologic agent, Puumala hantavirus is genetically closely related to Sin Nombre virus, which causes a frequently lethal febrile syndrome with pulmonary involvement (hantavirus pulmonary syndrome, HPS). HPS is characterized by acute respiratory distress, non-cardiogenic pulmonary edema and severe and hypotension, but usually no significant renal involvement. Pulmonary involvement and respiratory symptoms also occur in NE. To understand the mechanisms of pulmonary involvement in NE, we studied the clinical records and chest X-rays of 125 hospital-treated acutely ill NE patients. Twenty-eight percent of the patients had disease-related changes in their chest radiographs. Pleural effusion and atelectasis were the most common X-ray findings, whereas frank pulmonary edema was rare. The patients with pathologic X-ray findings had a more marked hypoproteinemia (lowest measured serum protein concentration 54 +/- 1 g/l) than those with normal X-ray (62.1 +/- 0.9 g/l, p < 0.001) and leukocytosis (highest measured blood leukocyte count 14.1 +/- 0.9 x 10(9)/l vs. 10.6 +/- 0.6 x 10(9)/l, p < 0.001) and more severe renal insufficiency (highest measured serum creatinine 590 +/- 60 mumol/l vs. 356 +/- 29 mumol/l, p < 0.05). Hypoproteinemia best predicted the occurrence of abnormal chest X-ray findings in NE. This suggests, that capillary leakage and inflammation may play a role in the pathogenesis of NE lung involvement, similarly as in HPS. Differently from HPS, the fluid volume overload associated with renal insufficiency seemed to contribute strongly to the chest X-ray changes in NE.