title: Another case of "European hantavirus pulmonary syndrome" with severe lung, prior to kidney, involvement, and diagnosed by viral inclusions in lung macrophages.
abstract: Puumala virus (PUUV) is considered a classic Old World etiologic agent of nephropathia epidemica (NE), or hemorrhagic fever with renal syndrome (HFRS). HFRS is considered to be distinct from hantavirus (cardio-)pulmonary syndrome (HPS or HCPS), described in the New World. Here, we report a severe case, which fulfilled most, if not all, Centers for Disease Control and Prevention (CDC) criteria for HPS, needing non-invasive ventilation and subsequent acute hemodialysis. However, the etiological agent was PUUV, as proved by serological testing, real-time polymerase chain reaction (PCR), and sequencing. Viral antigen was detected by specific anti-PUUV immunostaining, showing, for the first time, greenish intracytoplasmic inclusions in bronchoalveolar lavage (BAL) macrophages. This case definitely confirms that HPS can be encountered during PUUV infections. Interestingly, special findings could render the diagnosis easier, such as greenish homogeneous cytoplasmic inclusions, surrounded by a fine clear halo in BAL macrophages. Therefore, although the diagnosis remains difficult before the onset of renal involvement, the occurrence of severe respiratory failure mimicking community-acquired pneumonia must alert the clinician for possible HPS, especially in endemic areas.
authors.affiliation: Intensive Care Unit, Centre Hospitalier Universitaire de Mont-Godinne, Université Catholique de Louvain, 5530, Yvoir, Belgium.
authors.forename: M
authors.initials: M
authors.lastname: Gizzi
authors.forename: B
authors.initials: B
authors.lastname: Delaere
authors.forename: B
authors.initials: B
authors.lastname: Weynand
authors.forename: J
authors.initials: J
authors.lastname: Clement
authors.forename: P
authors.initials: P
authors.lastname: Maes
authors.forename: V
authors.initials: V
authors.lastname: Vergote
authors.forename: L
authors.initials: L
authors.lastname: Laenen
authors.forename: B
authors.initials: B
authors.lastname: Hjelle
authors.forename: A
authors.initials: A
authors.lastname: Verroken
authors.forename: A
authors.initials: A
authors.lastname: Dive
authors.forename: I
authors.initials: I
authors.lastname: Michaux
authors.forename: P
authors.initials: P
authors.lastname: Evrard
authors.forename: D
authors.initials: D
authors.lastname: Creytens
authors.forename: P
authors.initials: P
authors.lastname: Bulpa
mesh_terms: D000328:Adult; D001992:Bronchoalveolar Lavage Fluid / Q000166:cytology / Q000821:virology; D016000:Cluster Analysis; D005260:Female; D018804:Hantavirus Pulmonary Syndrome / Q000150:complications* / Q000175:diagnosis*; D006480:Hemorrhagic Fever with Renal Syndrome / Q000175:diagnosis*; D006801:Humans; D007181:Inclusion Bodies, Viral; D008168:Lung / Q000821:virology*; D016676:Macrophages, Alveolar / Q000821:virology*; D010802:Phylogeny; D029262:Puumala virus / Q000145:classification / Q000235:genetics / Q000302:isolation & purification*; D013902:Radiography, Thoracic; D060888:Real-Time Polymerase Chain Reaction; D017422:Sequence Analysis, DNA; D012703:Serotyping; D014057:Tomography, X-Ray Computed