title: Cardiopulmonary involvement in Puumala hantavirus infection.
abstract: BACKGROUND
  Hantavirus infections cause potentially life-threatening disease in humans world-wide. Infections with American hantaviruses may lead to hantavirus pulmonary syndrome characterised by severe cardiopulmonary distress with high mortality. Pulmonary involvement in European Puumala hantavirus (PUUV) infection has been reported, whereas knowledge of potential cardiac manifestations is limited. We aimed to comprehensively investigate cardiopulmonary involvement in patients with PUUV-infection.
  
  
  METHODS
  Twenty-seven hospitalised patients with PUUV-infection were examined with lung function tests, chest high-resolution CT (HRCT), echocardiography including speckle tracking strain rate analysis, ECG and measurements of cardiac biomarkers N-terminal pro-B-type natriuretic peptide (NT-ProBNP) and troponin T. Patients were re-evaluated after 3 months. Twenty-five age and sex-matched volunteers acted as controls for echocardiography data.
  
  
  RESULTS
  Two-thirds of the patients experienced respiratory symptoms as dry cough or dyspnoea. Gas diffusing capacity was impaired in most patients, significantly improving at follow-up but still subnormal in 38%. HRCT showed thoracic effusions or pulmonary oedema in 46% of the patients. Compared to controls, the main echocardiographic findings in patients during the acute phase were significantly higher pulmonary vascular resistance, higher systolic pulmonary artery pressure, lower left ventricular ejection fraction and impaired left atrial myocardial motion. Pathological ECG, atrial fibrillation or T-wave changes, was demonstrated in 26% of patients. NT-ProBNP concentrations were markedly increased and were inversely associated with gas diffusing capacity but positively correlated to pulmonary vascular resistance. Furthermore, patients experiencing impaired general condition at follow-up had significantly lower gas diffusing capacity and higher pulmonary vascular resistance, compared to those feeling fully recovered.
  
  
  CONCLUSIONS
  In a majority of patients with PUUV-infection, both cardiac and pulmonary involvement was demonstrated with implications on patients' recovery. The results demonstrate vascular leakage in the lungs that most likely is responsible for impaired gas diffusing capacity and increased pulmonary vascular resistance with secondary pulmonary hypertension and right heart distress. Interestingly, NT-ProBNP was markedly elevated even in the absence of overt ventricular heart failure. The method of simultaneous investigations of important cardiac and respiratory measurements improves the interpretation of the underlying pathophysiologic mechanisms.
authors.affiliation: Department of Clinical Microbiology, Umeå University, SE - 901 85 Umeå, Sweden. johan.rasmuson@climi.umu.se.
authors.forename: Johan
authors.initials: J
authors.lastname: Rasmuson
authors.forename: Per
authors.initials: P
authors.lastname: Lindqvist
authors.forename: Karen
authors.initials: K
authors.lastname: Sörensen
authors.forename: Magnus
authors.initials: M
authors.lastname: Hedström
authors.forename: Anders
authors.initials: A
authors.lastname: Blomberg
authors.forename: Clas
authors.initials: C
authors.lastname: Ahlm
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D004452:Echocardiography; D005260:Female; D006331:Heart Diseases / Q000097:blood / Q000503:physiopathology / Q000821:virology*; D006480:Hemorrhagic Fever with Renal Syndrome / Q000097:blood / Q000503:physiopathology*; D006801:Humans; D008171:Lung Diseases / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000821:virology*; D008297:Male; D008875:Middle Aged; D020097:Natriuretic Peptide, Brain / Q000097:blood; D010446:Peptide Fragments / Q000097:blood; D011654:Pulmonary Edema / Q000000981:diagnostic imaging; D029262:Puumala virus / Q000302:isolation & purification*; D011859:Radiography; D020107:Troponin T / Q000097:blood; D055815:Young Adult
chemical_list: D010446:Peptide Fragments; D020107:Troponin T; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain