Peritonitis secondary to hemorrhagic fever with renal syndrome: a case report in GuangZhou China.

BACKGROUND: Hantavirus infection is worldwide epidemic and can cause life-threatening consequences. With more and more cases reported in countries with atypical morbidity, it is necessarily urgent to know some atypical symptoms and signs of Hantavirus infection. CASE PRESENTATION: Here we report the case of a 44-year old male with a complaint of fever and diffuse abdominal pain, initially suspiciously diagnosed with acute peritonitis. The patient was eventually diagnosed as hemorrhagic fever with renal syndrome and enhanced CT scan showed peritonitis. The clinical condition of the patient was relatively mild and he was recovered 9 days later. CONCLUSION: Peritonitis secondary to hemorrhagic fever with renal syndrome is rare in clinically practice. When confronted with atypical celialgia, it is important to make differential diagnosis of hantavirus infection.

Cytokine response to Hantaan virus infection in patients with hemorrhagic fever with renal syndrome.

Hantaan virus (HTNV) infection of the human body causes a severe acute infectious disease known as hemorrhagic fever renal syndrome (HFRS). The aim of this study was to correlate patient cytokine profiles to HFRS severity. In this study, we discuss the clinical significance of evaluating HFRS treatment outcomes using cytokine information. The levels of 18 cytokines were quantitatively determined in three groups: 34 HTNV IgM+ cases, 63 HTNV IgM- negative cases, and 78 healthy volunteers. The level of 14 serum cytokines were higher in the patient group than that in the healthy control group. In the 34 HTNV IgM+ patient sera, a set of 27 cytokines was further assessed. The cytokines of TNF-ß, IL-1ra, and IL-6 were detected at higher level in the IgM+ group than that in the IgM- group. The deterioration of HFRS was accompanied with multiple cytokines increased, such as IL-1ra, IL-12p70, IL-10, IP-10, IL-17, IL-2, and IL-6. Our data indicate that serum cytokine levels are associated with the progression of HFRS.

The murine model for Hantaan virus-induced lethal disease shows two distinct paths in viral evolutionary trajectory with and without ribavirin treatment.

In vitro, ribavirin acts as a lethal mutagen in Hantaan virus (HTNV)-infected Vero E6 cells, resulting in an increased mutation load and viral population extinction. In this study, we asked whether ribavirin treatment in the lethal, suckling mouse model of HTNV infection would act similarly. The HTNV genomic RNA (vRNA) copy number and infectious virus were measured in lungs of untreated and ribavirin-treated mice. In untreated, HTNV-infected mice, the vRNA copy number increased for 10 days postinfection (dpi) and thereafter remained constant through 26 dpi. Surprisingly, in ribavirin-treated, HTNV-infected mice, vRNA levels were similar to those in untreated mice between 10 and 26 dpi. Infectious virus levels, however, were different: in ribavirin-treated mice, the amount of infectious HTNV was significantly decreased relative to that in untreated mice, suggesting that ribavirin reduced the specific infectivity of the virus (amount of infectious virus produced per vRNA copy). Mutational analysis revealed a ribavirin-associated elevation in mutation frequency in HTNV vRNA similar to that previously reported in vitro. Codon-based analyses of rates of nonsynonymous (dN) and synonymous (dS) substitutions in the S segment revealed a positive selection for codons within the HTNV N protein gene in the ribavirin-treated vRNA population. In contrast, the vRNA population in untreated, HTNV-infected mice showed a lower level of diversity, reflecting purifying selection for the wild-type genome. In summary, these experiments show two different evolutionary paths that Hantavirus may take during infection in a lethal murine model of disease, as well as the importance of the in vivo host environment in the evolution of the virus, which was not apparent in our prior in vitro model system.

Establishment of SYBR green-based qPCR assay for rapid evaluation and quantification for anti-Hantaan virus compounds in vitro and in suckling mice.

Hantaan viruses cause two severe diseases lacking efficient treatment, yet no effective prophylactic vaccines are available. Continued exploration of alternative antiviral agents to treat hantavirus-related syndromes remains compulsory. The fluorescence-based quantitative real-time PCR (qPCR) has become the touchstone for target gene quantification. In the present study, standard curves for Hantaan virus (HTNV), mouse, and human glyceraldehyde-3-phosphate dehydrogenase (GAPDH) were generated by serial 10-fold dilutions of the constructed recombinant plasmid pGEM-T/HTNV, pGEM-T/mouse-GAPDH, and pGEM-T/human-GAPDH, respectively. Comparisons between the indirect immunofluorescence assay and qPCR assay in the detection of HTNV-infected Vero E6 cells showed improved detection limit and sensitivity of latter method. To characterize the inhibitory effect of several conventional antivirals (arbidol and ribavirin) and unconventional antivirals (indomethacin and curcumin) on HTNV, the levels of viral RNAs were measured for 4 days post-treatment of HTNV-infected Vero E6 cells and 18 days post-inoculation of HTNV-infected suckling mice. Our results validated that HTNV was sensitive to ribavirin and arbidol treatment, while indomethacin and curcumin may also be therapeutically effective in treating HTNV infection. As a result, the establishment and application of qPCR may be a useful tool for the evaluation of potential antivirals for Hantaan virus infection in vitro and in vivo.

[Systemic hantavirus-infection in a comatose HIV patient]. / Systemische Hantavirus-Infektion bei einem komatösen HIV Patienten.

SYMPTOMS: A 40 year old, disoriented, HIV- and Hepatitis B positive male patient was admitted with 40.3 °C. Clinically he presented a sinustachycardia (160/min) and hypotension (70/60 mmHg). INVESTIGATIONS/DIAGNOSIS: Laboratory analyses showed elevated infection parameters, azotemia, proteinuria and thrombopenia. CD(4+)T-helper cells: 320/µl (32 %), HIV RNA: <40 copies/ml, Hepatitis B DNA: 20800 copies/ml. Hantavirus serology (immunofluorescence antibody assay): 1:2048; serotype Puumala. TREATMENT/COURSE: An early-goal-directed therapy and antibiotic treatment with Piperacillin and Tazobactam was initiated. The patient developed a bipulmonal infiltrate and an acute respiratory distress syndrome (ARDS ) requiring tracheal intubation, as well as a triad of fever, renal failure and profound hemorrhagic symptoms. This led to the diagnosis of the Puumala infection. Due to the parallel HIV- and Hepatits B infection an antiretroviral therapy was initiated. CONCLUSION: In summary the Puumala infection bears the potential for a severe multi-organ failure, which is not typical for this usually benign infection.

In-cell Western assay to quantify infection with pathogenic orthohantavirus Puumala virus in replication kinetics and antiviral drug testing.

Hemorrhagic fever with renal syndrome (HFRS) represents a serious zoonotic disease caused by orthohantaviruses in Eurasia. A specific antiviral therapy is not available. HFRS is characterized by acute kidney injury (AKI) with often massive proteinuria. Infection of kidney cells may contribute to the clinical picture. However, orthohantaviral replication in kidney cells is not well characterized. Therefore, we aimed to perform a reliable high-throughput assay that allows the quantification of infection rates and testing of antiviral compounds in different cell types. We quantified relative infection rates of Eurasian pathogenic Puumala virus (PUUV) by staining of nucleocapsid protein (N protein) in an in-cell Western (ICW) assay. Vero E6 cells, derived from the African green monkey and commonly used in viral cell culture studies, and the human podocyte cell line CIHP (conditionally immortalized human podocytes) were used to test the ICW assay for replication kinetics and antiviral drug testing. Quantification of infection by ICW revealed reliable results for both cell types, as shown by their correlation with immunofluorescence quantification results by counting infected cells. Evaluation of antiviral efficacy of ribavirin by ICW assay revealed differences in the toxicity (TC) and inhibitory concentrations (IC) between Vero E6 cells and podocytes. IC5O of ribavirin in podocytes is about 12-fold lower than in Vero E6 cells. In summary, ICW assay together with relevant human target cells represents an important tool for the study of hantaviral replication and drug testing.

Ibuprofen or diclofenac is associated with more severe acute kidney injury in nephropathia epidemica.

OBJECTIVE: In many parts of Europe, nephropathia epidemica (NE) is an endemic zoonosis. After a flu-like prodrome, this viral disease often manifests with acute kidney injury. Use of non-steroidal anti-inflammatory drugs is discouraged during the disease, but no data from clinical investigations are available on the association between disease course and the use of analgesics. MATERIAL AND METHODS: The charts of 59 patients admitted with NE to a hospital in 2007 were retrospectively analysed. Creatinine levels were compared between users of different analgesics. RESULTS: Patients taking analgesics before admission had higher peak creatinine levels, but not after adjustment for confounders. The subgroup taking ibuprofen or diclofenac had higher initial and peak creatinine levels than the group who did not, even after adjustment for confounders. CONCLUSION: Since NE cannot be accurately diagnosed in the early disease phase, metamizole, acetaminophen or acetylsalicylic acid may be preferable analgesics to ibuprofen or diclofenac for flu-like symptoms in endemic areas.

An algal lectin griffithsin inhibits Hantaan virus infection in vitro and in vivo.

Hantaan virus (HTNV) is the etiological pathogen of hemorrhagic fever with renal syndrome in East Asia. There are currently no effective therapeutics approved for HTNV and other hantavirus infections. We found that griffithsin (GRFT), an algae-derived lectin with broad-spectrum antiviral activity against various enveloped viruses, can inhibit the growth and spread of HTNV. In vitro experiments using recombinant vesicular stomatitis virus (rVSV) with HTNV glycoproteins as a model revealed that the GRFT inhibited the entry of rVSV-HTNV-G into host cells. In addition, we demonstrated that GRFT prevented authentic HTNV infection in vitro by binding to the viral N-glycans. In vivo experiments showed that GRFT partially protected the suckling mice from death induced by intracranial exposure to HTNV. These results demonstrated that GRFT can be a promising agent for inhibiting HTNV infection.

[Affection of central nervous system in hemorrhagic fever with renal syndrome].

The authors report results of comparative analysis of 897 cases of hemorrhagic fever with renal syndrome diagnosed in the Upper Amur region in 1960-2005. All the patients were grouped by 5-year intervals depending on the severity of clinical condition. The frequency of CNS affection accompanied by acute psychic disorders, convulsive and meningeal syndromes varied significantly in different years. Pituitary hemorrhage was revealed at autopsy in 36.8% of the patients, pituitary necrosis in 5.2%, brainstem hemorrhage in 68.4%. A case of severe hemorrhagic fever with renal syndrome is described characterized by acute renal insufficiency and eclamptic convulsions with moderately manifest hemorrhagic syndrome preceding the favourable outcome.

Early diagnosis of hantavirus infection by family doctors can reduce inappropriate antibiotic use and hospitalization.

OBJECTIVE: Hantavirus infections are emerging infections that cause either Hantavirus pulmonary syndrome or haemorrhagic fever with renal syndrome (HFRS). A recent Swedish outbreak of nephropathia epidemica, a European HFRS, was analysed to study the patient flow and clinical picture and to investigate the value of an early diagnosis in general practice. Design. In a retrospective design, medical records of verified cases of Hantavirus infection were studied. SETTING: The study was conducted in the county of Norrbotten, Sweden. SUBJECTS: Data from Hantavirus patients diagnosed between 2006 and 2008 were analysed. MAIN OUTCOME MEASURES: Demographic data, level of care, treatment, clinical symptoms, and laboratory findings were obtained. RESULTS: In total, 456 cases were included (58% males and 42% females). The majority of patients first saw their general practitioner and were exclusively treated in general practice (83% and 56%, respectively). When diagnosed correctly at the first visit, antibiotics and hospitalization were significantly lowered compared with delayed diagnosis (14% vs. 53% and 30% vs. 54%, respectively; p < 0.0001). The clinical picture was diverse. Early thrombocytopenia was found in 65% of the patients, and haemorrhagic manifestations were documented in a few cases. Signs of renal involvement--haematuria, proteinuria, and raised levels of serum creatinine--were found in a majority of patients. CONCLUSIONS: Raised awareness in general practice regarding emerging infections and better diagnostic tools are desirable. This study of a Hantavirus outbreak shows that general practitioners are frontline doctors during outbreaks and through early and correct diagnosis they can reduce antibiotic treatment and hospitalization.

Novel therapeutic approaches toward Hantaan virus and its clinical features' similarity with COVID-19.

Zoonotic virus spill over in human community has been an intensive area of viral pathogenesis and the outbreak of Hantaan virus and severe acute respiratory syndrome coronavirus 2 (SARS CoV2) after late December 2019 caused a global threat. Hantaan virus is second to the COVID-19 outbreak in China with seven cases positive and one death. Both RNA viruses have opposite sense as in (-) for Hantaan virus and (+) for SARS CoV2 but have similarity in the pathogenesis and relevant clinical features including dry cough, high fever, shortness of breath, and SARS associated with pneumonia and certain reported cases with multiple organ failure. Although COVID-19 has global impact with high death toll, Hantaan virus has varyingly high mortality rate between 1% and 40%. Hence, there is a need to explore novel therapeutic targets in Hantaan virus due to its rapid evolution rate in its genetic makeup which governs virulence and target host cells. This review emphasizes the importance of structural and nonstructural proteins of Hantaan virus with relevant insight from SARS CoV2. The envelope glycoproteins such as Gn, Gc, and nucleocapsid protein (N) direct the viral assembly and replication in host cells. Therapeutic treatment has similarity in using ribavirin and extracorporeal membrane oxygenation but lack of efficacious treatment in both cases of SARAS CoV2 and Hantaan virus. Therefore, potential features regarding therapeutic targets for drug discovery for Hantaan viruses are discussed herewith. The conclusive description highlights that N protein is substantially involved in evoking immune response and induces symptoms and could be precursive target for drug discovery studies.

Therapeutic effect of Xuebijing combined with thymosin on hemorrhagic fever with renal syndrome: A protocol of systematic review and meta-analysis.

BACKGROUND: The goal of this study is to assess the therapeutic effect of Xuebijing combined with thymosin (XBJ-T) for the treatment of patients with hemorrhagic fever with renal syndrome (HFRS). METHODS: We will search the electronic databases of Cochrane Library, PUBMED, EMBASE, PsycINFO, Scopus, Opengrey, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Google scholar, Allied and Complementary Medicine Database, and Chinese Biomedical Literature Database from inception to the present. No language and publication status will be employed in this study. Based on the predefined eligibility criteria, selection of study and data extraction will be performed by 2 researchers independently. Study quality will be assessed using Cochrane risk of bias tool. We will apply RevMan 5.3 software to pool and analyze the extracted data. RESULTS: This study will assess the therapeutic effect of XBJ-T for the treatment of patients with HFRS. CONCLUSION: The findings of this study may provide systematic evidence to judge whether XBJ-T is an effective and safety intervention for HFRS. STUDY REGISTRATION NUMBER: INPLASY202040068.

Efficacy of arbidol on lethal hantaan virus infections in suckling mice and in vitro.

AIM: Arbidol is an immunomodulator that was first developed in Russia. In this study, we report the antiviral activity of arbidol against Hantaan virus (HTNV) in vitro and in vivo. METHODS: The antiviral activity of arbidol in vitro was determined by plaque-forming assay, ranging from 0.5 to 8 microg/mL. To investigate whether arbidol has an antiviral effect in vivo, suckling BALB/c mice infected with HTNV were treated with arbidol at 24 h before infection with a 5, 10 or 20 mg.kg(-1).d(-1), once per day, for 10 days. On day 12 and 28 post infection (pi), histopathological changes and viral antigen were detected. On days 4, 8, 12, and 16 pi, the viral load of target organs and serum TNF-alpha levels of arbidol-treated animals were determined. RESULTS: Arbidol was found to have potent inhibitory activity against HTNV when added in vitro before or after viral infection, with a 50% inhibitory concentration (IC(50)) of 0.9 and 1.2 microg/mL, respectively. The 50% lethal dose (LD(50)) of arbidol for suckling mice was 78.42 mg.kg(-1).d(-1). Oral administration of arbidol increased both survival rate and mean time to death (MTD). Treatment with arbidol reduced histopathological changes, decreased viral load and viral antigen levels, and modulated the level of serum TNF-alpha. CONCLUSION: Arbidol has the ability to elicit protective antiviral activity against HTNV in vivo and in vitro.Acta Pharmacologica Sinica (2009) 30: 1015-1024; doi: 10.1038/aps.2009.53; published online 8 June 2009.

Synthesis of 1-beta-D-ribofuranosyl-3-ethynyl-[1,2,4]triazole and its in vitro and in vivo efficacy against Hantavirus.

There are no FDA approved drugs for the treatment of hemorrhagic fever with renal syndrome (HFRS), a serious human illnesses caused by hantaviruses. Clinical studies using ribavirin (RBV) to treat HFRS patients suggest that it provides an improved prognosis when given early in the course of disease. Given the unique antiviral activity of RBV and the lack of other lead scaffolds, we prepared a diverse series of 3-substituted 1,2,4-triazole-beta-ribosides and identified one with antiviral activity, 1-beta-d-ribofuranosyl-3-ethynyl-[1,2,4]triazole (ETAR). ETAR showed an EC(50) value of 10 and 4.4 microM for Hantaan virus (HTNV) and Andes virus, respectively. ETAR had weak activity against Crimean Congo hemorrhagic fever virus, but had no activity against Rift Valley fever virus. Intraperitoneally delivered ETAR offered protection to suckling mice challenged with HTNV with a approximately 25% survival at 12.5 and 25mg/kg ETAR, and a MTD of 17.1+/-0.7 days. ETAR was phosphorylated in Vero E6 cells to its 5'-triphosphate and reduced cellular GTP levels. In contrast to RBV, ETAR did not increase mutation frequency of the HTNV genome, which suggests it has a different mechanism of action than RBV. ETAR is an exciting and promising lead compound that will be elaborated in further synthetic investigations as a framework for the rational design of new antivirals for treatment of HFRS.

Real-time RT-PCR of Hantaan virus RNA used for the detection of virus response to antiviral drugs.

Hantaan virus (HTN) is an important cause of hemorrhagic fever with renal syndrome (HFRS) in Korea. HTN RNA can be detected with the RT-PCR and the quantity of HTN RNA in infected cells can be measured by competitive RT-PCR. The current study used the real-time RT-PCR for the detection of viral RNA S gene in a more detailed fashion than in the previous study (Nam et al., Virus Genes 26, 31-38, 2003). A standard curve was generated with serial 10-fold dilutions of the HTN RNA. The sensitivity of RNA detection was approximately 10 PFU of HTN. The cells infected with HTN were treated with the antiviral drugs ribavirin, zidovudine, and amantadine. 24 hrs after infection, real-time RT-PCR was used to detect the HTN RNA synthesized in the infected cells. No viral RNA was detected in the HTN-infected cells treated with antiviral drugs, but HTN RNA was detected in untreated HTN-infected cells. This finding suggested that real-time RTPCR should be used for the detection of antiviral activity against HTN.

[Inhibiting effects of fucoidans on Hantaan virus adsorption on a model of peritoneal macrophages in vitro].

A model of peritoneal macrophages was used to study the effect of fucoidans from brown seaweeds on the adsorption of Hantaan virus. Fucoidans were found to have antiviral activity, but to differ in the inhibition of hantavirus adsorption, which was associated with their structural features. The mechanism of their action is assumed to be shown via ligand-receptor interaction with certain cell membrane receptors and via blockage of hantavirus glycoproteins (G1 and G2), resulting in adsorption inhibition and preventing viral penetration into the macrophages.

[3 cases of hemorrhagic fever with renal syndrome morbidity].

Viral origin of hemorrhagic fever with renal syndrome (HFRS) is known since 40th years of last century. Also it is known that contamination of person is performed mainly by air pollution way. We observed a focus with 3 HFRS cases (with laboratory confirmation--antibodies to HFRS Hantavirus were found) in one family with one lethal outcome. Contamination of patients occurred by air pollution way during stocking vegetables contaminated with rodent's excrements. Lethal outcome was stipulated by incorrect diagnosis made by district doctor (nonmetering epidemiological anamnesis and HFRS territory endemicity and seasonal prevalence) which leaded to late hospitalization and absence of possibility to render all complex of treatment and reanimation in the hospital.

[Hemorrhagic fever with renal syndrome coursing with neurologic symptomatology].

At present it is known 2 forms of hantavirus infections in humans: hemorrhagic fever with renal syndrome (HFRS) induced by viruses Hantaan, Seoul, Puumala and Dobrava/Belgrade; and hantaviral pulmonary syndrome, induced by Sin Nombre et al. A case of HRFS, induced by hantavirus Dobrava, is described. Features of this case are developed neurological manifestations against the background of renal pathology, and difficulties of clinical and laboratory diagnostics in practice.

[Observations on clinic curative effect of oxymatrine to cure hemorrhagic fever with renal syndrome (HFRS)].

OBJECTIVE: To observe the curative effect of oxymatrine to cure hemorrhagic fever with renal syndrome. METHODS: Randomly divide 418 patients suffering from hemorrhagic fever with renal syndrome into a treatment group and a control group, use oxymatrine to give an intravenous drip to the patients in the treatment group, one time a day, each time 600 mg, lasting for 7 days as one period of treatment and meanwhile take a traditional equilibrium salt treatment for the patients in the control group. Observe the change of the illness in both groups and occurrence of complications, dynamically test the magnitude of serum urination-regulated protein (THP) and beta(2) microglobulin (beta(2)M) of the patients, in the meantime observe the change in magnitude of serum white blood cell medium 15 (IL-15) and soluble intercellular adhesion molecules (sICAM-1). RESULTS: Shorten the course of the disease of the patients in the oxymatrine treatment group, make an improvement after the recovery and obviously reduce the magnitude of serum urination-regulated protein (THP) and beta(2) microglobulin and show a striking difference in magnitude of serum IL-15 and sICAM-1 after the treatment compared with that of the patients in the control group. CONCLUSION: Oxymatrine has a certainly true curative effect to hemorrhagic fever with renal syndrome and worth of furthering its widespread use in clinics.

[A familial case of severe hemorrhagic fever with renal syndrome].

The authors describe two lethal outcomes of severe hemorrhagic fever with renal syndrome in spouses aged 50 and 44. A detailed description of clinical symptoms, the results of laboratory and instrumental tests, and possible mechanisms of contamination is given. Cross-sectional photographs of kidneys and hypophyseal hemorrhage, as well as radiograms of renal arteries and right pulmonary blood vessels after post-mortem filling with radiopaque mass are presented.