FDG PET/CT in Hantavirus Hemorrhagic Fever With Renal Syndrome.

ABSTRACT: A 58-year-old man with fever, myalgia, and dysuria was admitted to the hospital. Because of prolonged fever, FDG PET/CT was performed. Surprisingly, bilateral kidneys were rapidly enlarged for 5 days with the renal parenchyma showing intense hypermetabolism. FDG PET/CT demonstrated physiology of Hantavirus invading kidneys and causing nephritis. This case illustrates that FDG PET/CT could be the choice of image modality for diagnosis and treatment evaluation of patients suspected of hemorrhagic fever with renal syndrome. To the best of our knowledge, this is the first report of FDG PET/CT image for a patient with hemorrhagic fever with renal syndrome.

Hemorrhagic fever with renal syndrome and reversible splenial lesion syndrome.

Hemorrhagic fever with renal syndrome (HFRS) and reversible splenial lesion syndrome are both considered uncommon conditions relatively rare. Fever, hemorrhage, and acute kidney injury are the prevailing symptoms frequently observed in cases of HFRS. We describe a case of a middle-aged man who had been hospitalized with fever and acute neurological symptoms. His main symptom was recurrent dizziness. Cranial computed tomography (CT) did not reveal any obvious lesions, such as encephalorrhagia or infarctions. The splenium of corpus callosum showed hyperintensity on brain magnetic resonance imaging (MRI), which is in line with the characteristic radiographic observations of reversible splenial lesion syndrome (RESLES). Further analyses revealed that the patient's platelet counts had decreased to 7×109/L while hemorrhagic fever antibodies were positive. Eventually, the patient was diagnosed with HFRS and exhibited clinical improvements after active treatment.

Lung ultrasonography versus chest CT for assessing peripheric pulmonary lesions in hemorrhagic fever with renal syndrome: a prospective comparative study in China.

OBJECTIVES: To compare the performances of lung ultrasonography (LUS) versus chest CT for assessing peripheric pulmonary lesions in hemorrhagic fever with renal syndrome (HFRS). METHODS: Paired LUS and chest CT scan were prospectively performed and compared when in diagnosing five pathologies including region with alveolar-interstitial pattern (RAIP), alveolar-interstitial syndrome (AIS), lung consolidation, pleural effusion (PE), and pericardial effusion, in each patient with HFRS. RESULTS: Forty-four patients (aged 39.9 ± 15.0 years, 35 males) were included, from which 68 paired LUS and chest CT imaging data of 816 lung regions were obtained and analyzed. Compared with chest CT, LUS showed high sensitivity (92.19-100%) and negative predictive value (95.9-100%), but relatively low specificity (39.47-97.21%) and positive predictive value (37.5-76.47%) for diagnosing the above pathologies. McNemer's test showed LUS detected more positive findings than chest CT (all p ≤ 0.002). There was a strong correlation between LUS and chest CT scores (rs = 0.7141, p < 0.0001) and both scores correlated with the disease severity, hospital days, and partial laboratory profiles in HFRS patients. CONCLUSIONS: LUS was comparable with chest CT for diagnosing peripheric pulmonary lesions and clinical assessment in patients with HFRS. Given the high sensitivity and negative predictive value compared with chest CT, LUS can be used as an excellent rule-out tool in HFRS, while its use in rule-in still requires more evidence. Considering the obvious advantages of LUS being a bedside, less expansive, and non-radiating exam, future multi-center randomized LUS versus chest CT studies may help to guide the preferred method. KEY POINTS: • LUS could detect more positive findings than chest CT in assessing peripheric pulmonary lesions in patients with hemorrhagic fever with renal syndrome (HFRS). • Compared with chest CT, LUS showed high sensitivity but relatively low specificity when diagnosing the peripheric pulmonary lesions caused by HFRS. • Both LUS and chest CT scores correlated with the disease severity, hospital days, and partial laboratory profiles in HFRS.

Abdominal CT findings in Puumala hantavirus-infected patients.

BACKGROUND: Previous clinical studies have reported abdominal findings on ultrasonography or MRI in Puumala hantavirus-infected patients. PURPOSE: To determine if abdominal computed tomography (CT) can lead to a diagnosis of Puumala virus infection in the presence of a suggestive clinical picture. MATERIAL AND METHODS: CT findings were studied retrospectively in 30 patients who presented to the emergency department of two (Belgian) hospitals with serologically confirmed Puumala hantavirus infection. RESULTS: The most frequent finding was perirenal fascial thickening (90%), followed by perirenal fat stranding (87%). Retroperitoneal fat stranding was found in 19 patients (64%) in the perivesical spaces along the fascia of the external iliac vessels with or without involvement of the presacral fat. Half of the patients had pelvic ascites, and pleural fluid was found in 7 of them. The right and left mean pole-to-pole kidney's lengths were respectively 125.7 mm and 127.8 mm in 28 patients. CONCLUSION: Retroperitoneal fat stranding, perirenal fascial thickening and/or perirenal fat stranding were found in most patients with acute Puumala virus infection who have undergone CT. Although nonspecific, these findings may help to suggest Puumala hantavirus infection in the right clinical settings.

Puumala hantavirus: an imaging review.

Puumala virus (PUUV) is the most common hantavirus in Europe. It is known to cause nephropathia epidemica, which is considered a mild type of hemorrhagic fever with renal syndrome. However, it does not only involve the kidneys and is rarely accompanied by symptomatic hemorrhage. We review the imaging abnormalities caused by PUUV infection, from head to pelvis, emphasizing the broad spectrum of possible findings and bringing further support to a previously suggested denomination "Hantavirus disease" that would encompass all clinical manifestations. Although non-specific, knowledge of radiological appearances is useful to support clinically suspected PUUV infection, before confirmation by serology.

Hemorrhagic fever with renal syndrome accompanied by panhypopituitarism and central diabetes insipidus: a case report.

Central diabetes insipidus (DI) was detected in a patient with hemorrhagic fever with renal syndrome (HFRS) who had been molecularly and serologically diagnosed with Hantaan virus infection. We recommend that clinicians differentiate central DI in HFRS patients with a persistent diuretic phase even when pituitary MRI findings are normal.

Pulmonary high-resolution computed tomography findings in nephropathia epidemica.

PURPOSE: To evaluate lung high-resolution computed tomography (HRCT) findings in patients with Puumala hantavirus-induced nephropathia epidemica (NE), and to determine if these findings correspond to chest radiograph findings. MATERIALS AND METHODS: HRCT findings and clinical course were studied in 13 hospital-treated NE patients. Chest radiograph findings were studied in 12 of them. RESULTS: Twelve patients (92%) showed lung parenchymal abnormalities in HRCT, while only 8 had changes in their chest radiography. Atelectasis, pleural effusion, intralobular and interlobular septal thickening were the most common HRCT findings. Ground-glass opacification (GGO) was seen in 4 and hilar and mediastinal lymphadenopathy in 3 patients. Atelectasis and pleural effusion were also mostly seen in chest radiographs, other findings only in HRCT. CONCLUSION: Almost every NE patient showed lung parenchymal abnormalities in HRCT. The most common findings of lung involvement in NE can be defined as accumulation of pleural fluid and atelectasis and intralobular and interlobular septal thickening, most profusely in the lower parts of the lung. As a novel finding, lymphadenopathy was seen in a minority, probably related to capillary leakage and overall fluid overload. Pleural effusion is not the prominent feature in other viral pneumonias, whereas intralobular and interlobular septal thickening are characteristic of other viral pulmonary infections as well. Lung parenchymal findings in HRCT can thus be taken not to be disease-specific in NE and HRCT is useful only for scientific purposes.

Imaging of hemorrhagic fever with renal syndrome: a potential bioterrorism agent of military significance.

Hemorrhagic fever with renal syndrome (HFRS) is a potentially fatal infectious disease with worldwide distribution. Its etiologic agents are viruses of the genus Hantavirus of the virus family Bunyaviridae. Hypothetical ease of production and distribution of these agents, with their propensity to incapacitate victims and overwhelm health care resources, lend themselves as significant potential biological agents of terrorism. HFRS has protean clinical manifestations, which may mimic upper respiratory tract infection, nephrolithiasis, and Hantavirus pulmonary syndrome and may delay proper treatment. Sequelae of HFRS, such as hemorrhage, acute renal failure, retroperitoneal edema, pancreatitis, pulmonary edema, and neurologic symptoms, can be detected by different imaging modalities. Medical providers caring for HFRS patients must be aware of its radiologic features, which may help to confirm its clinical diagnosis. In this article, the authors review the epidemiology, pathophysiology, clinical presentation, diagnosis, treatment, and complications of HFRS.

Puumala virus infection: radiologic findings.

A 33-year-old male patient was admitted to our nephrology department with rapidly deteriorating general health, fever, respiratory difficulties, and acute renal failure. Computed tomography of the thorax revealed interstitial edema with thickening of the interlobular septa, peribronchial cuffing, ground-glass opacities, and small pleural and pericardial effusions. Polymerase chain reaction tests verified Puumala virus infection. The patient recovered with supportive treatment. Hantavirus infection should be considered in the differential diagnosis of young patients who present with acute renal failure of an unknown origin and the nonspecific radiologic finding of noncardiogenic interstitial edema, which in combination with typical clinical symptoms and laboratory parameters, can be indicative of this disease.

[Long-term outcomes and formation of chronic disease of the kidneys in patients with a history of hemorrhagic fever with renal syndrome].

AIM: To evaluate renal function, persistence of renal dysfunction and probability of chronic renal pathology in convalescents of hemorrhagic fever with renal syndrome (HFRS). MATERIAL AND METHODS: A total of 370 HFRS convalescents were examined with estimation of renal functional reserve, albuminuria, uric acid clearance, activity of urine N-acetil-beta-D-hexosaminidase in the urine, 18-h deprevation test, duplex scanning of renal vessels. Correlation between prevalence of chronic renal failure in Udmurtia and HFRS incidence was analysed. RESULTS: Glomerular and tubular dysfunctions in HFRS convalescents (intraglomerular hypertension, albuminuria, regress of a concentration ability of the kidneys, impairment of tubular transport) are characterized by persistence in the presence of renal hypoperfusion and hypoexcretory hyperuricemia. 13% convalescents developed chronic disease of the kidneys (CDK) which clinically presented as chronic tubulointerstitial nephritis. HFRS may contribute to formation of population of patients with chronic renal failure in the territory of active natural foci. A significant positive correlation was registered between mean annual levels of HFRS morbidity and prevalence of chronic renal failure in different regions of Udmurtia. According to clinical data, chronic renal failure develops in patients who earlier have suffered from renal disease. CONCLUSION: Persistance of renal dysfunctions in HFRS convalescents and possible onset of chronic disease of the kidneys necessitate active follow-up of the disease convalescents.

Corticosteroids combined with continuous veno-venous hemodiafiltration for treatment of hantavirus pulmonary syndrome caused by Puumala virus infection.

Reported here are two cases of hantavirus pulmonary syndrome caused by Puumala virus infection, which rapidly resolved after initiation of corticosteroid treatment combined with continuous veno-venous hemodiafiltration. These cases emphasize the role of the inflammatory response in the pathogenesis of hantavirus pulmonary syndrome.

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.

Pulmonary-renal syndrome due to hemorrhagic fever with renal syndrome: an unusual manifestation of puumala virus infection in France.

The authors report about a patient who presented with acute respiratory failure, bilateral alveolar infiltrates, without signs of fluid overload, and acute renal failure. Percutaneous renal biopsy revealed acute interstitial nephritis with medulla hemorrhages. Serologic tests for Puumala virus infection were positive. Hemorrhagic fever with renal syndrome should be considered when patients present with pulmonary-renal syndrome.

[Ultrasound findings on abdominal organs in the acute phase of hemorrhagic fever with renal syndrome]. / Ultrasonografski nalaz na abdominalnim organima u akutnoj fazi hemoragijske vrucice s bubreznim sindromom.

INTRODUCTION: There are significant changes in small blood vessels with increased permeability, edema of abdominal organs and ascites in the acute phase of hemorrhagic fever with renal syndrome (HFRS). We analyzed ultrasound changes of abdominal organs in patients with serologically verified HFRS, in order to assess the value of this method in the diagnosis of acute renal failure (ARF). METHODS: The study included 14 sporadic patients with ARF and suspicion of HFRS, treated in 2002. Ultrasonography of the liver, gallbladder, pancreas, spleen, kidneys, prostate and retroperitoneum was performed on a Toshiba 220 SSA. RESULTS: Parenchymal edema with increased echogenicity, sinus narrowing and enlargement of both kidneys were found in all 14 (100%) patients. Hepatosplenomegaly was found in seven (50%), ascites in four (28.6%), and pleural effusion in two (14.3%) patients. Increased thickness of the bladder wall was found in two (14.3%), gallbladder enlargement in one (7%), and edema of the pancreas in one (7%) patient. CONCLUSION: Ultrasound examination has a very important role in the diagnosis and follow-up of changes in the parenchymal organs in the acute acute phase of the disease.

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.

Sonographic evaluation of gallbladder-wall thickening in hemorrhagic fever with renal syndrome: prediction of disease severity.

PURPOSE: Gallbladder-wall thickening (GBWT) frequently occurs in patients with hemorrhagic fever with renal syndrome (HFRS), an acute infectious disease caused by hantaviruses. HFRS is manifested by fever, hemorrhage, renal failure, and in many cases gastrointestinal symptoms, such as abdominal pain and tenderness. The clinical significance of GBWT in HFRS has not been reported. The purpose of this study was to investigate the incidence of GBWT and the relationship between GBWT and the severity of HFRS. METHODS: We retrospectively reviewed the medical records and sonograms of 68 patients with HFRS (47 males and 21 females, with an age range of 10-76 years) who underwent abdominal sonography in the acute stage of the disease. We measured the gallbladder-wall thickness on the sonograms and reviewed other sonographic and radiographic findings. Clinical factors that reflect the severity of HFRS were compared between the patients with GBWT (defined as thickness of 4 mm or more) and those without GBWT. RESULTS: Of the 68 patients, 29 (43%) had GBWT, which was even and diffuse in all cases. The patients with GBWT had a significantly lower mean platelet count and serum albumin level and significantly higher serum aspartate aminotransferase and serum lactate dehydrogenase levels than did the patients without GBWT. In addition, the incidence of renal failure requiring hemodialysis and the incidences of ascites and pleural effusion were higher in the patients with GBWT than in those without GBWT. Five patients died of HFRS; all 5 had GBWT (p = 0.011 for comparison with patients without GBWT). CONCLUSIONS: Our results suggest that the sonographic measurement of gallbladder-wall thickness during the acute stage of HFRS is useful for determining the severity of HFRS.

Intestinal protein loss in patients with haemorrhagic fever with renal syndrome.

BACKGROUND: In haemorrhagic fever with renal syndrome (HFRS) vascular dysfunction has been observed in various organs, but the involvement of the intestine has not yet been reported. This study was performed to evaluate the association of intestinal protein loss in this disease with other clinical parameters reflecting vascular permeability or disease severity. METHODS: Twenty patients with HFRS were included in this study. Intestinal protein loss was measured by (99m)Tc-human serum albumin ((99m)Tc-HSA) scintigraphy in the acute stage, and quantitative analysis of protein loss was measured by the faecal clearance of alpha 1-antitrypsin (C(AT)) in the acute and the recovery stages. C(AT) was then compared with clinical parameters reflecting disease activity and vascular permeability. RESULTS: (99m)Tc-HSA scintigraphy was positive in 13 (65%) patients, and C(AT) in the acute stage was significantly increased as compared with C(AT) in the recovery stage (40.5+/-24.1 vs 9.2+/-4.2 ml/day, P<0.001). C(AT) was associated with serum albumin levels, frequency of hypotensive episodes, severity of acute renal failure, and degree of thrombocytopenia. CONCLUSIONS: Our data suggest that the increased vascular permeability of HFRS is associated with the increased intestinal loss of plasma proteins, which might represent one of the parameters of disease severity in HFRS.

An explanation of renal hemodynamics in acute renal failure based on sequential CT in patients with Korean hemorrhagic fever.

The pattern of renal enhancement and washout of contrast medium was observed on sequential follow-up CT in 12 patients with Korean hemorrhagic fever, in which acute renal failure is one of the most important clinical features. Renal contrast enhancement and contrast medium washout were delayed longer in patients with severe oliguric renal failure. The delayed washout peaked at 4-5 days and did not return to normal until 8-9 days in the patients with severe oliguria; in the patients without severe oliguria the times were 1-2 days and 3-4 days, respectively. A characteristic "cart-wheel" pattern was observed during the washout stage in patients without severe oliguria. This "cart-wheel" pattern of washout is thought to result from relief of vasoconstriction and repair of tubular function. Multifocal "wedge-shaped" nonenhanced areas of the kidney, seen on the 2 week follow-up postcontrast CT, are thought to be ischemic zones due to persistent vasoconstriction. On the 6 week follow-up postcontrast CT in one patient, scarring of the kidney was detected in the same area that did not enhance on the 2 week CT. This scarring is thought to be a result of permanent vasoconstriction.

Pituitary atrophy in Korean (epidemic) hemorrhagic fever: CT correlation with pituitary function and visual field.

Eleven patients with Korean (epidemic) hemorrhagic fever were each studied three times with high-resolution CT in order to demonstrate necrosis of the pituitary gland and to correlate the CT findings with the patients' pituitary function and visual fields. Seven of the 11 patients showed varying degrees of progressive decrease in the height of the pituitary gland: one severe, two moderate, and four mild. The visual fields of all the patients were checked at the time of the third (last) follow-up CT. Six of the 11 patients had bitemporal superior quadrantanopsia. In five patients, the decreased height (atrophic change) of the pituitary gland and the visual-field defect were coincidental. The visual-field defects in those patients were not improved on follow-up examination 5 weeks later. Two patients in whom a 1-year follow-up examination was performed showed no interval changes in the defects. Pituitary function tests were performed in nine of the 11 patients (six with atrophic pituitary glands and three without atrophic changes) at the time of the third CT. Five of the six patients with atrophy showed decreased pituitary reserve function for follicle-stimulating hormone, cortisol, or human growth hormone, while only one patient showed decreased reserve function for cortisol among the three patients without atrophic change. The pituitary atrophic changes observed on follow-up sellar CT are thought to be the result of the ischemic necrosis of the gland. The high probability (five of seven) of visual-field defects in those patients with atrophic glands suggests optochiasmatic and pituitary ischemia as the basic pathogenesis.