Factores pronósticos de síndrome cardio-pulmonar y muerte por hantavirus Andes Sur: estudio de cohorte en San Carlos de Bariloche y su zona de influencia sanitaria / Prognostic factors for cardio-pulmonary syndrome and death by hantavirus Andes Sur: cohort study in San Carlos de Bariloche and health influence área

Resumen Las infecciones por hantavirus, ocurren a través de la inhalación de aerosoles provenientes de excretas de roedores infectados. Estos virus causan síndrome cardiopulmonar en el caso de la variante Andes Sur, con una mortalidad que puede alcanzar el 50%. Se presenta como casos esporádicos o en pequeños conglomerados, en los que predomina el contagio interhumano. En este estudio observacional de tipo cohorte histórica, en personas infectadas con hantavirus Andes Sur durante los años 2009 a 2019 que fueron asistidas en el subsector público de salud de San Carlos de Bariloche(Argentina), se buscó identificar factores que pudieran predecir mala evolución (síndrome cardiopulmonar y muerte). Para ello se caracterizó el riesgo para cada una de las variables y, para obtener información clave sobre las relaciones entre las mismas, se aplicó además un análisis de correspondencias múltiples. Durante el período de estudio, 38 personas fueron incluidas. La edad media fue de 35 años. Se sospechó contagio de persona a persona en 10/38 (26.8%) casos. El 21.1% (8/28) tuvo al momento del diagnóstico un síndrome pulmonar por hantavirus. Mientras que, 55.3% (21/38) lo desarrolló durante su evolución y 44.7% (17/38) de los infectados fallecieron durante la internación. La edad mayor a 15 años y la plaquetopenia, se asociaron con un mayor riesgo de progresión clínica, mientras que las formas de leves o las personas asintomáticas, el contagio persona a persona o durante un brote epidemiológico, se asociaron con un menor riesgo de muerte.

Abstract Hantavirus infections occur through the inhalation of aerosols from the excreta of infected rodents. These viruses cause a cardiopulmonary syn drome in the case of the Andes Sur variant, with a mortality that can reach 50%. It occurs in sporadic cases or in small clusters, in which interhuman contagion predominates. In this historical cohort-type observational study, in people infected with Andes Sur hantavirus during the years 2009 to 2019 who was assisted in the public health subsector of San Carlos de Bariloche (Argentina), it was sought to identify factors that could predict poor evolution (cardiopulmonary syndrome and death). For this, the risk for each of the variables was characterized and, to obtain key information about the relationships between them, a multiple correspondence analysis was also applied. During the study period, 38 people were included. The mean age was 35 years. Person-to-person contagion was suspected in 10/38 (26.8%) cases. 21.1% (8/28) presented a hantavirus pulmonary syndrome at the time of diagnosis, while 55.3% (21/38) developed it during their evolution, and 44.7% (17/38) of those infected died during hospitalization. Age over 15 years and thrombocytopenia were associated with a higher risk of clinical progression, while mild forms or asymptomatic people, person-to-person transmission, or during an epidemiological outbreak, were associated with a lower risk of death.

Expanded distribution of orthohantavirus Pergamino genotype: First record in Entre Rios province, Argentina / Ampliación de la distribución del Orthohantavirus genotipo Pergamino: Primer registro en la Provincia de Entre Ríos, Argentina

Abstract Hantavirus Pulmonary Syndrome (HPS) is an emerging infectious disease of the Americas. Eight native rodent species have been identified as HPS virus reservoirs in Argentina. The aim of this work was to detect the orthohantavirus genotypes present in a rodent commu-nity that inhabits a zone where a fatal HPS case occurred within an endemic locality of Central Argentina. We captured 27 rodents with a trapping effort of 723 trap nights. We detected 14.3% of infected Akodon azarae with the Pergamino genotype. This result expands the known distribution of this orthohantavirus. Although the Pergamino genotype has not been associated with human cases, the information about its distribution is relevant for risk assessment against potential changes in the virus infectivity.

Resumen El síndrome pulmonar por hantavirus (SPH) es una enfermedad infecciosa emergente en América. Ocho especies de roedores nativos han sido identificadas como reservorios del virus causante del SPH en la Argentina. El objetivo de este trabajo fue detectar los genotipos de orthohantavirus presentes en una comunidad de roedores que habita en una zona donde ocurrió un caso fatal de SPH, en una localidad endémica de Argentina central. Se capturaron 27 individuos con un esfuerzo de 723 trampas-noche. Se detectó un 14,3% de Akodon azarae infectados con el genotipo pergamino. Este resultado amplía el conocido rango de distribución de este orthohantavirus. A pesar de que el genotipo pergamino no ha sido asociado con casos humanos hasta el momento, la información sobre su distribución es relevante para analizar el riesgo ante un potencial cambio en la infectividad del virus.

Expanded distribution of orthohantavirus Pergamino genotype: First record in Entre Rios province, Argentina.

Hantavirus Pulmonary Syndrome (HPS) is an emerging infectious disease of the Americas. Eight native rodent species have been identified as HPS virus reservoirs in Argentina. The aim of this work was to detect the orthohantavirus genotypes present in a rodent community that inhabits a zone where a fatal HPS case occurred within an endemic locality of Central Argentina. We captured 27 rodents with a trapping effort of 723 trap nights. We detected 14.3% of infected Akodon azarae with the Pergamino genotype. This result expands the known distribution of this orthohantavirus. Although the Pergamino genotype has not been associated with human cases, the information about its distribution is relevant for risk assessment against potential changes in the virus infectivity.

Factores ambientales y síndrome cardiopulmonar por virus hanta en Chile / Environmental factors and cardiopulmonary syndrome due to hanta virus in Chile

RESUMEN Objetivo Evaluar la relación entre la temperatura ambiente, humedad relativa y el material particulado ambiental 2,5 con el número de casos de síndrome cardiopulmonar por virus hanta en Chile durante el periodo 2015-2017. Métodos Estudio observacional transversal en 197 casos de síndrome cardiopulmonar por virus hanta notificados y confirmados, ocurridos entre los años 2015 y 2017 en Chile. Se realizó análisis bi- y multivariado entre variables de estudio. Resultados Se determinó una relación positiva y significativa entre temperatura ambiente y número de casos de Síndrome Cardiopulmonar por virus Hanta y una relación negativa y significativa entre el número de casos de Síndrome Cardiopulmonar por virus Hanta y la humedad relativa. Además se observó que la temperatura ambiental junto con material particulado 2,5 aumentan significativamente el número de casos de Síndrome Cardiopulmonar por virus Hanta. Conclusiones Los factores ambientales están relacionados con el número de casos de síndrome cardiopulmonar por virus Hanta en Chile entre los años 2015 y 2017.(AU)

ABSTRACT Objective Evaluate the relationship between ambient temperature, relative humidity and particulate matter 2,5 with the number of cases Hantavirus Cardiopulmonary Syndrome in Chile between 2015 and 2017. Methods Observational, cross-sectional study in 197 cases of Hantavirus Cardiopulmonary Syndrome reported and confirmed, occurring between 2015 and 2017 in Chile. Results Positive and significant relationship was identified between ambient temperature and number of cases of Hantavirus Cardiopulmonary Syndrome and a negative and significant relationship between the number of cases Hantavirus Cardiopulmonary Syndrome and the relative humidity. Also, ambient temperature together with particulate matter 2,5 was observed to increase significantly the number of cases of Hantavirus Cardiopulmonary Syndrome. Conclusions Environmental factors are related to the number of cases Hantavirus Pulmonary Syndrome in Chile between the years 2015 to 2017.(AU)

Síndrome cardiopulmonar por hantavirus / Hanta syndromevirus cardiopulmonary

Introducción: En el ámbito mundial las enfermedades infecciosas son la segunda causa de muerte en el presente siglo. La epidemiología de las enfermedades infecciosas emergentes y reemergentes plantean desafíos a la clínica y a la salud pública en general, tal es el caso del síndrome cardiopulmonar por hantavirus. Objetivo: Actualizar los conocimientos sobre la vigilancia epidemiológica del microorganismo responsable y documentar a los profesionales de la salud. Métodos: Revisión de artículos de investigación referentes al síndrome cardiopulmonar por hantavirus en el presente siglo. Se realizaron búsquedas en las fuentes de indexación Scopus, SciELO, Medline, Latindex, Bireme, Google. Lilacs, PubMed sobre el microorganismo, patogenia, manifestaciones clínicas, diagnóstico y tratamiento. Conclusiones: La emergencia y reemergencia de este síndrome con alta letalidad debe ser de dominio de clínicos, pediatras, intensivistas, epidemiólogos y los médicos de la atención primaria para su prevención, diagnóstico precoz y conducta oportuna. La vigilancia epidemiológica es fundamental(AU)

Introduction: Infectious diseases are globally the second cause of death in this century. The epidemiology of emerging and reemerging infectious diseases poses clinical and public health challenges in general; such is the home of Hantavirus cardiopulmonary syndrome. Objective: Updating information on the epidemiological surveillance of the causing microorganism and provide said knowledge to health professionals. Methods: Reviewing research articles related to cardiopulmonary syndrome by Hantavirus conducted in the present century. Researches were carried out about the microorganism, pathogenesis, clinical manifestations, diagnosis and treatment in the indexing sources Scopus, SciELO, Medline, Latindex, Bireme, Google, Lilacs and PubMed. Conclusions: The emergence and reemergence of this highly lethal syndrome should be known by clinicians, pediatricians, intensive care staff, epidemiologists and primary care physicians for prevention, early diagnosis and timely treatment. Epidemiological surveillance is essential(AU)

Aspectos clínico-epidemiológico dos pacientes convalescentes após infecção por hantavírus em Mato Grosso / Clinical-epidemiological aspects of convalescent patients after hantavirus infection in Mato Grosso / Aspectos clínico-epidemiológicos de los pacientes convalecientes después de la infección por hantavirus en Mato Grosso

Justificativa e Objetivos: As hantaviroses são zoonoses que nas américas são caracterizadas pela Síndrome Pulmonar por Hantavírus SPH), caracterizada pela alta letalidade. Dessa forma, objetivou-se, identificar o perfil dos pacientes em convalescência após a infecção por hantavírus em Mato Grosso. Métodos: Foi realizado um estudo epidemiológico descritivo de uma série de dados secundários, referente aos casos confirmados de SPH em Mato Grosso, registrados entre os anos de 1999 a 2016. A coleta de dados foi realizada através de consulta às fichas de notificação e posteriormente realizada a análise estatística descritiva dos dados, sendo respeitados os preceitos éticos em pesquisa envolvendo seres humanos. Resultados: Utilizou-se 160 fichas de notificação de pacientes convalescentes. Nessa população predominou o sexo masculino, faixa etária de 25 a 34 anos, raça/cor branca, ensino fundamental incompleto e atividade profissional voltadas à área agrícola. As situações de risco envolveram desmatamento, aragem de terra, plantio ou colheita agrícola. Os principais sinais e sintomas descritos foram febre (86,9%), cefaleia (74,4%) e dispneia (72,5%). Do total de pacientes, 77,5% realizaram exames laboratoriais e 79,4% exame de imagem por raio X, destes a maioria com infiltrado pulmonar difuso (66,9%). Além disso, 87,5% foram hospitalizados, com utilização de assistência respiratória mecânica (46,5%), uso de antibioticoterapia (50,5%) e drogas vasoativas (35,5%). Conclusão: Conhecer o perfil dos pacientes que evoluíram para cura possibilita instrumentalizar os profissionais para a adoção de medidas adequadas tanto no diagnóstico precoce, como na terapêutica eficaz, com o intuito de reduzir a letalidade.(AU)

Background and Objectives: Hantaviruses are zoonoses that in the Americas are characterized by Hantavirus Pulmonary Syndrome (HPS), characterized by high lethality. Thus, it is aimed to identify the profile of patients in convalescence after hantavirus infection in Mato Grosso. Methods: A descriptive epidemiological study was performed on a series of secondary data referring to the confirmed cases of HPS in Mato Grosso recorded between 1999 and 2016. The data collection was done through consultation of the notification sheets and subsequently performed the descriptive statistical analysis of the data, respecting the ethical precepts in research involving human beings. Results: A total of 160 patient notification cards were used. In this population, males, aged between 25 and 34 years old, white race / color, incomplete elementary school and professional activity focused on the agricultural area predominated. The risk situations involved deforestation, land plowing, planting or agricultural harvesting. The main signs and symptoms described were fever (86.9%), headache (74.4%) and dyspnea (72.5%). Of the total number of patients, 77.5% performed laboratory tests and 79.4% had X-ray imaging, of which the majority had diffuse pulmonary infiltrate (66.9%). In addition, 87.5% were hospitalized, using mechanical respiratory assistance (46.5%), antibiotic therapy (50.5%) and vasoactive drugs (35.5%). Conclusion: Knowing the profile of the patients that evolve to cure makes it possible to instrumentalize the professionals for the adoption of adequate measures both in the early diagnosis and in the effective therapy that can contribute to the reduction of the lethality.(AU)

Justificación y objetivos: Las hantavirosis son zoonosis que en las américas se caracterizan por el Síndrome Pulmonar por Hantavirus (SPH), caracterizada por la alta letalidad. De esta forma, se objetiva, identificar el perfil de los pacientes en convalecencia después de la infección por hantavirus en Mato Grosso. Métodos: Se realizó un estudio epidemiológico descriptivo de una serie de datos secundarios, referentes a los casos confirmados de SPH en Mato Grosso, registrados entre los años 1999 a 2016. La recolección de datos fue realizada a través de consulta a las fichas de notificación y posteriormente realizada el análisis estadístico descriptivo de los datos, siendo respetados los preceptos éticos en investigación envolviendo seres humanos. Resultados: Se utilizaron 160 fichas de notificación de pacientes convalecientes. En esta población predominó el sexo masculino, grupo de edad de 25 a 34 años, raza / color blanco, enseñanza fundamental incompleta y actividad profesional orientadas al área agrícola. Las situaciones de riesgo involucraron deforestación, ajo de tierra, siembra o cosecha agrícola. Los principales signos y síntomas descritos fueron fiebre (86,9%), cefalea (74,4%) y disnea (72,5%). Del total de pacientes, el 77,5% realizaron exámenes de laboratorio y el 79,4% examen de imagen por radiografía, de éstos la mayoría con infiltrado pulmonar difuso (66,9%). Además, 87,5% fueron hospitalizados, con utilización de asistencia respiratoria mecánica (46,5%), uso de antibioticoterapia (50,5%) y drogas vasoactivas (35,5%). Conclusiones: Conocer el perfil de los pacientes que evolucionan a curación posibilita instrumentalizar a los profesionales para la adopción de medidas adecuadas tanto en el diagnóstico precoz, como en la terapéutica eficaz que puedan contribuir con la reducción de la letalidad.(AU)

Soporte vital extracorpóreo en adultos con insuficiencia respiratoria aguda refractaria / Extra-corporeal life support for adults with refractory severe respiratory failure / Suporte vital extracorpóreo em adultos com insuficiência respiratória aguda refratária

Resumen: Introducción: El soporte vital extracorpóreo (ECLS - por sus siglas en inglés extra-corporeal life support) se aplica exitosamente en neonatos con insuficiencia respiratoria aguda (IRA). Las dificultades técnicas, los costos y los resultados desalentadores confinaron a esta técnica como última estrategia en adultos. Nuestro objetivo es reportar nuestra experiencia con ECLS en adultos. Material y métodos: Se analizaron pacientes adultos tratados con ECLS entre febrero de 2002 y enero de 2012. Se recolectaron variables demográficas y cardiopulmonares. Los datos son expresados como mediana (rango). Se analizaron las diferencias entre los pacientes afectados con IRA aislada y con síndrome cardiopulmonar por Hantavirus (SCPH) con test U de Mann Whitney y se consideró estadísticamente significativo un valor de p < 0.05. Resultados: Se aplicó ECLS a15 pacientes. Cinco venoarteriales (VA), siete venovenoso (V-V) y tres asistencias pulmonares extracorpóreas sin bomba (P-ELA). Se describen variables demográficas, cardiopulmonares, diagnóstico, tiempo en ECLS y los desenlaces. Los días en ventilación mecánica (VM), la estadía en UCI y hospital fueron: 17 (4-49), 38 (4-93) y 46 (4-102) días respectivamente. Siete de los 15 pacientes fallecieron (47%). Dos pacientes murieron por shock séptico por bacilos Gram negativos después de un ECLS exitoso. La única diferencia estadísticamente significativa entre los pacientes con IRA aislada (ECLS-VV venovenosa o P-ELA) y los pacientes con SCPH (ECLS-VA venoarterial) fue el lactato al ingreso (p < 0.05). Conclusión: ECLS es una estrategia útil como rescate de adultos con IRA refractaria a estrategias de VM avanzada. El progreso en los equipos y el uso de algoritmos en la toma de decisiones han contribuido a reducir la morbimortalidad.

Abstract: Introduction: Extra-corporeal life support (ECLS) is an established technique for neonates with acute respiratory failure (ARF). Technical difficulties, expense and discouraging outcomes explains its confinement to a last resource tool for adults with ARF. Our objective is report the experience with adult ECLS in two hospitals. Material and methods: All consecutive adult patients treated with different ECLS techniques from 2002 to 2012 were analyzed. Demographic and cardiopulmonary variables were collected. Data are expressed as median (range). The differences between patients affected with ARF isolated and patients with hantavirus cardiopulmonary syndrome was obtained with Mann Whitney U test and a value of p < 0.05 was considered statistically significant. Results: Fifteen patients received ECLS. Five were veno-arterial (VA), 7 veno-venous (VV), and 3 pumpless extracorporeal lung assist (P-ELA). Demographic, cardiopulmonary variables, diagnosis, time on ECLS and outcome are described. Mechanical ventilation (MV), ICU and hospital stay were 17 (4-49), 38 (4-93) and 46 (4-102) days respectively. All patients who required VA-ECLS were affected for Hanta cardiopulmonary syndrome. Seven of fifteen patients died. Two out of five VA-ECLS suffered some degree of lower extremity (arterial cannulation) compartmental syndrome and a mild abnormal gait sequel affected them. Vascular accesses and bleeding were not a concern. Two patients died due to septic shock from gram negative bacilli after leaving ECLS. Conclusion: ECLS for catastrophic ARF in adults is useful therapeutic option to rescue patients who do not respond to conventional MV strategies. The progress in technical devices, use an algorithm to medical decision making contribute to reducing morbidity and mortality.

Resumo: Introdução: O suporte de vida extracorpórea (ECLS) é usado com sucesso em neonatos com insuficiência respiratória aguda (IRA). As dificuldades técnicas, custos e resultados decepcionantes confinaram a esta técnica como última estratégia em adultos. Nosso objetivo é relatar nossa experiência com ECLS em adultos. Métodos: Foram analisados pacientes adultos tratados com ECLS entre 2002 e 2012. Foram recolhidas as variáveis demográficas e cardiopulmonares. Os dados são expressos em mediana (desvio padrão). As diferenças entre os pacientes com IRA isolada e com síndrome cardiopulmonar por Hantavírus foi analisada com o teste U de Mann Whitney e foi considerou um valor estatisticamente significativo p < 0.05. Resultados: Quinze pacientes receberam ECLS. Cinco veno-arteriais (VA), 7 veno-venosas (V-V) e trêis asssistências pulmonares extracorpóreas sem bomba (P-ELA). Se descrevem variáveis demográficas, cardiopulmonar, diagnóstico, tempo no ECLS e os resultados. Os dias de ventilação mecânica (VM), tempo de UTI e hospitalar foram: 17 (4-49), 38 (4-93) e 46 (4-102) dias respectivamente. Sete dos quinze pacientes morreram (47%). Dois pacientes morreram com choque séptico por bacilos gram negativos depois de um ECLS exitoso. A única diferença estatisticamente significativa entre os pacientes com IRA isolada (ECLS-VV ou P-ELA) e pacientes com SCPH (ECLS-VA) foi o lactato na admissão (p < 0.05). Conclusão: O ECLS é uma estratégia útil como resgate de adultos com IRA refractária a estratégias de VM avançada. O progresso dos equipamentos e o uso de algoritmos na tomada de decisões têm ajudado a reduzir a morbimortalidade.

Tratamento bem-sucedido da síndrome cardiopulmonar por hantavírus com uso de hemofiltração de alto volume / Hantavirus cardiopulmonary syndrome successfully treated with high-volume hemofiltration

RESUMO A síndrome cardiopulmonar por hantavírus tem elevada taxa de mortalidade. Sugere-se que uma conexão precoce com oxigenação por membrana extracorpórea melhore os resultados. Relatamos o caso de uma paciente que apresentou síndrome cardiopulmonar por hantavírus e choque refratário, que preenchia os critérios para oxigenação por membrana extracorpórea e que teve resposta satisfatória com uso de hemofiltração contínua de alto volume. A implantação de hemofiltração contínua de alto volume, juntamente da ventilação protetora, reverteu o choque dentro de poucas horas e pode ter levado à recuperação. Em pacientes com síndrome cardiopulmonar por hantavírus, um curso rápido de hemofiltração contínua de alto volume pode ajudar a diferenciar pacientes que podem ser tratados com cuidados convencionais da unidade de terapia intensiva dos que necessitarão de terapias mais complexas, como oxigenação por membrana extracorpórea.

ABSTRACT Hantavirus cardiopulmonary syndrome has a high mortality rate, and early connection to extracorporeal membrane oxygenation has been suggested to improve outcomes. We report the case of a patient with demonstrated Hantavirus cardiopulmonary syndrome and refractory shock who fulfilled the criteria for extracorporeal membrane oxygenation and responded successfully to high volume continuous hemofiltration. The implementation of high volume continuous hemofiltration along with protective ventilation reversed the shock within a few hours and may have prompted recovery. In patients with Hantavirus cardiopulmonary syndrome, a short course of high volume continuous hemofiltration may help differentiate patients who can be treated with conventional intensive care unit management from those who will require more complex therapies, such as extracorporeal membrane oxygenation.

Hantavirus cardiopulmonary syndrome: a report of two cases / Síndrome cardiopulmonar por hantavírus: relato de dois casos

Infection with hantavirus, from the family Bunyaviridae, causes hantavirus cardiopulmonary syndrome (HCPS) in the Americas. This highly lethal anthropozoonosis afflicts preferentially individuals in rural areas and is transmitted by aerosol of excreta from infected wild rodents. The aim of this study is to report the almost simultaneous occurrence of two cases of HCPS in the municipality of Jataí, state of Goiás, Brazil.

A infecção por hantavírus, família Bunyaviridae, provoca a síndrome cardiopulmonar por hantavírus (SCPH) nos países da América. Ela é uma antropozoonose, de elevada letalidade, que tem acometido preferencialmente indivíduos em contato com o meio rural, sendo transmitida por aerossóis a partir das excretas dos roedores silvestres infectados. O objetivo deste estudo foi relatar a ocorrência, quase que simultânea, de dois casos de SCPH ocorridos no município de Jataí, Estado de Goiás, Brasil.

Síndrome pulmonar por Hantavirus (Virus Río Mamoré) en la Amazonía Peruana / Hantavirus pulmonary syndrome (Rio Mamore Virus) in the Peruvian Amazon region

La hantavirosis es una infección viral zoonótica transmitida por roedores cuya forma clínica más letal es el síndrome pulmonar por Hantavirus (SPH). La variante río Mamoré es autóctona de Sudamérica y fue descrita en roedores sin asociarla a enfermedad en humanos. Se presenta dos casos de SPH causados por hantavirus río Mamoré en la Amazonía peruana en noviembre de 2011. En ambos casos, el diagnóstico confirmatorio fue molecular, efectuados en el Instituto Nacional de Salud de Perú. Se realizó análisis filogenético del fragmento de genoma viral y la evaluación histopatológica. Ambos pacientes evolucionaron a síndrome de distrés respiratorio del adulto y estado de choque refractario. Un paciente falleció y el otro se recuperó a los doce días.

Hantavirus infection is a viral zoonotic infection borne by rodents which most letal form clinical is the Hantavirus Pulmonary Syndrome (SPH, Spanish abbreviation). The Mamore River variant originates in South America and was found in rodents without any association to human diseases. Two cases of SPH were identified in the Peruvian Amazon region in November 2011. In both cases, a molecular diagnostic testing was conducted by the Instituto Nacional de Salud from Peru. A phylogenetic analysis of a viral genome fragment and a histopathological evaluation were conducted. Both patients developed adult respiratory distress syndrome and refractory shock. A patient died and another one recovered 12 days later.

Prevalence of serum antibodies to hantavirus in a rural population from the southern state of Santa Catarina, Brazil / Prevalência de anticorpos séricos para hantavírus em população rural do extremo sul do estado de Santa Catarina, Brasil

INTRODUCTION: Rodent-borne hantaviruses cause severe human diseases. We completed a serological survey of hantavirus infection in rural inhabitants of Turvo County, in the southern State of Santa Catarina, Brazil, in which seropositivity for hantavirus was correlated to previous disease in the participants. METHODS: The levels of IgG antibodies to hantavirus Araraquara in the sera of 257 individuals were determined using an immunoenzymatic assay. RESULTS: IgG antibodies to hantavirus were found in 2.3 percent of the participants. All seropositive participants reported previous disease with symptoms suggestive of hantavirus cardiopulmonary syndrome. CONCLUSIONS: Human infections causing unreported cardiopulmonary syndrome probably occur in the southern State of Santa Catarina.

INTRODUÇÃO: Hantaviroses são zoonoses de roedores silvestres que causam doenças graves em seres humanos. Este trabalho mostra inquérito sorológico para hantavírus em população rural e periurbana do município de Turvo, Estado de Santa Catarina e a correlação da presença de anticorpos anti-hantavírus com a história mórbida pregressa dos indivíduos. MÉTODOS: Investigaram-se os 257 participantes do estudo quanto à presença de anticorpos IgG séricos anti-hantavírus Araraquara, por método imunoenzimático. RESULTADOS: A prevalência de anticorpos anti-hantavírus na população foi de 2,3 por cento. Os soropositivos possuíam antecedente nosológico sugestivo de hantavirose pregressa. CONCLUSÕES: Os achados mostram a ocorrência de infecções por hantavírus no extremo sul de Santa Catarina.

Vigilancia epidemiológica de la enfermedad por hantavirus en los años 2009 y 2010 / Epidemiologic surveillance of hantaviral disease between 2009 and 2010

En Chile es la variedad Andes del hantavirus la que provoca el síndrome cardiopulmonar. El reservorio es el roedor silvestre Oligoryzomys longicaudatus y su hábitat se extiende desde el sur de la Región de Atacama a la Región de Magallanes. Durante los años 2009 y 2010 se confirmaron 35 y 61 casos de síndrome cardiopulmonar por hantavirus, cifra sobre lo esperado para el año 2010, en relación al quinquenio anterior. La letalidad alcanzó en el período a un 32 por ciento. La incidencia en el 2010 fue de 0,35 por 100.000 habitantes. El mayor el riesgo se mantiene en las regiones del sur del país. Sin embargo, se observó un número de casos sobre lo esperado en 2 regiones del centro-sur del país, las que fueron afectadas por el terremoto de 2010. La alta letalidad de esta enfermedad requiere mantener la detección y hospitalización precoz en los casos sospechosos de hantavirus a través de la capacitación a los equipos de salud y realizar campañas de prevención periódica dirigidas a la población y grupos de mayor riesgo.

In Chile, Andes strain causes hantavirus cardiopulmonary syndrome. The reservoir is the wild rodent Oligoryzomys longicaudatus and its habitat extends from south of Atacama region to Magallanes region. During 2009 and 2010, 35 and 61 cases of hantavirus cardiopulmonary syndrome were confirmed, a figure above the expected for 2010 compared to theprevious five years. Lethality reached 32 percent in this period. Incidence in 2010 was 0.35 per 100,000 inhabitants. The greater risk remains in the southern regions of the country. However, a number of cases more than expected were observed in 2 regions in south-central portion of the country, which were affected by the earthquake of 2010. High lethality level of thisdisease requires maintaining early detection and hospitalization in suspected cases of hantavirus through health teams training and conducting periodic prevention campaigns focused at the population and risk groups.

Expansión geográfica del síndrome pulmonar por hantavirus en la Argentina: Informe del caso más austral / Geographic expansion of hantavirus pulmonary syndrome in Argentina: The southernest case report

Desde 1995 se han informado más de 1000 casos de síndrome pulmonar por hantavirus (SPH) en la Argentina, enfermedad grave y muchas veces fatal para los humanos. La mayoría de los casos fueron asociados al virus Andes (AND) único hantavirus que ha sido informado como causante de transmisión persona a persona. Se han descrito varios linajes patogénicos del virus AND, de los cuales AND Sur, cuyo reservorio es el roedor Oligoryzomys longicaudatus, afecta a la región patagónica de Argentina y Chile. En el presente estudio se informan las manifestaciones clínicas y las características epidemiológicas de un caso de SPH. El objetivo fue describir la presentación clínica del caso, su entorno epidemiológico, el sitio probable de contagio, la variante viral implicada y su relación con los casos más cercanos notificados. Se realizó el seguimiento clínico, el diagnóstico serológico y molecular y la investigación epidemiológica, incluyendo un estudio de la población de roedores reservorios en las áreas involucradas. Se trató de una presentación clásica de SPH moderada, causada por el linaje viral AND sur y su secuencia nucleotídica se comparó con casos del sur argentino y chileno. El caso de hantavirus investigado resultó ser el más austral (48° 46´ 1.2´´ S; 70° 15´ 0´´ O) notificado hasta el momento e involucró a una nueva provincia argentina.

Since 1995 more than 1000 cases of hantavirus pulmonary syndrome (HPS) were reported in Argentina, a severe disease and often fatal to humans. Most cases were associated with Andes virus (AND) that caused few events of person-to-person transmission. Several lineages of pathogenic AND viruses have been described, including AND South, hosted by the rodent Oligoryzomys longicaudatus which affects the Patagonian region of Argentina and Chile. We studied the clinical and epidemiological characteristics of a HPS case. The objective was to describe the clinical presentation of the case, its epidemiology, the likely site of infection, the viral variant implicated and its relationship with the closest reported cases. We carried out the clinical follow up, serological and molecular diagnosis and the epidemiological research, including a rodent reservoir study. The clinical presentation of the case was the classical and moderate, caused by AND South virus. Its viral nucleotide sequence was compared with cases from Southern Argentina and Chile. This case was found to be the most Southern (48° 46´ 1.2´´ S; 70° 15´ O) case reported and involved a new Argentinean province.

Knowledge and practices about hantavirus pulmonary syndrome in a cluster of Japanese communities in Argentina / Conocimientos y prácticas relacionados con el síndrome pulmonar por hantavirus en un conglomerado de comunidades japonesas en Argentina

Objectives. To provide information on hantavirus pulmonary syndrome (HPS) knowledge and practices among a cluster of the rural Japanese communities near La Plata in central Argentina, an area with confirmed HPS cases. Particular emphasis was placed on testing the hypothesis that there would be differences between household use of HPS prevention measures based on the head-of-household’s knowledge of HPS. Methods. A questionnaire was designed in three sections: (1) household demographic characteristics, (2) HPS knowledge, and (3) HPS preventive measures. Questionnaires were givento the household head or other adult representing the household at an HPS prevention seminar sponsored by the Japanese Association of La Plata in February 2007. Total HPS knowledgescores were dichotomized into high (equal to or more than the median knowledge score) and low (less than the median). Differences between the two household groups were categorized,according to the degree of HPS knowledge, and analyzed. Results. The 86 households that responded accounted for about 72% of the total study households in the area. The median knowledge score of 5 (range: 0–9, of 10) divided the study households into two groups: high knowledge score group (n = 40) and low knowledge scoregroup (n = 46). The findings suggest an association between a household’s accurate HPS knowledge and its respective use of HPS preventive measures. Conclusions. The findings of the study have important implications for taking further steps toward improved HPS management and prevention strategies.

Objetivos. Documentar los conocimientos y las prácticas relacionadas con el síndrome pulmonar por hantavirus (SPH) en un conglomerado de comunidades rurales japonesas cerca de La Plata, en la parte central de Argentina, una zona con casos confirmados de SPH. Se hizo hincapié especial en probar la hipótesis de que habría diferencias en el empleo de medidas preventivas contra el SPH en los hogares según el nivel de conocimientos del jefe de familia sobre este síndrome. Métodos. Se diseñó un cuestionario con tres secciones: a) características demográficas del núcleo familiar, b) conocimientos sobre el SPH y c) medidas preventivas contra elSPH. Los cuestionarios se aplicaron a los jefes de familia o a algún adulto que representara al núcleo familiar durante un seminario sobre prevención del SPH patrocinado por la Asociación Japonesa de La Plata en febrero de 2007. El conocimiento sobre el SPH se clasificó según su puntuación total en alto (igual o mayor que la mediana de las puntuaciones) y bajo (menor que la mediana). Se analizaron las diferencias entre los dos grupos según el grado de conocimientos sobre el SPH. Resultados. Respondieron representantes de 86 hogares, aproximadamente 72% deltotal de la zona. La mediana de la puntuación fue de 5 (entre 0 y 9 en una escala de 10) y permitió clasificar los hogares en dos grupos: 40 tenían un nivel de conocimientos alto y 46, bajo. Los resultados indicaron una asociación entre los conocimientos correctos sobreel SPH en un hogar y el empleo de medidas preventivas contra el SPH en ese hogar. Conclusiones. Estos resultados tienen implicaciones importantes para emprender accionesdirigidas a mejorar el control y la prevención del SPH.

Los hantavirus causantes de la fiebre hemorrágica con síndrome renal y del síndrome pulmonar / The hantaviruses causing hemorrhagic fever with renal syndrome and pulmonary syndrome

Este trabajo de revisión se enfoca en el análisis de la información básica sobre los hantavirus, agentes causales de dos enfermedades importantes en salud pública: la fiebre hemorrágica con síndrome renal (FHSR) y el síndrome pulmonar por hantavirus (SPH), dos zoonosis distribuidas en Asia/Europa y el continente americano, respectivamente. Los hantavirus se transmiten al hombre a través de la manipulación y contacto directos de roedores infectados o tejidos y secreciones (orina, heces y saliva). La FHSR y el SPH comparten algunas características clínicas, aunque las hemorragias y la afectación renal son propias de la FHSR,y los problemas respiratorios del SPH. Se aportan algunos datos sobre estudios realizados en México sobre hantavirus y se mencionan las condiciones ecológicas vinculadas con la distribución de los virus y sus reservorios naturales, así como algunas medidas para evitar o reducir el riesgo de infección.

The goal of this review is to provide basic information on hantaviruses as causative agents of Hemorrhagic Fever with Renal Syndrome (HFRS) and Hantavirus Pulmonary Syndrome (HPS), two zoonotic diseases widely distributed in Asia/Europe, and the American continent, respectively. Hantaviruses are rodent-borne and transmitted to humans by direct contact with infected rodents or their secretions (urine, feces and saliva). Both, HFRS and HPS share some clinical aspects, however, hemorrhage and renal failure are the hallmark of HFRS, while respiratory problems are distinctive signs and symptoms of patients with HPS. Studies on hantavirus infection in rodents from Mexico are included, some recomendations to prevent or avoid contact with rodents are mentioned, and some determinant ecologic factors of hantaviruses distribution and their natural rodents, are also included.

Aspectos climáticos em áreas de transmissão de hantavirose no Estado de São Paulo, Brasil / Climatic aspects in hantavirus transmission areas in São Paulo State, Brazil

O objetivo deste trabalho foi investigar a distribuição espacial dos casos notificados de hantavirose (n = 80) no Estado de São Paulo, Brasil, de 1993 a 2005, e identificar os padrões climáticos locais nos anos de registro da doença. Foi utilizado o estimador de densidade de pontos de kernel que apontou maior concentração nas regiões de Ribeirão Preto, São Carlos, Franca, Tupi Paulista e Grande São Paulo. O aumento do número de casos no período sugere disseminação da doença, embora se considere o aumento da capacidade diagnóstica e maior sensibilidade do sistema de saúde. Registrou-se marcada sazonalidade da hantavirose nas áreas de cerrado, com padrão comum, isto é, maior incidência em meses com baixa pluviosidade, comparados com médias dos últimos quarenta anos. Esses períodos coincidem com épocas de maior disponibilidade de alimentos a roedores em cultura de grãos, cana e outros. A colheita e armazenamento desses grãos aumentam a exposição de populações humanas aos roedores. Indicadores climáticos em conjunto com variáveis ecológicas podem compor marcadores de risco de transmissão local a serem valorizados nas ações de vigilância epidemiológica e controle da doença.

The objective of this study was to investigate the spatial distribution of reported hantavirus cases in São Paulo State, Brazil (n = 80), from 1993 to 2005 and identify local climatic patterns during this period. Kernel point estimation of density was used to show the highest concentrations in Ribeirão Preto, São Carlos, Franca, Tupi Paulista, and Greater São Paulo. Increase in the number of cases during this period suggests disease dissemination even when considering increased diagnostic capacity and higher sensitivity of the health services. There was a marked seasonal variation in hantavirus in the cerrado (savannah) areas; the common pattern is a higher incidence in drier months as compared to mean levels in the last 40 years. These coincide with periods of high rodent food source levels in grains, sugarcane, and other crops. Harvesting and storing grains increases human exposure to rodents. Climatic indicators together with ecological variables can be local transmission risk markers and should receive more attention in epidemiological monitoring and control of the disease.

Síndrome pulmonar por hantavírus com disfunção de múltiplos órgãos: relato de caso / Hantavirus pulmonary syndrome with multiple organ dysfunctions: case report

JUSTIFICATIVA E OBJETIVOS: A hantavirose é uma zoonose que apresenta distribuição mundial e sua transmissão está relacionada com o íntimo contato com roedores. Causa dois tipos de doença: a febre hemorrágica com síndrome renal (FHSR), endêmica na Ásia e Europa e a síndrome pulmonar por hantavírus (SPH), encontrada no continente americano, inclusive no Brasil, com elevadas taxas de mortalidade. O objetivo deste estudo foi relatar um caso de SPH com disfunção de múltiplos órgãos, que recebeu tratamento intensivo precoce e reanimação guiada por parâmetros de fluxo e de perfusão tecidual. RELATO DO CASO: Paciente do sexo masculino, 36 anos, iniciou quadro febril inespecífico, dispnéia progressiva, hipóxia grave e insuficiência respiratória aguda. Apresentava infiltrado interstício-alveolar difuso na radiografia de tórax. Evoluiu com disfunção de múltiplos órgãos (pulmonar, renal, hematológica, cardiovascular e metabólica). Recebeu tratamento e monitorização hemodinâmica invasiva precoces. As alterações laboratoriais mais importantes foram plaquetopenia, elevação dos níveis de hematócrito e hemoglobina, leucocitose, elevação de transaminases, de lactado desidrogenase e sorologia positiva para hantavírus (ELISA IgM positivo). O paciente apresentou reversão das disfunções orgânicas, recebendo alta hospitalar após 21 dias de hospitalização. CONCLUSÕES: A reanimação precoce e agressiva dirigida por metas levou à reversão da síndrome de falência de múltiplos órgãos e a um desfecho clínico favorável, apesar da gravidade da doença.

BACKGROUND AND OBJECTIVES: Hantavirus infection is a zoonose with worldwide distribution. The transmission is related to the intimal contact with rodents. It causes two syndromes: hemorrhagic fever with renal syndrome (HFRS), endemic in Asia and Europe and the Hantavirus pulmonary syndrome (HPS), found in the American continent, including Brazil, with high mortality rates. The aim of this study is to report a case of HPS with multiple organ failure, managed with early goal-directed therapy guided by flow and tissue perfusion parameters. CASE REPORT: A 36 year-old male had fever with progressive dispnea, severe hypoxia and acute respiratory failure. Diffuse interstitial alveolar infiltrates were seen in the chest X-Ray. He developed multiple organ dysfunction syndromes (pulmonary, renal, coagulation, cardiovascular and metabolic). Treatment and invasive hemodynamic monitoring with pulmonary artery catheter was early instituted. The most important laboratory findings were thrombocytopenia, elevated hematocrit and hemoglobin concentrations, elevated liver enzymes, elevated lactate dehydrogenase and a positive sorology for Hantavirus (ELISA IgM positive). Organ dysfunctions reverted to normal and he was discharged after 21 days in hospital. CONCLUSIONS: An early and adequate resuscitation with goal-directed therapy enabled the reversion of the multiple organ failure syndromes and a favorable outcome, despite the severity of the disease.

Bilateral acute acquired toxoplasmic retinochoroiditis after steroid therapy for hantavirus pulmonary syndrome: case report

Description of a case of acute acquired ocular toxoplasmosis following hantavirus pulmonary syndrome. A 41-year-old man presenting hantavirus pulmonary syndrome, confirmed in the laboratory by detection of IgM antibodies to the virus, was submitted to high doses of intravenous corticosteroids for two months. After clinical improvement of hantavirus pulmonary syndrome the patient presented visual loss in both eyes that was secondary to a toxoplasmosis retinitis. The retinitis resolved with anti-toxoplasma therapy. Acquired toxoplasmic retinochoroiditis can occur following steroid therapy for hantavirus pulmonary syndrome.

Descrição de um caso de toxoplasmose ocular adquirida pós-síndrome pulmonar por hantavírus. Paciente com 41 anos do sexo masculino apresentando síndrome pulmonar por hantavírus, confirmado no laboratório pela detecção de anticorpos IGM para o vírus, foi submetido a altas doses de corticosteróides intravenosos durante dois meses. Após melhora clínica da síndrome pulmonar por hantavírus, apresentou perda visual em ambos os olhos secundária a retinite por toxoplasmose confirmada com sorologia (IGG e IGM positivo) A retinite resolveu após terapia sistêmica específica. A retinite por toxoplasmose pode ocorrer após terapia sistêmica com esteróide para síndrome pulmonar por hantavírus.

Contribuiçäo ao conhecimento sobre a Hantavirose no Brasil / A contribution to the knowledge of hantaviruses in Brazil

Foram revistos diferentes aspectos da síndrome pulmonar e cardiovascular por hantavírus, uma doença emergente transmitida pela inalação das excretas de roedores silvestres e que ocorre principalmente em indivíduos que têm contato com o meio rural e com estes animais. Trata-se de doença grave, com letalidade acima de 50%, que leva à insuficiência respiratória e ao choque. A terapia de suporte ventilatório e cardiovascular deve ser precocemente instituída, preferencialmente em unidades de terapia intensiva. A presença de edema pulmonar exige cuidados de ventilação precoces. Apesar dos pacientes apresentarem-se em choque, deve-se ter cuidados com a infusão de líquidos para que não se agrave o edema pulmonar. É necessário informar os profissionais de saúde sobre a doença, considerando que muitos casos devem passar despercebidos. O diagnóstico laboratorial de hantavirose acessível e rápido precisa ser implementado e para tanto, precisa-se de pesquisas desenvolvendo métodos diagnósticos sensíveis e confiáveis. O controle da doença exige envolvimento de múltiplos profissionais visando conhecer sua história natural, a biologia do reservatório e a do vírus.

Hantavirus pulmonary and cardiovascular syndrome, an emerging disease transmitted by the inhalation of wild rodent excreta and affecting mostly agriculture workers and other professionals in contact with these animals, is reviewed. Hantavirus pulmonary syndrome is a severe disease with case fatality ratio greater than 50%. The syndrome is characterized by respiratory distress and shock. Disease management includes early mechanical ventilation and volume administration, preferable in intensive care units. Caution is advised during liquid infusion for shock treatment since pulmonary edema develops frequently. Information about hantavirus pulmonary and cardiovascular syndrome should be widely disseminated among the Brazilian medical community considering that, many cases can be undiagnosed. Rapid and accessible laboratory diagnosis of hantaviruses must be implemented in Brazil and research focused on the development of sensible and reliable diagnostic methods and reagents is encouraged. The control of hantaviruses depends on a multi-professional approach aiming to know the natural history, the biology of the reservoir and of the virus.