Hemorrhagic fever with renal syndrome Acute febrile illness

Hemorrhagic fever with renal syndrome (부제) Acute febrile illness of Autumn. Winter type

Etiology and Epidemiology • Widely distributed over Europe and Asia – Puumala virus, Hantaan virus – Dobrava virus (Balkan), Seoul virus • Most in rural residents or vacationers – Excep. Seoul virus : urban, laboratory rat • > 100, 000 cases of severe disease in Asia in annually Harrison’s 18 th

Etiology and Epidemiology • Most common in spiring and fall – Related to rodent density and agricultural practices • Through aerosolized particle inhalation or contact infected rodent urine, secretions or feces 질병관리본부 • Not infectious in human to human Harrison’s 18 th

Pathogenesis of renal disease • Increased vascular permeability – Hct↑, Serum protein↓ • Abrupt decline in GFR often observed – Contributing factor • Damage to vascular endothelium • Acute tubulointerstitial nephritis • Some genetic factor Uptodate

Clinical manifestations • Fever, hemorrhage, hypotension, renal failure • Incubation period – Typically 2 weeks, vary from 5 to 42 days • Evolve in identifiable stages – – Febrile stage with myalgia, lasting 3 or 4 days Hypotensive stage, shock, few hrs to 48 h Oliguric stage with renal failure, 3 – 10 days Polyuric stage with diuresis and hyposthenuria Harrison’s 18 th Mandell’s 7 th Infectious disease

Febrile(Toxic) stage : 3 -4 d • Abrupt onset of fever, headache, severe myalgia, often nausea and vomiting, retroorbital pain • Flushing over the face, the V area of the neck and the back • Petechiae and conjunctival injection • Relative bradycardia • Back pain and CVA Td Harrison’s 18 th Mandell’s 7 th Infectious disease 신증후군 출혈열, 감염학

Hypotensive stage : 4 -6 d • Often associated with shock • Hematocrit↑ : > 50% • Leukocytosis : > 20, 000/mm 3 • Thrombocytopenia : < 50, 000/mm 3 • Proteinuria is marked Harrison’s 18 th Mandell’s 7 th Infectious disease 신증후군 출혈열, 감염학

Oliguric stage : 4 -9 d • 2, 3차 병원 내원 당시 가장 흔한 임상 병기 (60%) • Persist 3 – 10 days • 45 ~ 60%에서 400 cc 미만의 핍뇨, AKI • 4 ~ 15%에서 무뇨 • CNS symptoms, Hypertension Harrison’s 18 th Mandell’s 7 th Infectious disease 신증후군 출혈열, 감염학

Polyuric stage • Return of renal function • Danger of dehydration and electrolyte abnormalities • Most patients generally return to baseline GFR in 3 weeks to 3 months Harrison’s 18 th Mandell’s 7 th Infectious disease 신증후군 출혈열, 감염학

Renal manifestations • Proteinuria : almost all – 25%에서는 nephrotic range • Microscopic hematuria – Hantaan & Dobrava virus : 85 ~ 100% – Puumala virus : 58 ~ 85% • GFR 감소 (Dialysis) – Hantaan, Seoul, Dobrava virus : 20 ~ 40% – Puumala virus : 5% Harrison’s 18 th Mandell’s 7 th Infectious disease 신증후군 출혈열, 감염학

Diagnosis • Suspected in patients with rural exposure in an endemic area • High fever, headache, abdominal pain and back pain; No respiratory symptoms • Leukocytosis, elevated CRP, thrombocytopenia, elevated serum Cr, proteinuria and hematuria • Serologic test : Ig. M & Ig. G antiviral Ab • DDx : Leptospirosis, drug induced acute interstitial nephritis, non-infectious pulmonary hemorrhagic dz. Harrison’s 18 th Mandell’s 7 th Infectious disease 신증후군 출혈열, 감염학

Treatment • No specific antiviral therapies • Use of IV ribavirin has reduced mortality and morbidity rates, but within the first 4 days of illness Huggins JW et al. J Infect Dis 1991; 164: 1119 • Supportive care – Pain control with analgesics, Platelet transfusion, Dialysis • Case-fatality ratio may be as high as 15% but with proper therapy should be <5% Harrison’s 18 th Mandell’s 7 th Infectious disease 신증후군 출혈열, 감염학