Correspondence
Hantavirus-Associated Acute Respiratory Failure
N Engl J Med 1993; 329:1744December 2, 1993
- Article
To the Editor:
In May 1993, a new hantavirus-associated acute respiratory illness was recognized in the southwestern United States. Laboratory evidence of the infection has been confirmed in 30 patients, of whom 20 have died. All three Colorado patients died. A confirmed case is characterized by the abrupt onset of fever, myalgias, and headache, rapidly followed by unexplained adult respiratory distress syndrome or bilateral pulmonary interstitial infiltrates with respiratory failure and laboratory evidence of recent hantavirus infection1-3. We describe a confirmed case of hantavirus infection treated successfully with intravenous ribavirin.
A previously healthy 36-year-old woman was admitted to a rural Colorado hospital with abrupt onset of fever (temperature, 102 °F), weakness, and back pain. The physical examination was unremarkable. A urinalysis performed on admission led to the working diagnosis of pyelonephritis. The white-cell count was 4100 per cubic millimeter, with 64 percent segmented forms and 11 percent band forms. The chest radiograph was normal. The patient was initially treated with intravenous cefazolin. On day 3, she remained febrile, with vomiting, hypotension, hypoxemia, and new bilateral, diffuse infiltrates on the chest radiograph. The white-cell count was 10,000 per cubic millimeter, with 15 percent segmented forms, 43 percent band forms, and 23 percent lymphocytes. The hematocrit was 45 percent, and the platelet count was 67,000 per cubic millimeter. Antibiotic coverage was broadened to include high-dose erythromycin and cefotaxime. The patient's level of oxygenation decreased, and she required mechanical ventilation and dopamine for pressor support. Sedation and paralysis were initiated, since she required a fraction of inspired oxygen of 1.0 and a positive end-expiratory pressure of 7.5 cm of water. A pulmonary-artery catheter was placed and revealed a pulmonary-capillary wedge pressure of 14 mm Hg, a cardiac index of 3.4 liters per minute per square meter of body-surface area, and a systemic vascular resistance of 1111 dyn • sec • cm-5. The white-cell count was 30,000 per cubic millimeter, with 66 percent band forms. Doxycycline was added to the antibiotic regimen. On day 4, the patient received a 2-g loading dose of intravenous ribavirin, followed by a dose of 15 mg per kilogram of body weight every six hours for four days and then by a dose of 7.5 mg per kilogram every eight hours for four days (Centers for Disease Control and Prevention protocol4). Thoracentesis was performed on large bilateral pleural effusions, which were found to be exudative and culture negative. On day 5, the fraction of inspired oxygen was decreased to 0.55. Total parenteral nutrition was started for nutritional support. On day 8, the patient was extubated. Ribavirin therapy was completed on day 14, and the patient was sent home the next day with no need of ventilatory support. All cultures from the patient remained negative. An enzyme-linked immunosorbent assay of the patient's serum performed by the Centers for Disease Control and Prevention was positive for hantavirus.
This patient is the first known Colorado survivor of a confirmed respiratory infection due to hantavirus that was treated with intravenous ribavirin.
4 ReferencesKaryn Prochoda, M.D.
Steven R. Mostow, M.D.
Kenneth Greenberg, D.O., Pharm.D.
University of Colorado Health Sciences Center, Denver, CO 802201
Outbreak of acute illness -- southwestern United States, 1993
Medline2
Update: hantavirus disease -- United States, 1993
Medline3
From the Centers for Disease Control and Prevention: update: hantavirus infection -- United States, 1993 4
Huggins JW ,Hsiang CM ,Cosgriff TM , et al. Prospective, double-blind, concurrent, placebo-controlled clinical trial of intravenous ribavirin therapy of hemorrhagic fever with renal syndrome. J Infect Dis 1991;164:1119-1127
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