Correspondence

Fatal Hantavirus Pulmonary Syndrome in Indiana

N Engl J Med 1994; 330:1010April 7, 1994

Article

To the Editor:

On January 8, 1994, a 48-year-old diabetic male teacher from a small town in rural Indiana presented to the hospital with a three-day history of myalgia, weakness, fever, chills, a nonproductive cough, and progressive shortness of breath. He had not traveled to the southwestern United States and had no known exposure to rodent excreta1-3. He had a temperature of 39 °C (102 °F), tachycardia, tachypnea, diaphoresis, and a moderate amount of respiratory distress. Moist rales and decreased breath sounds were noted in all lung fields, but he had no petechiae, ecchymoses, or other signs of coagulopathy.

The white-cell count was 40,500 per cubic millimeter, with 56 percent segmented neutrophils, 31 percent band forms, 5 percent lymphocytes, 7 percent monocytes, and 1 percent atypical lymphocytes. A chest radiograph revealed bilateral interstitial infiltrates. The patient's respiratory distress progressed, and he required intubation and mechanical ventilation 14 hours after admission. Despite aggressive supportive measures, including vasopressor therapy and continued mechanical ventilation, acute renal failure and disseminated intravascular coagulopathy developed, and the patient died 27 hours after admission.

An autopsy revealed large (2.5 liter) pleural effusions and edematous lungs (weight, 1000 g each). Histologic analysis of the lungs revealed early diffuse alveolar damage classified as the exudative stage. Smudging nuclei in the alveolar pneumonocytes were also noted. The spleen had florid follicular hyperplasia of the white pulp with accompanying immunoblastic proliferation.

Because of the clinical course and autopsy findings, the patient's serum and lung tissue were sent to the Centers for Disease Control and Prevention. The diagnosis of hantavirus was confirmed by an enzyme-linked immunosorbent assay (ELISA) of the patient's serum and immunoperoxidase staining for hantavirus antigen on lung tissue.

After the diagnosis of hantavirus pulmonary syndrome was confirmed, 26 rodents from the area where the patient lived were captured and killed. Four of the rodents were positive for hantavirus; three were deer mice and one a meadow vole. No family members or close contacts of the patient had serologic evidence of hantavirus infection on ELISA.

This case documents that the hantavirus pulmonary syndrome is not limited to the western United States, and it may be diagnosed more frequently as physician and patient awareness increases4,5.

Thomas G. Slama, M.D.
Indiana University School of Medicine, Indianapolis, IN 46280

Robin Zon, M.D.
St. Vincent Hospital, Indianapolis, IN 46260

5 References

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   Outbreak of acute illness -- southwestern United States, 1993. MMWR Morb Mortal Wkly Rep 1993;42:421-424
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   Update: hantavirus infection -- United States, 1993. MMWR Morb Mortal Wkly Rep 1993;42:517-519
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   Hughes JM, Peters CJ, Cohen ML, Mahy BWJ. Hantavirus pulmonary syndrome: an emerging infectious disease. Science 1993;262:850-851
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   Update: hantavirus infection -- United States, 1993. JAMA 1993;270:429, 432-429, 432
   

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   Hantavirus infection -- southwestern United States: interim recommendations for risk reduction. MMWR Morb Mortal Wkly Rep 1993;42:1-13
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Citing Articles (3)

Citing Articles

1. 1

   N. Iniesta Arandia, J.J. Ríos Blanco, M.C. Fernández Capitán, F.J. Barbado Hernández. (2009) Cambio climático: ¿nuevas enfermedades para un nuevo clima?. Revista Clínica Española 209:5, 234-240
   CrossRef

2. 2

   (1994) Hantavirus Pulmonary Syndrome in New England and Europe. New England Journal of Medicine 331:8, 545-548
   Full Text

3. 3

   Wenzel, Richard P., . (1994) A New Hantavirus Infection in North America. New England Journal of Medicine 330:14, 1004-1005
   Full Text