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Puumala virus infection with multiorgan involvement

2003; Springer Science+Business Media; Volume: 29; Issue: 3 Linguagem: Inglês

10.1007/s00134-002-1626-6

1432-1238

Josef Finsterer, Andreas Valentin, Claudia Stöllberger, Martin Jankovic, Christian Prainer,

COVID-19 epidemiological studies

On the evening of day 2 the patient's pulmonary condition deteriorated.Chest radiography revealed progressive, bilateral and spotted infiltrates.On day 4 the patient became respiratory insufficient, requiring mechanical ventilation.Chest radiography revealed a "white lung," being interpreted as acute respiratory distress syndrome.Spiral computed tomography on day 5 suggested atypical pneumonia or alveolitis with pleural effusions.The antibiotic regimen was changed to trimetoprim/sulfamethoxazol, clarythromycin, and ceftriaxone.Pneumonia resolved within 8 days.The further disease course was complicated by a sepsis with a methicillin-resistant Staphylococcus aureus.Under proper therapy the patient recovered from the methicillin-resistant Staphylococcus aureus infection and was extubated on day 26.From day 6 acute renal failure developed.Ultrasonography of the abdomen revealed splenomegaly, absent renal parenchyma/cortex delineation, and thickened renal parenchyma, suggesting nephrosis or nephritis.Kidney biopsy on day 10 disclosed tubular necrosis and cabbagelike degeneration of the interstitial cells.Renal failure and hepatopathy did not resolve before day 38.The described abnormalities were caused by an infection with the Puumula virus, being serologically detected upon IgG and IgM antibodies on immune-fluorescence test on days 15 and 17.Six weeks after admission the patient was dismissed symptom-free.At follow-up 4 months after dismissal he complained of impaired concentration exclusively.Organs other than the lungs affected by a puumala virus infection are the kidneys [1] liver [2], spleen [1], eyes [3], and hematopoietic system [4].Neurological manifestations of a puumala virus infection are rare and comprise dizziness [1], hypopituitarism [2], encephalitis [5], and acute disseminated encephalomyelitis [6].Usually the virus is transmitted by inhalation of infected aerosolized rodent urine or dried excreta from rodent hosts [1], as presumably in the presented case [1].A tick-borne transmission was excluded.The latency of 12 days between transmission and occurrence of the first symptoms is in accordance with the incubation time of 1-4 weeks.The histological lesions on kidney biopsy were attributed to the viral infection rather than the therapy with trimetoprim/sulfamethoxazol; in accordance with previous reports and because trimetoprim/sulfamethoxazol was given only briefly.Thrombocytopenia on admission was attributed to the viral infection.The second thrombocyte decline was most likely due to the methicillin-resistant Staphylococcus aureus sepsis.Differential diagnoses excluded were other pulmorenal syndromes (Wegener's granulomatosis and Goodpasture syndrome), acute respiratory distress syndrome, drug-induced noncardiac pulmonary edema, atypical communityacquired pneumonia, and other bacterial and viral infections.In conclusion, infection with the puumala virus be accompanied by lymphocytic meningoencephalitis, pulmonary failure, renal failure, hepatopathy, splenomegaly, leukocytosis, and thrombocytopenia.Symptomatic therapy may lead to a favorable outcome