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Sudden high fever, headache and oliguria 3 weeks after detective dog bite

 Last Update: 2022-01-21
 Source: Internet
 Author: User

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、

，，49，

：4

：

2021-12-13 （D0），37.
2021-12-14 （D1），Tmax39.
2021-12-16 （D3），Hb188g/L，WBC 17.
2021-12-17 （D4），
2021-11-20 ，12-044

2021-12-13 （D0），37.

2021-12-14 （D1），Tmax39.

2021-12-16 （D3），Hb188g/L，WBC 17.

WBC 17.

2021-12-17 （D4），

2021-11-20 ，12-044

2021-11-20 ，12-044
。2021-12-11
。，，、
。

：2，180/110mmHg，15mg qd，
。、、
。

、(2021-12-17)

【】

T：36℃　P：81/ R：20/ BP：148/99mmHg
，，，，，，，，，，，，(－)
。

T：36℃　P：81/ R：20/ BP：148/99mmHg

，，，，，，，，，，，，(－)
。

【】

：WBC 25.
65×10^9/L↑，N 70.
0%，HB 159g/L，PLT 49X10^9/L↓;，，，
。
：hsCRP 20.
9mg/L↑，ESR 10mm/H，PCT 6.
34ng/ml↑
。
： 1.
017，++，RBC 4-6/HP，WBC
。
：TB/CB 6.
8/2.
3μmol/L，ALT/AST 38/67↑U/L；Alb 30g/L↓；LDH 492 U/L↑
。
：BUN 15.
3mmol/L↑，sCr 269μmol/L↑，UREA 433μmol/L↑
。
：Na+ 129mmol/L↓，K + 3.
7mmol/L，Cl - 99mmol/L
。
：PT 12.
7s，INR 1.
08, TT 22.
1s，APTT 36.
9s↑，FIB265mg/dL，D：5.
49mg/L↑
。
T-SPOT A/B 0/0（/:0/630）
。
：
。
：CEA、AFP、CA72-4、CA19-9、NSE 、SCC、Cyfra211
。

Blood routine: WBC 25.
65×10^9/L↑ , N 70.
0%, HB 159g/L, PLT 49X10^9/L↓; most of the lymphocytes are irregular in shape, distorted, and the shape is similar to heterolymphocytes.
easy to see
.

WBC 25.
65×10^9/L↑ PLT 49X10^9/L↓; Most of the lymphocytes are irregular in shape, distorted, and the shape is similar to the lymphocytes, and the smeared cells are easier to see

Inflammatory markers: hsCRP 20.
9mg/L↑ , ESR 10mm/H, PCT 6.
34ng/ml↑
.

hsCRP 20.
9mg/L↑PCT 6.
34ng/ml↑

Urine routine: specific gravity 1.
017, protein ++ , RBC 4-6/HP , WBC negative
.

Protein++ RBC 4-6/HP

Liver function: TB/CB 6.
8/2.
3μmol/L, ALT/AST 38/ 67↑ U/L; Alb 30g/L↓ ; LDH 492 U/L↑
.

67↑Alb 30g/L↓LDH 492 U/L↑

Renal function: BUN 15.
3mmol/L↑, sCr 269μmol/L↑ , UREA 433μmol/L↑
.

sCr 269μmol/L↑

Electrolyte: Na+ 129mmol/L↓, K+ 3.
7mmol/L, Cl - 99mmol/L
.

Na + 129mmol / L ，， K + 3.
7mmol / L ， Cl - 99mmol / L

Coagulation function: PT 12.
7s, INR 1.
08, TT 22.
1s, APTT 36.
9s↑ , FIB265mg/dL, D dimer: 5.
49mg/L↑
.

APTT 36.
9s↑ D dimer: 5.
49mg/L↑

T-SPOT A/B 0/0 (negative/positive control: 0/630)
.

Thyroid function: normal
.

Tumor markers: CEA, AFP, CA72-4, CA19-9, NSE, SCC, Cyfra211 were all negative
.

【Auxiliary inspection】

ECG: A normal ECG
.
Echocardiography: no abnormality
Chest CT: bilateral pleural effusion with partial atelectasis of the lower lungs
.
Plain CT scan of abdomen and pelvis: multiple exudation and effusion in the abdomen and pelvis ; calcification in the right lobe of the liver; cholestasis in the gallbladder; poor density of both kidneys and cystic lesions in the left kidney
.

ECG: A normal ECG
.

Echocardiography: no abnormality

Chest CT: bilateral pleural effusion with partial atelectasis of the lower lungs
.

Bilateral pleural effusion with partial atelectasis of both lower lungs

Plain CT scan of abdomen and pelvis: multiple exudation and effusion in the abdomen and pelvis ; calcification in the right lobe of the liver; cholestasis in the gallbladder; poor density of both kidneys and cystic lesions in the left kidney
.

Multiple exudation and effusion in the abdominal and pelvic cavity

3.
Clinical analysis

History characteristics : middle-aged male, acute course of disease, mainly manifested as fever, fatigue, abdominal distension, laboratory examinations increased WBC, PCT, decreased PLT, renal insufficiency, increased LDH, CT showed abdominal pelvic exudation, polyserosal Cavity effusion
.
A variety of antibacterial drugs are ineffective, and the diagnosis and differential diagnosis of the cause of fever are as follows:

Features of the medical history

1.
Infectious diseases:

Spontaneous peritonitis : Fever, abdominal distension, significantly elevated blood WBC and PCT, abdominal CT showed diffuse exudative inflammation in the abdominal and pelvic cavity, and abdominal infection such as spontaneous peritonitis should be considered
.
However, the patient had no definite history of underlying diseases, no definite abdominal pain during the course of the disease, no abdominal tenderness/rebound tenderness on physical examination, only mild elevation of CRP, and less possibility of peritonitis
.
Hemorrhagic fever with renal syndrome : acute onset, headache in the course of the disease, laboratory tests revealing thrombocytopenia, proteinuria, renal damage, and creatinine seems to have a tendency to increase in a short period of time.
Hemorrhagic fever with renal syndrome due to tadvirus infection
.
However, the patient had no clear history of living in the epidemic area or contact with rodents before the onset of the disease, which was not a support point
.
Diagnosis depends on hantavirus antibody and nucleic acid detection
.
Other infectious diseases : other diseases that can cause fever with thrombocytopenia in China, such as rickettsial infection, jungle typhus, bunya virus infection, leptospirosis, dengue fever, etc.
, need to be considered.
Diagnosis mainly depends on PCR or serological methods are clear
.
Dog bite-related infections : such as Pasteurella, Capnophilus, anaerobic infections, as well as tetanus, rabies, etc.
, due to the patient's dog bite and the onset of disease for more than 3 weeks, rabies vaccine was promptly vaccinated, and there was no related disease.
Symptoms, local wound healing is good, and the above canine injury-related infections are temporarily ignored
.

Spontaneous peritonitis : Fever, abdominal distension, significantly elevated blood WBC and PCT, abdominal CT showed diffuse exudative inflammation in the abdominal and pelvic cavity, and abdominal infection such as spontaneous peritonitis should be considered
.
However, the patient had no definite history of underlying diseases, no definite abdominal pain during the course of the disease, no abdominal tenderness/rebound tenderness on physical examination, only mild elevation of CRP, and less possibility of peritonitis
.

spontaneous peritonitis

Hemorrhagic fever with renal syndrome : acute onset, headache in the course of the disease, laboratory tests revealing thrombocytopenia, proteinuria, renal damage, and creatinine seems to have a tendency to increase in a short period of time.
Hemorrhagic fever with renal syndrome due to tadvirus infection
.
However, the patient had no clear history of living in the epidemic area or contact with rodents before the onset of the disease, which was not a support point
.
Diagnosis depends on hantavirus antibody and nucleic acid detection
.

hemorrhagic fever with renal syndrome

Other infectious diseases : other diseases that can cause fever with thrombocytopenia in China, such as rickettsial infection, jungle typhus, bunya virus infection, leptospirosis, dengue fever, etc.
, need to be considered.
Diagnosis mainly depends on PCR or serological methods are clear
.

other infectious diseases

Dog bite-related infections : such as Pasteurella, Capnophilus, anaerobic infections, as well as tetanus, rabies, etc.
, due to the patient's dog bite and the onset of disease for more than 3 weeks, rabies vaccine was promptly vaccinated, and there was no related disease.
Symptoms, local wound healing is good, and the above canine injury-related infections are temporarily ignored
.

Infections associated with dog bites

2.
Non-infectious diseases:

Glomerulonephritis : Middle-aged onset, with fever, multiple serous effusions, kidney damage, proteinuria, diseases such as ANCA-related vasculitis , anti-GBM antibody glomerulonephritis, and lupus nephritis should be considered.
Pay attention to the results of serum ANCA, anti-GMB, dsDNA and other antibodies, recheck the titer if necessary, and improve the renal biopsy to assist the diagnosis
.
Lymphoma : Peripheral blood smear shows irregular lymphocyte morphology, visible distortion, smeared cells are more likely to be seen, blood lactate dehydrogenase is elevated, CT imaging shows abdominal and pelvic exudation, and peritoneal thickening seems to be present, lymphoma should be considered Malignant tumors of the lymphohematopoietic system
.
PET-CT, peritoneal puncture for detection of exfoliated cells, flow cytometry, bone marrow aspirate + smear, etc.
can be further improved to assist in diagnosis
.
Drug-induced renal damage : The patient reported that the renal function was normal in the previous physical examination.
After taking 4-5 acetaminophen tablets after the onset of the disease, acute interstitial nephritis caused by NSAIDS drugs cannot be ruled out, but it can only explain the renal damage and cannot be explained.
Fever, thrombocytopenia, and other abnormalities should not be considered in the first place
.

Glomerulonephritis : Middle-aged onset, with fever, multiple serous effusions, kidney damage, proteinuria, diseases such as ANCA-related vasculitis , anti-GBM antibody glomerulonephritis, and lupus nephritis should be considered.
Pay attention to the results of serum ANCA, anti-GMB, dsDNA and other antibodies, recheck the titer if necessary, and improve the renal biopsy to assist the diagnosis
.

glomerulonephritis blood vessels

Lymphoma : Peripheral blood smear shows irregular lymphocyte morphology, visible distortion, smeared cells are more likely to be seen, blood lactate dehydrogenase is elevated, CT imaging shows abdominal and pelvic exudation, and peritoneal thickening seems to be present, lymphoma should be considered Malignant tumors of the lymphohematopoietic system
.
PET-CT, peritoneal puncture for detection of exfoliated cells, flow cytometry, bone marrow aspirate + smear, etc.
can be further improved to assist in diagnosis
.

lymphoma lymphoma

Drug-induced renal damage : The patient reported that the renal function was normal in the previous physical examination.
After taking 4-5 acetaminophen tablets after the onset of the disease, acute interstitial nephritis caused by NSAIDS drugs cannot be ruled out, but it can only explain the renal damage and cannot be explained.
Fever, thrombocytopenia, and other abnormalities should not be considered in the first place
.

drug-induced renal impairment

Fourth, further examination, diagnosis and treatment process and treatment response

2021-12-17 (D4) Empirical anti-infective treatment with meropenem + doxycycline , glutathione for kidney protection, albumin supplementation, oral sodium supplementation and other treatments
.
The body temperature was flat from the day, and the patient complained of abdominal distension in the evening, without abdominal pain, and the gas stopped.
The urine output consciously decreased compared with the previous day (1000+ml on the previous day, and the urine was only dissolved once on the same day), and the urine volume was recorded for 24 hours
.
In the afternoon of 2021-12-18 (D5), the body temperature was flat, the abdominal distension was severe, there was a small amount of gas and stools, and the complaint was unresolved on the day, BP136/78mmHg
.
Emergency abdominal and pelvic CT scan: extensive exudation of the abdominal and pelvic cavity with slightly progressive fluid accumulation , no clear intestinal obstruction and perforation of the digestive tract
.
Rechecked blood: WBC 19.
27×10^9/L↑ , N 58.
0%, PLT 54X10^9/L↓ ; hsCRP 19.
9mg/L↑ ; sCr 321μmol/L↑
.
Torasemide 20mg diuretic, 24 hours urine output 400ml
on the same day .
Nephrology consultation considers AKI, and it is recommended to track the results of autoantibodies, immunofixation electrophoresis, improve kidney + renal artery and venous ultrasound, 24-hour proteinuria detection, continue antioxidative, diuretic and other treatments, and emergency dialysis if necessary
.
The results of ANA, EBA, ANCA, anti-GBM antibody, and immunofixation electrophoresis were all negative that night
.
2021-12-19 (D6) There is still abdominal distension, accompanied by chest tightness, HR90bpm, Luqi, RR20bpm, BP135/85mmHg, SpO2% 99%, 24-hour urine output after strengthening intravenous diuresis totaling 700ml (daily urine output see body temperature in the figure below) single)
.
2021-12-20 (D7) Professor Hu Bijie's ward rounds, combined with the patient's high fever, thrombocytopenia, oliguria and acute renal insufficiency, although no bleeding and other manifestations, considering the possibility of atypical renal syndrome hemorrhagic fever, urgently investigate Hantan Viral IgM, IgG, RNA detection; acute kidney injury, one time of bedside emergency hemodialysis, BP130-150/85-95mmHg
.
2021-12-21 (D8) PET/CT: multiple lymphadenitis and reactive hyperplasia of the spleen are possible; slightly thickened peritoneum with abdominal and pelvic effusion; bilateral testicular hydrocele; bilateral pleural effusion
.
2021-12-22 (D9) Renal Ultrasound: Both kidneys are plump with slightly increased cortical echoes, and acute changes may be considered
.
Right kidney biopsy was performed
.
That night, the third-party test for epidemic hemorrhagic fever virus (Hantavirus) IgG, IgM, and RNA returned positive
.
Report and send blood to Shanghai Center for Disease Control and Prevention for review as required
.
Blood microbial DNA-mNGS (12-20 for inspection) returned negative
.
After intravenous diuresis, the urine output increased to 3240ml in 24 hours and entered the polyuria period
.

2021-12-17 (D4) Empirical anti-infective treatment with meropenem + doxycycline , glutathione for kidney protection, albumin supplementation, oral sodium supplementation and other treatments
.
The body temperature was flat from the day, and the patient complained of abdominal distension in the evening, without abdominal pain, and the gas stopped.
The urine output consciously decreased compared with the previous day (1000+ml on the previous day, and the urine was only dissolved once on the same day), and the urine volume was recorded for 24 hours
.

Meropenem + Doxycycline

In the afternoon of 2021-12-18 (D5), the body temperature was flat, the abdominal distension was severe, there was a small amount of gas and stools, and the complaint was unresolved on the day, BP136/78mmHg
.
Emergency abdominal and pelvic CT scan: extensive exudation of the abdominal and pelvic cavity with slightly progressive fluid accumulation , no clear intestinal obstruction and perforation of the digestive tract
.
Rechecked blood: WBC 19.
27×10^9/L↑ , N 58.
0%, PLT 54X10^9/L↓ ; hsCRP 19.
9mg/L↑ ; sCr 321μmol/L↑
.
Torasemide 20mg diuretic, 24 hours urine output 400ml
on the same day .
Nephrology consultation considers AKI, and it is recommended to track the results of autoantibodies, immunofixation electrophoresis, improve kidney + renal artery and venous ultrasound, 24-hour proteinuria detection, continue antioxidative, diuretic and other treatments, and emergency dialysis if necessary
.
The results of ANA, EBA, ANCA, anti-GBM antibody, and immunofixation electrophoresis were all negative that night
.

Extensive exudation of abdominal and pelvic cavity with effusion progressed slightly compared to before Digestion 19.
27×10^9/L↑ PLT 54X10^9/L↓ hsCRP 19.
9mg/L↑ sCr 321μmol/L↑ 24-hour urine output 400ml immune

2021-12-19 (D6) There is still abdominal distension, accompanied by chest tightness, HR90bpm, Luqi, RR20bpm, BP135/85mmHg, SpO2% 99%, 24-hour urine output after strengthening intravenous diuresis totaling 700ml (daily urine output see body temperature in the figure below) single)
.

(See the temperature list in the figure below for daily urine output)

2021-12-20 (D7) Professor Hu Bijie's ward rounds, combined with the patient's high fever, thrombocytopenia, oliguria and acute renal insufficiency, although no bleeding and other manifestations, considering the possibility of atypical renal syndrome hemorrhagic fever, urgently investigate Hantan Viral IgM, IgG, RNA detection; acute kidney injury, one time of bedside emergency hemodialysis, BP130-150/85-95mmHg
.

2021-12-21 (D8) PET/CT: multiple lymphadenitis and reactive hyperplasia of the spleen are possible; slightly thickened peritoneum with abdominal and pelvic effusion; bilateral testicular hydrocele; bilateral pleural effusion
.

Multiple lymphadenitis and reactive hyperplasia of spleen may be possible; slightly thickened peritoneum with abdominal and pelvic effusion; bilateral testicular hydrocele; bilateral pleural effusion

2021-12-22 (D9) Renal Ultrasound: Both kidneys are plump with slightly increased cortical echoes, and acute changes may be considered
.
Right kidney biopsy was performed
.
That night, the third-party test for epidemic hemorrhagic fever virus (Hantavirus) IgG, IgM, and RNA returned positive
.
Report and send blood to Shanghai Center for Disease Control and Prevention for review as required
.
Blood microbial DNA-mNGS (12-20 for inspection) returned negative
.
After intravenous diuresis, the urine output increased to 3240ml in 24 hours and entered the polyuria period
.

Positive prevention 24-hour urine output increased to 3240ml

2021-12-23 (D10) Consider the diagnosis of hemorrhagic fever with renal syndrome
.
Supplementary medical history was inquired.
The patient denied the history of rodent exposure, animal husbandry, and camping, and denied that his relatives, friends and colleagues had the disease
.
Review WBC 11.
78×10^9/L↑ , N 60.
0%, PLT 387X10^9/L; hsCRP 8.
1mg/L↑ ; sCr 429μmol/L↑ ; Na138mmol/L; BNP 10066pg/ml↑
.
To stop antibiotics , continue to protect the kidneys, alkalization of urine, 24 hours of urine output a total of 5650ml
.
2021-12-24 (D11) Abdominal distention and chest tightness improved compared with before, and lower extremity edema slightly subsided
.
Renal puncture pathological return: acute tubular necrosis
.
Shanghai CDC report: Epidemic hemorrhagic fever virus (Hantavirus) IgM and RNA positive, IgG negative
.
12-27 (D14) The urine volume was the largest, reaching 8650ml/day.
The chest tightness, abdominal distension, and lower extremity edema were completely relieved.
The treatment with glutathione and potassium supplementation was continued, and the renal function and electrolytes were closely monitored
.
After that, the urine output gradually recovered to 4200-4900ml/day
.
2022-01-03 (D21) follow-up blood WBC 9×10^9/L, PLT 326X10^9/L; hsCRP 1.
1mg/L; PCT0.
1ng/ml; sCr 98μmol/L; BNP 72.
1pg/ml
.
In stable condition, he was discharged from hospital
.

2021-12-23 (D10) Consider the diagnosis of hemorrhagic fever with renal syndrome
.
Supplementary medical history was inquired.
The patient denied the history of rodent exposure, animal husbandry, and camping, and denied that his relatives, friends and colleagues had the disease
.
Review WBC 11.
78×10^9/L↑ , N 60.
0%, PLT 387X10^9/L; hsCRP 8.
1mg/L↑ ; sCr 429μmol/L↑ ; Na138mmol/L; BNP 10066pg/ml↑
.
To stop antibiotics , continue to protect the kidneys, alkalization of urine, 24 hours of urine output a total of 5650ml
.

WBC 11.
78×10^9/L↑ hsCRP 8.
1mg/L↑ sCr 429μmol/L↑ BNP 10066pg/ml↑ 24-hour urine output of antibiotics totaled 5650ml

2021-12-24 (D11) Abdominal distention and chest tightness improved compared with before, and lower extremity edema slightly subsided
.
Renal puncture pathological return: acute tubular necrosis
.
Shanghai CDC report: Epidemic hemorrhagic fever virus (Hantavirus) IgM and RNA positive, IgG negative
.

Epidemic hemorrhagic fever virus (Hantavirus) positive for IgM and RNA, negative for IgG

12-27 (D14) The urine volume was the largest, reaching 8650ml/day.
The chest tightness, abdominal distension, and lower extremity edema were completely relieved.
The treatment with glutathione and potassium supplementation was continued, and the renal function and electrolytes were closely monitored
.
After that, the urine output gradually recovered to 4200-4900ml/day
.

2022-01-03 (D21) follow-up blood WBC 9×10^9/L, PLT 326X10^9/L; hsCRP 1.
1mg/L; PCT0.
1ng/ml; sCr 98μmol/L; BNP 72.
1pg/ml
.
In stable condition, he was discharged from hospital
.

Follow-up after discharge:

2022-01-10 (D28) Telephone return visit: The patient's body temperature is flat, there is no discomfort such as chest tightness, and the urine output gradually returns to 2500-3000ml per day
.

2022-01-10 (D28) Telephone return visit: The patient's body temperature is flat, there is no discomfort such as chest tightness, and the urine output gradually returns to 2500-3000ml per day
.

Fifth, the final diagnosis and diagnosis basis

Final diagnosis:

Diagnose based on:

Diagnosis by: Consensus

6.
Experience and experience

Hemorrhagic fever with renal syndrome (HFRS) is caused by Hantavirus infection of the Buniaviridae family, also known as epidemic hemorrhagic fever, hemorrhagic nephritis, Korean hemorrhagic fever and epidemic nephropathy, etc.

.
The medically important hantaviruses are carried by rodents of the murine and hamster families, and humans are infected by inhaling aerosols of animal secretions, urine, feces, or by direct contact with excreta
.
At present, China has the highest annual incidence rate in the world, with about 16,000-100,000 HFRS cases reported each year.
The prevalent Hantaviruses are mainly Hantaan virus (HTNV) and Seoul virus (SEOV), which are determined by the natural hosts of the two viruses
.
The host of Hantaan virus is mainly black-lined mouse, and the host of Seoul virus is mainly Rattus norvegicus
.
Besides HFRS, another severe disease caused by New World Hantavirus is Hantavirus Cardiopulmonary Syndrome (HCPS)
.
The typical clinical manifestations of HFRS are mainly characterized by fever, hemorrhage, hypotension and renal damage
.
It should be noted that the presentation varies widely among different patients, and the diagnosis does not require all symptoms or disease stages
.
For example, in this case, there was headache and edema at the beginning of the disease, but no orbital pain, low back pain, drunken appearance, bleeding or hypotensive shock
.
For patients with only partial symptoms or abnormalities, HFRS should also be vigilant to avoid missed and delayed diagnosis
.
According to reports, the annual fatality rate of HFRS cases in China fluctuates from 0.
60% to 13.
97%.
Timely diagnosis can reduce unnecessary antibiotic use, shorten hospital stay, and reduce mortality
.
Serological method of choice for diagnosis
.
When the symptoms are obvious, all patients have Hantavirus IgM antibodies, and most of them will have IgG antibodies
.
Although diagnosis does not require sophisticated technology, it requires clinicians to have solid basic skills and careful clinical thinking
.
Generally, renal biopsy is not required, but may be required for confirmation in patients with an atypical clinical course
.
The renal pathology of HFRS is common acute tubulointerstitial nephritis, and the inflammatory infiltrate is mainly composed of monocytes, CD8 lymphocytes and neutrophils
.
The biopsy of this case showed acute tubular necrosis, which was also consistent with the pathological changes of HFRS
.
In addition, the second-generation sequencing of the etiology was carried out in this case at the initial stage, but since DNA-mNGS was routinely carried out, a negative result was obtained, suggesting that in clinical work, RNA-mNGS detection should be carried out in a timely manner to avoid missed diagnosis of RNA virus infection
.
In terms of treatment, there is no specific antiviral drug for Hantavirus infection, and ribavirin can be used for antiviral treatment in the early stage of the disease
.
Treatment is mainly monitoring, fluid resuscitation, symptomatic and supportive treatment, including pain relief, platelet supplementation, diuresis during oliguria, etc.
, as well as blood purification for those who meet the indications
.
Since NSAIDS may lead to AKI, the use of these drugs should be avoided
.
Most patients who receive reasonable treatment recover completely, and a small number of patients have residual proteinuria and hypertension
.
The good news is that after the diagnosis was made, broad-spectrum antibiotics were stopped immediately, and the patient recovered quickly through active supportive treatment
.

Hemorrhagic fever with renal syndrome (HFRS) is caused by Hantavirus infection of the Buniaviridae family, also known as epidemic hemorrhagic fever, hemorrhagic nephritis, Korean hemorrhagic fever and epidemic nephropathy, etc.

.
The medically important hantaviruses are carried by rodents of the murine and hamster families, and humans are infected by inhaling aerosols of animal secretions, urine, feces, or by direct contact with excreta
.
At present, China has the highest annual incidence rate in the world, with about 16,000-100,000 HFRS cases reported each year.
The prevalent Hantaviruses are mainly Hantaan virus (HTNV) and Seoul virus (SEOV), which are determined by the natural hosts of the two viruses
.
The host of Hantaan virus is mainly black-lined mouse, and the host of Seoul virus is mainly Rattus norvegicus
.
Besides HFRS, another severe disease caused by New World Hantavirus is Hantavirus Cardiopulmonary Syndrome (HCPS)
.

The typical clinical manifestations of HFRS are mainly characterized by fever, hemorrhage, hypotension and renal damage
.
It should be noted that the presentation varies widely among different patients, and the diagnosis does not require all symptoms or disease stages
.
For example, in this case, there was headache and edema at the beginning of the disease, but no orbital pain, low back pain, drunken appearance, bleeding or hypotensive shock
.
For patients with only partial symptoms or abnormalities, HFRS should also be vigilant to avoid missed and delayed diagnosis
.
According to reports, the annual fatality rate of HFRS cases in China fluctuates from 0.
60% to 13.
97%.
Timely diagnosis can reduce unnecessary antibiotic use, shorten hospital stay, and reduce mortality
.

Serological method of choice for diagnosis
.
When the symptoms are obvious, all patients have Hantavirus IgM antibodies, and most of them will have IgG antibodies
.
Although diagnosis does not require sophisticated technology, it requires clinicians to have solid basic skills and careful clinical thinking
.
Generally, renal biopsy is not required, but may be required for confirmation in patients with an atypical clinical course
.
The renal pathology of HFRS is common acute tubulointerstitial nephritis, and the inflammatory infiltrate is mainly composed of monocytes, CD8 lymphocytes and neutrophils
.
The biopsy of this case showed acute tubular necrosis, which was also consistent with the pathological changes of HFRS
.
In addition, the second-generation sequencing of the etiology was carried out in this case at the initial stage, but since DNA-mNGS was routinely carried out, a negative result was obtained, suggesting that in clinical work, RNA-mNGS detection should be carried out in a timely manner to avoid missed diagnosis of RNA virus infection
.

In terms of treatment, there is no specific antiviral drug for Hantavirus infection, and ribavirin can be used for antiviral treatment in the early stage of the disease
.
Treatment is mainly monitoring, fluid resuscitation, symptomatic and supportive treatment, including pain relief, platelet supplementation, diuresis during oliguria, etc.
, as well as blood purification for those who meet the indications
.
Since NSAIDS may lead to AKI, the use of these drugs should be avoided
.
Most patients who receive reasonable treatment recover completely, and a small number of patients have residual proteinuria and hypertension
.
The good news is that after the diagnosis was made, broad-spectrum antibiotics were stopped immediately, and the patient recovered quickly through active supportive treatment
.

[1] Infectious Disease Prevention and Control Branch of Chinese Preventive Medicine Association, Infectious Diseases Branch of Chinese Medical Association.
Expert consensus on prevention and treatment of hemorrhagic fever with renal syndrome [J].
Chinese Journal of Infectious Diseases, 2021, 39(5):9.

[2] Zhang S, Wang S, Yin W, et al.
Epidemic characteristics of hemorrhagic fever with renal syndrome in China, 2006-2012[J].
BMC Infect Dis, 2014,14:384.

[3] Zhang R, Mao Z, Yang J, et al.
The changing epidemiology of hemorrhagic fever with renal syndrome in Southeastern China during 1963-2020: A retrospective analysis of surveillance data[J].
PLoS Negl Trop Dis, 2021,15(8):e9673.

[4] Brocato R L, Hooper J W.
Progress on the Prevention and Treatment of Hantavirus Disease[J].
Viruses, 2019,11(7):610.

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