NDT Plus Advance Access originally published online on March 20, 2008
NDT Plus 2008 1(3):178-181; doi:10.1093/ndtplus/sfn021
© The Author [2008]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.For Permissions, please e-mail: journals.permissions@oxfordjournals.org
Viral haemorrhagic fever and a skin rash—what is the link?
Katharina Friebe1,
Rüdiger Waldherr2 and
Markus Krautter1
1 Department of Nephrology, University of Heidelberg
2 Department of Pathology, Private Pathology Laboratory, Germany
Correspondence: Markus Krautter, Department of Nephrology, University of Heidelberg, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany. Tel: +49-06221-91120; Fax: +49-06221-9112-990; E-mail: Markus.Krautter{at}med.uni-heidelberg.de
Key Words: haemorrhagic fever • systemic lupus erythematodes
Received for publication February 8, 2008. Accepted for publication February 12, 2008.
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Case
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A 38-year-old, previously healthy woman was admitted with non-oliguric
acute renal failure. Prior to admission she had a 2-week history
of sudden fever with a peak of 40°C, lower back pain, severe
headache, abdominal pain, emesis, increasing faintness and impaired
vision. Initially she was admitted to a surgical unit, where
the symptoms resolved within 3 days.
Physical examination showed a weight gain of 5 kg, oedema of the lower legs and a butterfly rash (Figure 1). She lived in a forest area and regularly collected firewood. Laboratory results are shown in Table 1. A kidney biopsy was performed, which showed the images in Figures 2 and 3a–c.
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Question
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What is the most likely cause of the acute renal failure in
this patient, and is this related to her skin rash?
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Answer
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The cause of the acute renal failure was haemorrhagic fever
with renal syndrome, due to an infection with the Hanta- virus
serotype Puumala (IgG and IgM positive). The kidney biopsy showed
an interstitial lympho- and monocytic inflammatory infiltration,
a typical finding in haemorrhagic fever with renal syndrome
(Figure
2). A more thorough study of the renal biopsy including
immunofluorescence revealed mild mesangial expansion with IgG
and C3c deposits (Figures
3a–c), which were suggestive
for mild lupus nephritis (class 1 ISN/RPS) [
1] and a further
laboratory work-up documented an increased ANA (antinuclear
antibodies) titre of 1:160 (normal range <1:80) and the elevated
Cardiolipin level of 18.5 mpl (normal range <10 mpl). The
patient's history was re-evaluated and she was repeatedly seen
by other physicians since her facial skin rash prompted a clinical
and laboratory work-up for lupus erythematodes (Figure
1).
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Discussion
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The genus Hantavirus includes the following serotypes:
- Hantaan virus (HTN), found in Asia
- Puumala virus (PUU), found in Scandinavia and Central Europe
- Dobrava virus (DOB), area of circulation similar to PUU
- Seoul virus (SEO), found in Korea and
- Sin-Nombre virus, prevalent in the United States.
The serotype Puumala causes a mild to moderate haemorrhagic fever with renal syndrome (HFRS) and is also known as Nephropathia epidemica [2,3].
The viral agent is transmitted to humans from rodent reservoirs, especially from the red bank vole (Clethrionomys glareolus). The transmission occurs by inhaling aerosols of urine, saliva or faeces of infected rodents. The symptoms of HFRS are nausea, headache, vertigo as well as an acute renal failure with an increase of serum creatinine and proteinuria. In general, patients with HFRS due to Puumala serotype recover without persistent renal damage or hypertension, and the mortality during the course of the disease is very low [2–4].
The diagnosis of Hantavirus infection is based on serology [2]. A renal biopsy usually shows an acute tubulointerstitial nephritis with interstitial oedema, mononuclear cell infiltrates and interstitial haemorrhage [5].
The therapy of HFRS is limited to supportive procedures to control the symptoms since there are no antiviral drugs at present available. In 2007 the number of Hantavirus infections increased by <10-fold, possibly due to the mild winter and a rodent overpopulation due to beechnut mast which increased the number of rodent vectors [6].
The increased ANA titre, anticardiolipin IgM, the erythema (Figure 1) and the mild glomerulonephritis in this patient argue for concomitant pre-existing SLE.
In our patient, the serum creatinine decreased rapidly to normal values and at present the patient is doing well with a normal GFR. She has no immunosuppressive therapy and is seen by a nephrologist on a regular schedule.
Conflict of interest statement. None declared.
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References
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- Weening JJ, D’Agati VD, Schwartz MM, et al. The classification of glomerulonephritis in systemic lupus erythematosus revisited. J Am Soc Nephrol (2004) 15:241–250. Erratum in: J Am Soc Nephrol 2004; 15: 835–836.[Abstract/Free Full Text]
- Muranyi W, Bahr U, Zeier M, et al. Hantavirus infection. J Am Soc Nephrol (2005) 16:3669–3679.[Free Full Text]
- Peters CJ, Simpson GL, Levy H. Spectrum of hantavirus infection: hemorrhagic fever with renal syndrome and hanta- virus pulmonary syndrome. Annu Rev Med (1999) 50:531–545. Review.[CrossRef][Web of Science][Medline]
- Miettinen MH, Mäkelä SM, Ala-Houhala IO, et al. Ten-year prognosis of Puumala hantavirus-induced acute interstitial nephritis. Kidney Int (2006) 69:2043–2048.[CrossRef][Web of Science][Medline]
- Mustonen J, Helin H, Pietilä K, et al. Renal biopsy findings and clinicopathologic correlations in nephropathia epidemica. Clin Nephrol (1994) 41:121–126.[Web of Science][Medline]
- Russia Sees Ill Effects of ‘General Winter's’ Retreat Washington Post. April 2007.
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