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      When polyuria does not stop: a case report on an unusual complication of hantavirus infection

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          Abstract

          Background

          The clinical features, course and outcome of hantavirus infection is highly variable. Symptoms of the central nervous system may occur, but often present atypically and diagnostically challenging. Even though the incidence of hantavirus infection is increasing worldwide, this case is the first to describe diabetes insipidus centralis as a complication of hantavirus infection in the Western world.

          Case presentation

          A 49-year old male presenting with severe headache, nausea and photophobia to our neurology department was diagnosed with acute haemorrhage in the pituitary gland by magnetic resonance imaging. In the following days, the patient developed severe oliguric acute kidney failure. Diagnostic workup revealed a hantavirus infection, so that the pituitary haemorrhage resulting in hypopituitarism was seen as a consequence of hantavirus-induced hypophysitis. Under hormone replacement and symptomatic therapy, the patient’s condition and kidney function improved considerably, but significant polyuria persisted, which was initially attributed to recovery from kidney injury. However, water deprivation test revealed central diabetes insipidus, indicating involvement of the posterior pituitary gland. The amount of urine production normalized with desmopressin substitution.

          Conclusion

          Our case report highlights that neurological complications of hantavirus infection should be considered in patients with atypical clinical presentation.

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          Most cited references 24

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          Hantavirus infections in Europe.

          Hantaviruses are enveloped RNA viruses each carried by a specific rodent species. Three hantaviruses, Puumala, Dobrava, and Saaremaa viruses, are known to cause haemorrhagic fever with renal syndrome. In Europe. Puumala causes a generally mild disease, nephropathia epidemica, which presents most commonly with fever, headache, gastrointestinal symptoms, impaired renal function, and blurred vision, whereas Dobrava infections often also have haemorrhagic complications. There are few available data about the clinical picture of confirmed Saaremaa infections, but epidemiological evidence suggests that it is less pathogenic than Dobrava, and that Saaremaa infections are more similar to nephropathia epidemica caused by Puumala. Along with its rodent host, the bank vole (Clethrionomys glareolus), Puumala is reported throughout most of Europe (excluding the Mediterranean region), whereas Dobrava, carried by the yellow-necked mouse (Apodemus flavicollis), and Saaremaa, carried by the striped field mouse (Apodemus agrarius), are reported mainly in eastern and central Europe. The diagnosis of acute hantavirus infection is based on the detection of virus-specific IgM. Whereas Puumala is distinct, Dobrava and Saaremaa are genetically and antigenically very closely related and were previously thought to be variants of the same virus. Typing of a specific hantavirus infection requires neutralisation antibody assays or reverse transcriptase PCR and sequencing.
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            Uncovering the mysteries of hantavirus infections

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              Human hantavirus infections: epidemiology, clinical features, pathogenesis and immunology.

              In humans, hantaviruses can cause haemorrhagic fever with renal syndrome (HFRS) or hantavirus cardiopulmonary syndrome (HCPS). Currently it is estimated that 150,000 to 200,000 cases of hantavirus disease occur each year, the majority being reported in Asia. However, human hantavirus infections are increasingly reported in the Americas and Europe. Although many of the underlying pathogenic mechanisms still remain unclear, recent evidence rather argues against a purely immune-mediated pathophysiology of human disease. Despite the high morbidity and case-fatality rates of HFRS and HCPS, respectively, no vaccine or drug is currently proven to be preventive or therapeutic. This review summarises clinical features and current epidemiological findings, as well as concepts regarding the immunology, pathogenesis and intervention strategies of human hantaviral diseases.
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                Author and article information

                Contributors
                sebastian.schwab@ukbonn.de
                Journal
                BMC Infect Dis
                BMC Infect. Dis
                BMC Infectious Diseases
                BioMed Central (London )
                1471-2334
                29 September 2020
                29 September 2020
                2020
                : 20
                Affiliations
                [1 ]GRID grid.10388.32, ISNI 0000 0001 2240 3300, Department of Internal Medicine, , Faculty of Medicine, University Bonn, ; Bonn, Germany
                [2 ]GRID grid.10388.32, ISNI 0000 0001 2240 3300, Institute of Experimental Immunology, , Faculty of Medicine, University Bonn, ; Bonn, Germany
                [3 ]GRID grid.10388.32, ISNI 0000 0001 2240 3300, Department of Neurology, Faculty of Medicine, , University Bonn, ; Bonn, Germany
                [4 ]GRID grid.10388.32, ISNI 0000 0001 2240 3300, Department of Radiology, , Faculty of Medicine, University Bonn, University of Bonn, ; Bonn, Germany
                [5 ]GRID grid.10388.32, ISNI 0000 0001 2240 3300, Institute of Virology, Faculty of Medicine, , University Bonn, University of Bonn, ; Bonn, Germany
                [6 ]GRID grid.6363.0, ISNI 0000 0001 2218 4662, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Virology, , Charité – Universitätsmedizin Berlin, ; Berlin, Germany
                Article
                5429
                10.1186/s12879-020-05429-1
                7526136
                32993515
                © The Author(s) 2020

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

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