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Emerging Infectious Diseases Hantavirus Pulmonary Syndrome -- Virginia, 1993

Hantavirus pulmonary syndrome (HPS) was first recognized in June 1993 as a result of the investigation of a cluster of fatal cases of adult respiratory distress syndrome (ARDS) in the southwestern United States (1). During that month, a 61-year-old man was admitted to a hospital in southern Pennsylvania with ARDS; recent testing of all available specimens from this patient has confirmed the diagnosis of HPS. This report summarizes the case investigation.

When hospitalized on June 28, 1993, the man reported a 4-day history of fever, chills, headache, myalgia, nausea, vomiting, and diarrhea. After admission, he became hypotensive and increasingly short of breath and was transferred to a tertiary-care medical center. Laboratory findings included leukocytosis (white blood cell count 25,300/mm3), hemoconcentration (hemoglobin of 20.0 g/L), thrombocytopenia (platelet count 65,000/mm3), and elevated blood urea nitrogen, creatinine (peak value 6.8 ug/dL), prothrombin time, activated partial thromboplastin time, aspartate aminotransferase (peak value 8500 U/L), lactic dehydrogenase, and lipase levels. A chest radiograph indicated bilateral diffuse infiltrates. During his prolonged hospital course, he required respiratory and circulatory support and hemodialysis. He was discharged on July 22, 1993.

An enzyme-linked immunosorbent assay with heterologous antigens performed on serum samples obtained on July 2 and July 20 were highly suspect for hantavirus antibodies. Subsequent retesting of these samples, as well as of an additional sample obtained in September 1994, with Sin Nombre virus (SNV) antigens confirmed the diagnosis of HPS.

In April 1993, the patient had started hiking on the Appalachian Trail northbound from Georgia through North Carolina, Tennessee, Virginia, and West Virginia. From May 13 through June 20, he hiked primarily along the Appalachian Trail in Virginia and reported evidence of mice, including excreta and rodent traps in shelters and bunkhouses.

To further characterize the prevalence of hantavirus in local rodent populations, the offices of Epidemiology and Environmental Health of the Virginia Department of Health, local health departments, the National Park Service, and CDC are conducting rodent trapping. Reported by: BH Hamory, MD, C Zwillich, MD, T Bollard, MD, JO Ballard, MD, The Milton S Hershey Medical Center, Hershey; M Connor, DO, Chambersberg Hospital, Chambersberg; P Lurie, MD, M Moll, MD, J Rankin, DVM, State Epidemiologist, Pennsylvania Dept of Health. C Smith, MD, New River Health District, Radford; S Jenkins, VMD, E Barrett, DMD, GB Miller, Jr, MD, State Epidemiologist, Virginia Dept of Health. W Frampton, DVM, S Lanser MPH, CR Nichols, MPA, State Epidemiologist, Utah Dept of Health. DT King, Harpers Ferry, West Virginia; A Kingsbury, MS, Washington, DC, National Park Service, US Dept of the Interior. Special Pathogens Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: This report describes the first known case of HPS in the mid-Atlantic states. The patient's infection probably was acquired along the Appalachian Trail in Virginia, an area within the range of habitation of the primary rodent reservoir of SNV, Peromyscus maniculatus (deer mouse). The prodromal illness and respiratory failure are consistent with HPS (2); the renal involvement characteristic of Eurasian hemorrhagic fever with renal syndrome (HFRS) has not been typical of HPS. Moderate elevations ( greater than 2.5 ug/dL) in serum creatinine have occurred in only 10% of fatal cases of HPS; prominent renal involvement, such as that which occurred in this patient, has been documented only in two cases from the southeastern United States, both of which are believed to have been associated with hantaviruses other than SNV (provisionally named Black Creek Canal virus and Bayou virus) (3,4). Thus, the marked liver transaminase elevation in this patient has not been a prominent feature in other cases of HPS, although the prominent liver dysfunction has occurred with HFRS (5,6). However, because both renal and hepatic dysfunction can be caused by antecedent hypotension and other factors, additional case investigation is ongoing to clarify the relevance of these findings.

Since June 1993, when HPS was first recognized in the United States, 98 cases have been identified in 21 states. The mean age of case-patients has been 35.1 years (range: 12-69 years), and the case-fatality rate is 52%; 52 (54%) cases have occurred in males. The earliest retrospectively identified case, inferred by a history of a compatible illness and elevated IgG titers detected for SNV, occurred in a 38-year-old man in Utah in 1959.

The findings in this report extend the geographic area for risk of human infection with hantaviruses in the contiguous United States and emphasize the continued importance of minimizing exposure to rodents and their excreta. Persons engaged in outdoor activities such as camping or hiking should take precautions to reduce contact with rodents (7). National surveillance for HPS continues to characterize the spectrum of clinical illness associated with SNV and identify additional pathogenic hantaviruses and rodent hosts. Suspected cases of HPS should be reported through local and state health departments for evaluation and investigation.


  1. CDC. Outbreak of acute illness -- southwestern United States, 1993. MMWR 1993;42:421-4.

  2. Duchin JS, Koster FT, Peters CJ, et al. Hantavirus pulmonary syndrome: a clinical description of 17 patients with a newly recognized disease. N Engl J Med 1994;330:949-55.

  3. CDC. Newly identified hantavirus -- Florida, 1994. MMWR 1994;43:99,105.

  4. CDC. Hantavirus pulmonary syndrome -- northeastern United States, 1994. MMWR 1994;43:548-9,555-6.

  5. Chan YC, Wong TW, Yap EH, et al. Haemorrhagic fever with renal syndrome involving the liver. Med J Aust 1987;147:248-9.

  6. Elisaf M, Stefanaki S, Repanti M, Korakis H, Tsianos E, Siamopoulos KC. Liver involvement in hemorrhagic fever with renal syndrome. J Clin Gastroenterology 1993;17:33-7.

  7. CDC. Hantavirus infection -- southwestern United States: interim recommendations for risk reduction. MMWR 1993;42(no. RR-11).

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