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Weekly Chest CasesArchive of Old Cases

Case No : 626 Date 2009-10-25

  • Courtesy of Myeong Im Ahn, Seog Hee Park / Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea
  • Age/Sex 23 / M
  • Chief ComplaintFever, abdominal pain for 7 days
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 6

Initial Chest PA

Diagnosis With Brief Discussion

Diagnosis
Hemorrhagic fever with renal syndrome
Radiologic Findings
The patient had visited friend's home in rural area 2 weeks ago.
Initial chest PA shows no definite abnormal findings.
FU chest PA 2 days later reveals increased interstitial markings in both lungs, suggesting pulmonary edema with bilateral pleural effusion.
Chest CT shows diffuse ground glass attenuation and interlobular septal thickening in lung bases, and bilateral pleural effusion.
Dynamic CT images show diffusely enlarged both kidneys and perirenal fluid collection. Delayed nephrogram is noted in excretory phase CT.
Brief Review
Hantaviruses are lipid-enveloped, single-stranded RNA viruses. Several antigenically different viruses from around the world (Hantaan, Seoul, Puumala, Dobrava, Prospect Hill, and Sin Nombre) have been found to cause a typical symptom complex called hemorrhagic fever with renal syndrome. Infected patients experience clinically characteristic courses of fever, hypotension, and renal failure. The most recently identified sixth organism (Sin Nombre virus) is known to more frequently cause severe and fulminant pulmonary disease than other organisms.
The natural reservoir of all Hantaviruses is wild rodents and deer mice, the latter being the most important animal harboring the Sin Nombre variant in the United States. The organism is believed to be transmitted to humans by inhalation of dried rodent excreta associated with outdoor activities in rural areas, such as cleaning barns, plowing with hand tools, and harvesting rice.
Hantavirus pulmonary syndrome characteristically presents as respiratory distress from noncardiogenic edema. After an incubation period of 9-35 days, the syndrome begins to progress through its three stages. The initial stage is the prodromal phase, which is followed by the cardiopulmonary and convalescent phases. Histologically, interstitial and air-space edema, mild to moderate interstitial infiltrates of lymphocytes, epithelial necrosis, vascular thrombosis,
and hyaline membranes are seen (24). The lung disease in the Hantavirus syndrome has some distinct pathologic differences from diffuse alveolar damage due to other causes. They are extensive cellular debris, destruction of type I cells, prominence of type II cells, neutrophil infiltrates, and fibrosing alveolitis.
Radiographically, Hantavirus pulmonary syndrome presents as interstitial edema with or without rapid progression to air-space disease. The air-space disease shows a central or bibasilar distribution. Also, pleural effusion is a common finding. The radiographic findings in Hantavirus pulmonary syndrome are consistent with a pulmonary capillary leak. However, pulmonary manifestations may occasionally be secondary to renal failure. In these cases, pulmonary edema and cardiomegaly with or without pleuropericardial effusion are the predominant findings in the oliguric phase of renal failure. However, in infection of the Sin Nombre organism, more severe findings with diffuse alveolar damage are usually seen. Recently, Boroja et al identified two broad categories of Hantavirus pulmonary syndrome clinically and radiographically: a rapidly progressive, fulminant, and often fatal clinical form with radiographic features of rapidly progressive alveolar pulmonary edema, air-space consolidation, and pleural effusions; and a limited, less severe clinical form usually associated with mild interstitial edema and minimal air-space disease. All patients with the limited form of Hantavirus pulmonary syndrome survived the illness, whereas 46% of those with the fulminant form died.
References
1. Kim EA, Lee KS, Primack SL, Yoon HK, Byun HS, Kim TS, Suh GY, Kwon OJ, Han J.
Viral pneumonias in adults: radiologic and pathologic findings.
Radiographics. 2002 Oct;22 Spec No:S137-49.

2. Boroja M, Barrie JR, Raymond GS. Radiographic findings in 20 patients with Hantavirus pulmonary syndrome correlated with clinical outcome.
Am J Roentgenol 2002; 178:159?63.

3. Ketai LH, Williamson MR, Telepak RJ, et al. Hantavirus pulmonary syndrome: radiographic findings in 16 patients. Radiology 1994; 191:665?668
Keywords
Lung, Multiple organ, Infection, Viral infection,

No. of Applicants : 103

▶ Correct Answer : 12/103,  11.7%
  • - Assam medical college , India Karunakaran M
  • - Assam Medical College , India Pramod K.G
  • - SMC , Korea (South) Jihoon Cha
  • - Samsung Medical Center , Korea (South) Eun Kim
  • - Seoul National University Hospital , Korea (South) Sang Min Lee
  • - Kang buk samsung hospital, department of radiology , Korea (South) Hyojin Lim
  • - Gangnam Severance Hospital , Korea (South) Min Jeong Kim
  • - Shinsegye Rad Clinic, Daegu , Korea (South) Gi Beom Kim
  • - Soonchunhyang university hospital, Bucheon , Korea (South) ALEUM LEE
  • - Seoul Nationial University Bundang Hospital , Korea (South) Kyoung Jin Oh
  • - Seoul Nationial University Bundang Hospital , Korea (South) Hee Seok Choi
  • - Armed Forces Chun-Cheon Hospital , Korea (South) Chae Lim
▶ Correct Answer as Differential Diagnosis : 6/103,  5.8%
  • - Dong-A university hospital , Korea (South) Sang-yun LEE
  • - PingTung Christian Hospital ,China Medical University ,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - care hospital , India Chary D
  • - Uzunkopru Devlet Hastanesi , Turkey Armagan Sarac
  • - IRSA , France jean-luc BIGOT
  • - Armed Force Capital Hospital , Korea (South) Dae Kun Oh
▶ Semi-Correct Answer : 21/103,  20.4%
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - Father Muller Medical College , Mangalore , India nabil mahmood
  • - University of British Columbia , Canada Amr Ajlan
  • - KING KHALID UNIVERSITY HOSPITAL , Saudi Arabia Elbagir Nasser
  • - KKUH , Saudi Arabia JAMAL KAID
  • - EKH-Berlin , Germany Michael Weber
  • - hospital Sao Paulo , Brazil israel missrie
  • - Osaka University , Japan Osamu Honda
  • - Changhua Christian Hospital , Taiwan Chia-Fu Tsai
  • - POPOVO HOSPITAL , Bulgaria VLADISLAV RUSINOV
  • - THE OTTAWA HOSPITAL , Canada jitesh ahuja
  • - NOUR EL-ISLAM RADIOLOGY CENTER , Egypt Elsayed Mousa
  • - institute of chest diseases calicut , India divya nair
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - Assam Medical college , India samudra borah
  • - CHU Grenoble , France Fabrice Bing
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - hospital 12 de octubre , Spain sergio alonso
  • - Hital SacrCoeur, Montrl , Canada Andrea Ojanguren
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - Chungnam national university hospital , Korea (South) Jeoung Eun Lee
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