1. Case Study - Hantavirus Group 6 Microbiology 401 Fall 2007 Chona Herrella, Saray Felix, Yanping Fan

2. Case Study 61 year old healthy male Patient resided in a house on four rural acres Two months prior to hospitalization, he cleaned a mouse nest from a wood pile Observed mice in the basement and trapped two mice under the kitchen counters

3. Symptoms Vermont resident hospitalized for: Three episodes of chills, fever, nausea, vomiting and anorexia Patient had clear lungs and chest radiographs After admission in the hospital, patients health worsened: Respiratory failure Profound Hypoxemia Hypotension – required mechanical ventilation Fluid in the lungs – Acute Respiratory Distress Syndrome (ARDS) Disseminated Intravascular Coagulation and Renal Insufficiency

4. Family Bunyaviridae  (-) ss RNA  Enveloped  3 gene segments (L, M, S; some S genes are ambisense, all other segments are (-) sense)  Three helical, spherical  nucleocapsids

5. Segmented genomes of Hantavirus Glycoprotein G2 Capsid Glycoprotein G1 L Segment 3’ to 5’ terminal ends M Segment S Segment Envelope

6. Family Bunyaviridae  All package their genomes together with the necessary Replicase  All have flexible nucleocapsids with helical symmetry.  All have an envelope containing virally encoded glycoprotein spikes that are involved in attachment and penetration.  All have genomes without a 5’ cap or a 3’ poly A tail  Penetrates through cell-mediated endocytosis with pH-dependent fusion

7. Sin nombre virus  Our case was caused by one of five genera, the Hantavirus also called the Sin nombre virus

8. Diagnosis CBC (will show elevated white blood count) CBCwhite blood count Platelet count (will be less than 150,000 and decreasing) Platelet count X-ray of the chest (may show material invading the lungs, involving both lungs) X-ray of the chest Liver enzymes (LDH will be elevated)LDH Serum albumin (levels will be decreased) Serum albumin Hematocrit (will be increased, showing an increase in the levels of red blood cells) Hematocrit Serological indirect testing for hantavirus Serological serologic identification of IgM and IgG antibodies to SNV immunofluorescence assay

9. How does Sin Nombre virus cause Respiratory Distress? HANTAVIRUS PULMONARY SYNDROME (HPS) Infection process: The virus attacks host endothelial cells The immunological mechanism of host attacks the infected endothelial cells causing permeability of pulmonary arteries and capillaries. Studies have shown an increase amount of Cytokine- producing cells (TNF-, IL-2, and IFN-γ) and CD8+ T- cells in the lungs Extravasation of fluids into the pleura cavity of the lungs Results: shortness of breath

10. Radiologic Evolution of HPS http://www.aafp.org/afp/20020915/1015.html

11. Cont’d In severe cases the ff may occur: Myocardia depression resulting in Sinus Bradycardia - heart rate below 60 beats per min with subsequent electromechanical dissociation - may not have pulse ventricular tachycardia – increase in heart rate due to one of the ventricles in the heart Fibrillation – contraction of the cardiac muscle of the ventricles in the heart is uncoordinated. Which then fails to pump blood throughout the body causing unconsciousness within seconds and even death.

12. How can we get infected? Urine Feces Saliva Byproducts of mice that can infect humans through Aerolisation:

13. www.nsf.gov/news/mmg/mmg_disp.cfm?med_id=5854... NOTE: One cannot be infected by another human!!!!

14. HPS Demographics

15. Vermont

16. Preventing Hantavirus Outbreak Do not need to isolate patients infected with the virus! Why? It cannot be transmitted from person to person, only through aerolisation of by- products of an infected mouse Instead, one would need the demographics of the infected patients in order to…

17. Outbreak Prevention

18. Outbreak prevention cont’d Need to locate mice population infected with the hantavirus Need to remove or contain the population of infected mice Need to inform the residents near the infected location where outbreak took place Take preventive measures to assure that mice do not come into close contact with the residents through:

19. Preventive Measures: Educating the population on how to decontaminate possible infected areas (cabins, garage, etc) How to dispose of dead mice, waste materials and decontamination tools used (call local state health department) Educate the population with the precautions needed to take in order to prevent infection

20. Precautions to be used: Decontaminate infected (or possible infected) areas: Wear protective gear Do not stir up rodent by-products (feces, dried urine) Do not come in contact with rodents even if they do not show signs of infection Do not invite rodents into your home

21. Other Hantavirus Diseases: Hemorrhagic Fever with Renal Syndrome (HFRS) A disease mainly found in Europe and Asia (Korea, China, East Russia and Balkans) Can also be transmitted through byproducts of mice carrying the disease (urine, feces and saliva) Initial symptoms: flushing of the face, inflammation or redness of the eyes, or a rash. Later symptoms: low blood pressure, acute shock, vascular leakage malfunctioning of the kidneys and hemorrhaging (due to low platelet counts) Complete recovery can take weeks or months. The severity of the disease varies depending upon the location of the virus causing the infection…

22. Other Hantavirus Diseases cont’d: Hantavirus causing Hemorrhagic Fever with Renal Syndrome (HFRS): Hantaan virus Seoul virus Puumala virus Dobrava virus

23. Hantavirus Demographics