Gert van der Hoek
In Memoriam - Editor, Senior Moderator
Archive Number 20080606.1808
Published Date 06-JUN-2008
Subject PRO/AH/EDR> Leptospirosis - Sri Lanka (02): hantavirus also susp.
LEPTOSPIROSIS - SRI LANKA (02): HANTAVIRUS ALSO SUSPECTED
*********************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>
Date: Thu 5 Jun 2008
From: Jan Clement <jan.clement.dr@telenet.be>
Hantavirus infections may be part or most of the current problem in
Sri Lanka. Hantavirus infections often present in epidemic forms
after abundant rainfall, and differential diagnosis with
leptospirosis on clinical grounds alone, or even on renal biopsy, is
impossible to make.
Like leptospirosis, [hantavirus infection is] a mainly rodent-borne zoonotic
infection, but also with a truly global distribution, including the
(Far) East. Lately, different species of shrews (which are
insectivores, not rodents) have also been implicated as reservoirs for
"new" hantavirus species.
With a simple approach of screening leptospirosis-suspected cases of
AKI or acute kidney injury (a better and newer term for the formerly
ARF or acute kidney failure), we were able so far to document the 1st
seroconfirmed cases of hantavirus infection in the New World (1) and
in India (2). Both study groups presented with epidemic forms of AKI
after abundant rains. In India a fatal case was due to concomitant
renal and respiratory failure.
No clinically documented hantavirus infections were reported so far
from Sri Lanka. With the help of Prof Sunil-Chandra NP of the
University of Kelaniya, Sri Lanka, we are currently examining a
similar group from Sri Lanka, also presenting as leptospirosis.
Patients hospitalized for leptospirosis-like symptoms were screened
with ELISA (enzyme-linked immunosorbent assay) for leptospirosis, and
for hantavirus with the European prototype Puumalavirus (PUUV) and
the Asian prototype Hantaanvirus (HTNV). In brief, this prospective
study comprised 39 patients, aged 13-74 years (mean: 35), 34/39
males, with a history of rodent exposure in 34/39. IgM ELISA in 31/39
acute sera was positive in 9 (29 percent) cases for leptospirosis
only, 2 (6.5 percent) for hantavirus only, whereas 13 (41.9 percent)
were negative for both, but 7 (22.6 percent) appeared positive for
both pathogens. IgM seropositivity was for PUUV only in 2/9, for PUUV
predominantly in 5/9, and for HTNV predominantly in 2/9.
Convalescent
sera 2-3 weeks later confirmed an acute PUUV-like infection in 4/31
(12.9 percent) cases, but picked up additionally 8 leptospirosis
IgM-positive cases, resulting in a total of 17/31 (54.8 percent)
acute leptospirosis-only cases. Compared to seronegative or
leptospirosis-only cases, clinical symptoms were more severe in all 9
hantavirus-positive cases, with more jaundice, hepatomegaly,
hematuria, and cough. Serum bilirubin, and blood urea were likewise
more elevated. No deaths occurred (3). (Sunil-Chandra NP, Clement J, Maes
P Van Ranst M: Leptospirosis and hantavirus infections in Sri Lanka:
a mixed pattern. Manuscript in preparation).
In India, we found likewise PUUV-like serological predominance in
similar and fatal cases. India is a neighbouring country with rodent
fauna very similar to Sri Lanka. We are now attempting to identify
this new pathogen, since proven PUUV-infections occurred only in
Europe and Russia so far, and the responsible rodent reservoir
_Myodes glareolus_ is absent from both India and Sri Lanka.
We have
apparently to do with a new hantaviral pathogen, related to, but not
identical to PUUV, and whose rodent reservoir remains so far unknown.
Shrews have also to be considered as potential reservoirs.
We are offering the requested help to the health authorities of
Sri Lanka in trying to elucidate this enigma if they provide us with
the necessary sera of acute human or deceased cases, particularly if
local testing for leptospirosis would appear to be negative. However,
and as confirmed in our study, dual leptospirosis plus hantavirus
infections are also possible.
Sera of rodents and/or shrews with a conspicuous presence after the
floods or in the rice fields can also be very helpful. Even if the
rodent and/or shrew reservoir in Sri Lanka would appear to be same for
leptospirosis as for hantavirus -- which is far from proven -- the
treatment and prognosis of both human infections is totally different.
Effective measures of prevention will not be possible as long as the
exact small mammal reservoir is not known.
1. Hinrichsen S, Medeiros de Andrade A, Clement J, Leirs H, McKenna P,
Matthys P, Neild G: Evidence of hantavirus infection in Brazilian
patients from Recife with suspected leptospirosis. Lancet 1993; 341:50)
2. Clement J, Maes P, Muthusethupathi M, Nainan G, Van Ranst M: First
evidence of fatal hantavirus nephropathy in India, mimicking
leptospirosis. Nephrol Dial Transpl 2006; 21:826-7.
3. Sunil-Chandra NP, Clement J, Maes P Van Ranst M: Leptospirosis and
hantavirus infections in Sri Lanka: a mixed pattern. (Manuscript in
preparation).
--
Jan Clement MD
Hantavirus Reference Centre
Laboratory of Clinical and Epidemiological Virology
& Rega Institute for Medical Research
University of Leuven,
U.Z. Gasthuisberg, Herestraat, 49
B-300 Leuven
Belgium
jan.clement.dr@telenet.be
[ProMED-mail thanks Dr Clement for the interesting hantavirus
information that relates to the outbreak in Sri Lanka, which has been
presumed due to leptospirosis. Isolation of the suspected hantavirus
that might be involved in the Sri Lanka outbreak will be important to
establish the etiology of the pathogen(s) responsible for the disease.
Dr Clement's contribution is an important reminder that more than one
pathogenic agent may be responsible for the disease outbreak that
occurred, and underscores the importance of clinical observations
being supported by adequate laboratory testing.
A map showing the reported affected areas, Kandy in the center of the
country and Matara in the extreme south, can be accessed at
http://www.reddottours.com/images/accommodation/hotels/Kandy-KandyHouse/sl-map.gif
- Mod.TY
Hantavirus images may be seen at:
http://www.nsf.gov/news/special_reports/ecoinf/images/Hantavirus2.jpg
http://www.cdc.gov/ncidod/diseases/hanta/hps/noframes/phys/graphics/highres/6963-snvb.gif
- Mod.JW]
http://www.promedmail.org/pls/otn/f..._BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1000,72748
Published Date 06-JUN-2008
Subject PRO/AH/EDR> Leptospirosis - Sri Lanka (02): hantavirus also susp.
LEPTOSPIROSIS - SRI LANKA (02): HANTAVIRUS ALSO SUSPECTED
*********************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>
Date: Thu 5 Jun 2008
From: Jan Clement <jan.clement.dr@telenet.be>
Hantavirus infections may be part or most of the current problem in
Sri Lanka. Hantavirus infections often present in epidemic forms
after abundant rainfall, and differential diagnosis with
leptospirosis on clinical grounds alone, or even on renal biopsy, is
impossible to make.
Like leptospirosis, [hantavirus infection is] a mainly rodent-borne zoonotic
infection, but also with a truly global distribution, including the
(Far) East. Lately, different species of shrews (which are
insectivores, not rodents) have also been implicated as reservoirs for
"new" hantavirus species.
With a simple approach of screening leptospirosis-suspected cases of
AKI or acute kidney injury (a better and newer term for the formerly
ARF or acute kidney failure), we were able so far to document the 1st
seroconfirmed cases of hantavirus infection in the New World (1) and
in India (2). Both study groups presented with epidemic forms of AKI
after abundant rains. In India a fatal case was due to concomitant
renal and respiratory failure.
No clinically documented hantavirus infections were reported so far
from Sri Lanka. With the help of Prof Sunil-Chandra NP of the
University of Kelaniya, Sri Lanka, we are currently examining a
similar group from Sri Lanka, also presenting as leptospirosis.
Patients hospitalized for leptospirosis-like symptoms were screened
with ELISA (enzyme-linked immunosorbent assay) for leptospirosis, and
for hantavirus with the European prototype Puumalavirus (PUUV) and
the Asian prototype Hantaanvirus (HTNV). In brief, this prospective
study comprised 39 patients, aged 13-74 years (mean: 35), 34/39
males, with a history of rodent exposure in 34/39. IgM ELISA in 31/39
acute sera was positive in 9 (29 percent) cases for leptospirosis
only, 2 (6.5 percent) for hantavirus only, whereas 13 (41.9 percent)
were negative for both, but 7 (22.6 percent) appeared positive for
both pathogens. IgM seropositivity was for PUUV only in 2/9, for PUUV
predominantly in 5/9, and for HTNV predominantly in 2/9.
Convalescent
sera 2-3 weeks later confirmed an acute PUUV-like infection in 4/31
(12.9 percent) cases, but picked up additionally 8 leptospirosis
IgM-positive cases, resulting in a total of 17/31 (54.8 percent)
acute leptospirosis-only cases. Compared to seronegative or
leptospirosis-only cases, clinical symptoms were more severe in all 9
hantavirus-positive cases, with more jaundice, hepatomegaly,
hematuria, and cough. Serum bilirubin, and blood urea were likewise
more elevated. No deaths occurred (3). (Sunil-Chandra NP, Clement J, Maes
P Van Ranst M: Leptospirosis and hantavirus infections in Sri Lanka:
a mixed pattern. Manuscript in preparation).
In India, we found likewise PUUV-like serological predominance in
similar and fatal cases. India is a neighbouring country with rodent
fauna very similar to Sri Lanka. We are now attempting to identify
this new pathogen, since proven PUUV-infections occurred only in
Europe and Russia so far, and the responsible rodent reservoir
_Myodes glareolus_ is absent from both India and Sri Lanka.
We have
apparently to do with a new hantaviral pathogen, related to, but not
identical to PUUV, and whose rodent reservoir remains so far unknown.
Shrews have also to be considered as potential reservoirs.
We are offering the requested help to the health authorities of
Sri Lanka in trying to elucidate this enigma if they provide us with
the necessary sera of acute human or deceased cases, particularly if
local testing for leptospirosis would appear to be negative. However,
and as confirmed in our study, dual leptospirosis plus hantavirus
infections are also possible.
Sera of rodents and/or shrews with a conspicuous presence after the
floods or in the rice fields can also be very helpful. Even if the
rodent and/or shrew reservoir in Sri Lanka would appear to be same for
leptospirosis as for hantavirus -- which is far from proven -- the
treatment and prognosis of both human infections is totally different.
Effective measures of prevention will not be possible as long as the
exact small mammal reservoir is not known.
1. Hinrichsen S, Medeiros de Andrade A, Clement J, Leirs H, McKenna P,
Matthys P, Neild G: Evidence of hantavirus infection in Brazilian
patients from Recife with suspected leptospirosis. Lancet 1993; 341:50)
2. Clement J, Maes P, Muthusethupathi M, Nainan G, Van Ranst M: First
evidence of fatal hantavirus nephropathy in India, mimicking
leptospirosis. Nephrol Dial Transpl 2006; 21:826-7.
3. Sunil-Chandra NP, Clement J, Maes P Van Ranst M: Leptospirosis and
hantavirus infections in Sri Lanka: a mixed pattern. (Manuscript in
preparation).
--
Jan Clement MD
Hantavirus Reference Centre
Laboratory of Clinical and Epidemiological Virology
& Rega Institute for Medical Research
University of Leuven,
U.Z. Gasthuisberg, Herestraat, 49
B-300 Leuven
Belgium
jan.clement.dr@telenet.be
[ProMED-mail thanks Dr Clement for the interesting hantavirus
information that relates to the outbreak in Sri Lanka, which has been
presumed due to leptospirosis. Isolation of the suspected hantavirus
that might be involved in the Sri Lanka outbreak will be important to
establish the etiology of the pathogen(s) responsible for the disease.
Dr Clement's contribution is an important reminder that more than one
pathogenic agent may be responsible for the disease outbreak that
occurred, and underscores the importance of clinical observations
being supported by adequate laboratory testing.
A map showing the reported affected areas, Kandy in the center of the
country and Matara in the extreme south, can be accessed at
http://www.reddottours.com/images/accommodation/hotels/Kandy-KandyHouse/sl-map.gif
- Mod.TY
Hantavirus images may be seen at:
http://www.nsf.gov/news/special_reports/ecoinf/images/Hantavirus2.jpg
http://www.cdc.gov/ncidod/diseases/hanta/hps/noframes/phys/graphics/highres/6963-snvb.gif
- Mod.JW]
http://www.promedmail.org/pls/otn/f..._BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1000,72748