Article

UK hantavirus, renal failure, and pet rats

Rare and Imported Pathogens Department, Porton Down, UK. Electronic address: .
The Lancet (Impact Factor: 45.22). 03/2013; 381(9871):1070. DOI: 10.1016/S0140-6736(13)60599-1
ABSTRACT
In November, 2012, a 28-year-old man, presented with a 4-day history of fever, shivers, sweating, and vomiting. He had type-2 diabetes, which was being treated with sitagliptin and metformin. On admission he had evi dence of a systemic infl ammatory response (temperature 39·3°C, pulse 160 bpm, respiratory rate 30 per min, white cell count 15·0×10⁹ per L, with 12·3 neutrophils and 0·2 mye locytes), abnormalities of blood clotting (INR 1·6, PTT 57 s, fi brinogen 0·99 g/L (normal range 1·5–4·5); plate lets 19×10⁹ per L), multi-organ failure (creatinine 167 μmol/L, raised alanine aminotransferase 511 U/L and bilirubin 87 μmol/L), progressive hypoxia, hyperglycaemia glucose 20·6 mmol/L), and lactic acidosis (PH 7·29, lactate 7·5 mmol/L). He was diagnosed with overwhelming sepsis and transferred to the intensive care unit. Initial treatment was with piperacillin-tazobactam, insulin, oxygen, and aggressive fl uid replacement, including platelet infusions, fresh frozen plasma, and cryo-precipitate. Ventilatory support was required 15 h after admission, at which time he was anuric. Renal replace-ment therapy was needed for 21 days and ventilatory support for 38 days, partly because of pseudomonas superinfection of the chest that was diagnosed on day 17. Tests for legionella and leptospira and initial blood cultures were negative. Serum taken 30 days after admission had a high IgG titre to Seoul hantavirus (1:10 000 by IFA, Euroimmun, Medizinische Labor-diagnostika AG), although serum from 1 month before admission (sent for hepatitis screening because of a mild transaminasaemia) was negative. Hantavirus RNA was not detected in either sample. We learnt that he kept two pet agouti rats (Rattus norvegicus) that he had acquired from a larger pack bred in England. Seoul hantavirus RNA was detected by RT-PCR 1 in blood taken from these two rats and from seven of the larger group. In November, 2011, one of the English owners had been hospitalised with fever, renal impairment, spleno megaly, and thrombo cytopenia that was secondary to an unidentifi ed viral illness. Retrospective Seoul hantavirus serological Lancet 2013; 381: 1070 Rare and Imported Pathogens Department (S

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Case Report
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UK hantavirus, renal failure, and pet rats
Surabhi K Taori , Lisa J Jameson, Andrew Campbell, Peter J Drew, Noel D McCarthy, Judy Hart, Jane C Osborne, Malur Sudhanva, Timothy J G Brooks
In November, 2012, a 28-year-old man, presented with a
4-day history of fever, shivers, sweating, and vomiting. He
had type-2 diabetes, which was being treated with
sitagliptin and metformin. On admission he had evi dence
of a systemic infl ammatory response (temperature
39·3°C, pulse 160 bpm, respiratory rate 30 per min, white
cell count 15·0×10⁹ per L, with 12·3 neutrophils and
0·2 mye locytes), abnormalities of blood clotting (INR 1·6,
PTT 57 s, fi brinogen 0·99 g/L (normal range 1·5–4·5);
plate lets 19×10⁹ per L), multi-organ failure (creatinine
167 μmol/L, raised alanine aminotransferase 511 U/L and
bilirubin 87 μmol/L), progressive hypoxia, hyperglycaemia
glucose 20·6 mmol/L), and lactic acidosis (PH 7·29,
lactate 7·5 mmol/L). He was diagnosed with overwhelming
sepsis and transferred to the intensive care unit. Initial
treatment was with piperacillin-tazobactam, insulin,
oxygen, and aggressive fl uid replacement, including
platelet infusions, fresh frozen plasma, and cryo-
precipitate. Ventilatory support was required 15 h after
admission, at which time he was anuric. Renal replace-
ment therapy was needed for 21 days and ventilatory
support for 38 days, partly because of pseudomonas
superinfection of the chest that was diagnosed on day 17.
Tests for legionella and leptospira and initial blood
cultures were negative. Serum taken 30 days after
admission had a high IgG titre to Seoul hantavirus
(1:10 000 by IFA, Euroimmun, Medizinische Labor-
diagnostika AG), although serum from 1 month before
admission (sent for hepatitis screening because of a mild
transaminasaemia) was negative. Hantavirus RNA was
not detected in either sample. We learnt that he kept two
pet agouti rats (Rattus norvegicus) that he had acquired
from a larger pack bred in England. Seoul hantavirus
RNA was detected by RT-PCR
1
in blood taken from these
two rats and from seven of the larger group. In November,
2011, one of the English owners had been hospitalised
with fever, renal impairment, spleno megaly, and
thrombo cytopenia that was secondary to an unidentifi ed
viral illness. Retrospective Seoul hantavirus serological
Lancet 2013; 381: 1070
Rare and Imported Pathogens
Department (S K Taori FRCPath,
J C Osborne PhD
,
M Sudhanva FRCPath,
T J G Brooks FRCpath), and
Virology and Pathogenesis
Microbiology Services Health
Protection Agency, Porton
Down, UK (L J Jameson MSc);
Anaesthesia and Critical
Care Department,
(A Campbell FRCA), and Renal
Unit (P J T Drew MD), Wrexham
Maelor Hospital, Betsi
Cadwaladr University Health
Board, North Wales, UK;
Department of Zoology,
University of Oxford, Oxford,
UK (N D McCarthy DPhil);
Thames Valley Health
Protection Unit, Centre for
Radiation, Chemical and
Environmental Hazards, Health
Protection Agency, Chilton, UK
(N D McCarthy); and Public
Health Wales, Health
Protection Team, Preswylfa,
Flinshire, UK (J Hart FFPH)
Correspondence to:
Dr Surabhi K
Taori, Rare and
Imported Pathogens
Department, Health Protection
Agency, P
orton Down,
Salisbury SP4 0JG, UK
surabhi.taori@nhs.net
tests showed an increase in IgG titre (1:1000 to 1:10 000)
from November, 2011, to January, 2013, sug gest ing a
hantaviral cause for this episode. The second owner had a
low IgG titre (1:100, January, 2013), sug gesting past
hantavirus infection but not recalling any notable illness.
Low-level cross-reactivity to other hanta viruses was
frequently seen but was disregarded since Seoul
hantavirus RNA.
1
was identifi ed from the rats. Our patient
left hospital on day 52 with fully recovered renal function.
Hantavirus infection presents as hantavirus pulmonary
syndrome in the Americas and haemorrhagic fever with
renal syndrome in Eurasia.
2
Seoul hantaviruses can show a
spectrum ranging from benign undiff erentiated febrile
illness without renal failure to diff use haemorrhage,
intractable shock, and multiorgan failure. When con-
fronted with such an illness, a diff erential diagnosis of
hantavirus infection should be considered, especially if
history suggests contact with rats, even in the absence of
recent foreign travel. Viraemia is very short and viral RNA
is detectable only in early disease. Diagnosis is therefore
usually done by serological testing. Supportive therapy is
the mainstay of care for patients with haemorrhagic fever
with renal syndrome.
3
In 2012, a hantavirus infection
acquired in the UK was traced to wild rats and challenged
the notion that hantavirus infection is not indigenous to
the UK.
4
The two cases reported here are both associated
with pet rats and provide strong evidence of transmission
to the com munity that owns pet rats. Since there is a
regular interaction between diff erent rat colonies by way of
cross-breeding, pet-sitting, and rat exhibitions, this virus
may be more widespread than recognised. Hantaviruses
are transmitted by direct contact with rodents or their
excrement,
2
and prevention is targeted towards reducing
this exposure. Specifi c guidance on preventive measures is
available from the Health Pro tec tion Agency
5
and should
be made available to rat owners.
Contributors
AC, PD looked after the patient, SKT, LJJ, PJD wrote the report. SKT, LJJ,
NDM, JH, JCO, MS, TJGB did the investigations and analysis. Written
consent to publication was obtained.
References
1 Kramski M, Meisel H, Klempa B, Krüger DH, Pauli G, Nitsche A.
Detection and typing of human pathogenic Hantaviruses by
real-time reverse transcription-PCR and pyrosequencing. Clin Chem
2007; 53: 1899–1905.
2 Reusken C, Heyman P. Factors driving hantavirus emergence in
Europe. Curr Opin Virol 2013; 3: 1–8.
3 Krautkramer E, Zeier M, Plyusnin A. Hantavirus infection: an
emerging infectious disease causing acute renal failure. Kidney Int
2013; 83: 23–27.
4 Jameson LJ, Logue CH, Atkinson B, et al. The continued emergence
of hantaviruses: Isolation of a Seoul virus implicated in human
disease, United Kingdom, October 2012. Euro Surveill 2012; 18.
5 Reducing the risk of infection from pet rodents. http://www.hpa.
org.uk/Topics/InfectiousDiseases/InfectionsAZ/Zoonoses
(accessed Feb 28, 2013).
Linsenhejhej
Figure: Photograph of pet agouti rat
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    • "However, more recently the virus has been isolated from wild brown rats in the UK [17] and pet rats in the UK and Sweden181920. In addition, SEOV associated HFRS has been reported in four cases in the UK and France, all of which were clinically severe and involved renal impairment [17,21,22]. This study aimed to determine the presence of SEOV in wild rats (R. norvegicus) trapped in and around Lyon, France and analyse any resulting molecular epidemiological data. "
    Full-text · Dataset · Jun 2015
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    • "However, more recently the virus has been isolated from wild brown rats in the UK [17] and pet rats in the UK and Sweden181920. In addition, SEOV associated HFRS has been reported in four cases in the UK and France, all of which were clinically severe and involved renal impairment [17,21,22]. This study aimed to determine the presence of SEOV in wild rats (R. norvegicus) trapped in and around Lyon, France and analyse any resulting molecular epidemiological data. "
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