1995 - Hantaviruses Clinical, Microbiologic, and Epidemiologic Aspects

Crirical Reiiie,vs in Clinical Laboruroy Sciences, 32(5):469-508 ( 1995)
Hantaviruses: Clinical, Microbiologic,

and Epidemiologic Aspects
Brian Hjelle,1~2~4,' ~ , ~ E. G ~ a d e Wendy
Steven A. J e n i ~ o n ,Diane ,~ B.
Critical Reviews in Clinical Laboratory Sciences Downloaded from informahealthcare.com by CDL-UC San Diego on 01/05/15
Green, Richard M. Feddersen, and Amy A. Scott'

Departments of 'Pathology and 3Medicine, and %ancer Research and Treatment
Center, University of New Mexico Health Sciences Center, and 4United Blood
Services, Albuquerque, New Mexico
* Address for corresp?ndence: Brian Hjelle. M.D.. University of New Mexico School of Medicine, Department of Pathology,
Albuquerque, NM 87131-5301.
Referee: H. Arlsob, Laboratory Centre for Disease Control, Ottawa.
ABSTRACT: Hantaviruses comprise a genus of the family Bunyaviridae. Bunyaviruses are envel-
oped viruses with a negative-sense, tripartite RNA genome. Hantaviruses are etiologic agents for two
acute and severe illnesses of man, hemorrhagic fever with renal syndrome (HFRS) and hantavirus
pulmonary syndrome (HPS). Each hantavirus is primarily associated with a single rodent hnst species
or genus, and is transmitted to man through accidental inhalation or ingestion of virus-contaminated
For personal use only.
rodent excreta. The distribution of hantaviruses is worldwide. HFRS is caused by infection with
Hantaan, Seoul, DobravaBelgrade, and Puumala hantaviruses, all of which are enzootic in murid
rodents of Old World origin. HPS is caused by any of several hantavirus species associated with
indigenous New World rndents of the subfamily Sigmodontinae, family Muridae. HFRS and HPS
have numerous common epidemiologic, clinical, and laboratory characteristics. Common features
include fever, myalgia, thrombocytopenia, neutrophilia, and a profound capillary leak syndrome
associated with hypotension, decreased cardiac output, and shock. Worldwide, HPS is much less
common than HFRS but is associated with a higher mortality rate. Recovery from hantavirus disease
is generally complete, although chronic renal insufficiency may be a rare sequel of J-IFRS.
KEY WORDS: hantaviruses, review; hemorrhagic fever with renal syndrome: hantavirus pulmonary
syndrome; viral immunology; bunyaviruses.
1. INTRODUCTION
The family Bunyaviridae consists of more than 300 individual viruses, most of
which can be assigned to one of five genera.' These genera incIude Bunyavirus,
Hantavirus, Nairovirus, Phlebovirus, and Tospovirus. All except hantaviruses are
transmitted by arthropods, including members of the single plant-associated genus,
the thripborne tospoviruses. The other members of the family Bunyaviridae have
been isolated from mammals, birds, or arthropods. All members of the family are
enveloped viruses, and all possess a genome consisting of three strands of nega-
tive-sense RNA, designated L (large), M (medium), and S (small) (Figure 1). The
1040-8363/95/$.50
0 1995 by CRC Press, Inc.
469
FIGURE 1 Disposition of proteins within the hantavirus virion, and genomic coding strat-
egy. The virus-complementary RNAs (positive sense) are shown. Each mRNA contains a
single large open reading frame. A minor open reading frame, designated NSx, is present
on the S genome of all hantaviruses of sigmodontine or arvicolid rodents. Although it is
universally present in indigenous New World hantaviruses, it has not been shown to encode
a protein. RDRP is the putative RNA-dependent RNA polymerase.
three genomic segments are flanked at each end by short, complementary regions
of 9 to I 1 nucleotides (nt). Intramolecular hybridization of these terminal se-
quences is believed to result in formation of the circular or panhandle-shaped
genomic structures that are sometimes seen in electron micrographs. The se-
quences of the termini are specific for each genus of bunyavirus. There are also
some differences in the precise coding strategies employed by each genus.2 For the
hantaviruses, the L, M, and S genomic segments encode a putative RNA-depen-
dent RNA polymerase (RDRP), the precursor to the G1 and G2 glycoproteins, and
the nucleocapsid protein, respectively (Figure I). There is a second, small open
reading frame in the S segment of other bunyaviruses that encodes a nonstructural
protein, NSs. A similar open reading frame of 158 to 273 nt in length is consistently
found in certain hantaviruses but has not been demonstrated to encode a protein.
The L segment of hantaviruses is typically 6500 to 7000 nt in length; the M
segment is about 3700 nt, and the S segment measures 1600 to 2100 nt.
470
Bunyavirus virions are sensitive to heat, acid pH, detergents, formalin, and
lipid so1vents.l They measure 90 to 100 nm in diameter. Glycoprotein surface
projections are visible by electron microscopy. Despite morphologic and physical
similarities to other members of the family Bunyaviridae, as well as similar genetic
organization, there is no antigenic cross-reactivity between members of the genus
Hantavirus and other bunyaviruses or to other agents of hemorrhagic fever such as
arenaviruses or filo~iruses.*+~
II. HISTORICAL CONSIDERATIONS
Hantaviruses first came to the attention of Western medicine in 1951, when a

severe hemorrhagic illness struck thousands of U.S. troops stationed in Korea.*
High fever, shock, petechiae, hemorrhage, and renal failure were the hallmarks of
the newly recognized illness, which had a mortality of between 5 and 20%.
Uremia, shock, and pulmonary edema were common causes of death.
It was later recognized that epidemics of the Korean hemorrhagic fever had
occurred previously in Russian and Chinese populations, as well as among Japa-
nese troops in China. The first thorough clinical descriptions of the illness were
made by Soviet, Scandinavian, and Japanese investigators (reviewed in Refer-
ence 9). The disease has been known by more than 150 names, including muroid
nephropathy and epidemic hemorrhagic fever, but is now known as hemorrhagic

fever with renal syndrome (HFRS).
The epidemiological features of HFRS suggested that it was a zoonotic dis-
ease. Japanese and Russian investigators established that a virus was the likely
etiologic agent.3Numerous unsuccessful attempts at cultivation of the HFRS virus
were made in the 1950s and 1960s. In 1978, Lee and colleagues isolated Hantaan
virus (HTN), the etiologic agent for HFRS, from the lungs of striped field mice
(Apodernus agrurius).? The breakthrough came after Lee used serum samples of
patients with HFRS as immunologic probes for HFRS-agent antigens in animal
tissues. These studies produced evidence for a high abundance of antigenic mate-
rial in the tissues of this rodent host and allowed isolation attempts to be concen-
trated on tissues of the native host for HTN.
HFRS is a disease of varying severity. In addition to the epidemics of severe
HFRS that occurred primarily in eastern Asia, epidemics of less severe clinical
disease (nephropathia epidemica) had been noted west of the Ural mountains in
Russia, as well as in Scandinavia. The similarity of these diseases led Gajdusek to
conclude, as early as 1953, that similar pathogenic agents were probably in-
v01ved.I~The cultivation of HTN in Korea led to the isolation of a distant relative
of HTN, Puumala virus (PUU), from European bank voles (Clethrionomysglareolus)
in the 1980~.''-'~
In the 1980s, it became apparent that hantaviruses occurred outside of the
known sites of epidemic and endemic HFRS. Lee and colleagues were puzzled by
471
the occurrence of HFRS among residents of urban Seoul who had not had contact
with A. agrarius. A virus that was initially believed to be HTN was isolated from
Norway rats and black rats (Rattus nowegicus and R. rattus).14The Seoul virus
(SEO) was shown to cause HFRS, in a less severe clinical form than that caused
by HTN.14J5These two Rarrus species are extremely successful and widespread
commensals, in some cases displacing indigenous rodent species. It was discov-
ered that the SEO enzootic extended outside of its native Asia into sites as disparate
as Egypt, North America, Brazil, and Europe; SEO was enzootic in urban rats of
Baltimore, MD, as well as many other port cities of North In addition

to SEO, a genetically similar but distinct SEO-like hantavirus (THAI) was isolated
in Thailand from a bandicoot rat (Bandicora indica), a close relative of Rattus.20,21
As the worldwide spread of Asian hantavirus was being documented, Gajdusek
and colleagues sought to establish whether agents with HTN-like serologic prop-
erties could be identified in indigenous New World rodents. This search reached
fruition on the grounds of Gajdusek’s estate in Frederick, MD, with the isolation
of Prospect Hill virus (PH).22PH has not been established as a cause of human
disease. Its serologic and genetic characteristics are more similar to those of PUU
than HTN, THAI, or SE0.23.24PH was isolated from a meadow vole (Microtus
pennsylvanicus), a rodent of the same subfamily (microtinae) as C. glareolus, the
host for PUU. These observations led to the suggestion that hantavirus-host asso-
ciations are the products of ancient and stable coevolutionary histories, an infer-
ence that has been supported abundantly in subsequent studies.?(
111. HANTAVIRUS DISEASE IN THE U S .
Throughout the 198Os, a series of serologic surveys for hantavirus infection

were conducted in indigenous rodents, commensal rodents, and human populations
throughout North A m e r i ~ a . ?These
~ - ~ ~studies established that hantavirus infection
is present in numerous rodent species in the Americas. Antibodies to PH and
serologically similar agents were present in M.pennsylvanicus, M. califomicus,
Clethrionomys gapperi, C. rutilus, Peromyscus maniculatus (the deer mouse),
P. leucopus, P. di‘cilis, P. triiei, Neotoma spp. (woodrats), and Mus musculus
(house m i ~ e ) ~ ’ .(reviewed
~’ in Reference 36). The documentation of human
hantavirus infection in the Americas was more elusive. Searches for HFRS in
North America were inconclusive initially, although some serologic evidence for
human infection with PH-like, HTN-like, or SEO-like viruses was demon-
strated. 17*28.3 Ultimately, Glass and colleagues37were successful in identifying
three cases of mild HFRS contracted in Baltimore. It was also shown that humans
with antibodies to SEO were overrepresented among patients undergoing dialysis
for chronic hypertensive renal disease.38 This intriguing finding was taken as
evidence that hantavirus infection can, on rare occasion, result in long-term dam-
age to the kidney. This finding has not yet been documented outside of Baltimore.
472
A. Discovery of Hantavirus Pulmonary Syndrome
On May 14, 1993, the New Mexico Office of the Medical Investigator (OMI)
notified the New Mexico Department of Health of the occurrence of a cluster of
three unexplained deaths among previously healthy rural residents of northwestern
New Mexico and northeastern Arizona. By May 17, B. Tempest of the Indian
Health Service (IHS) had independently identified five fatal cases. The deaths
occurred near the only site in the U.S. in which the boundaries of four U.S. states
come together (New Mexico, Arizona, Utah, and Colorado), a region commonly
referred to as the Four Comers. One of the index patients was a man who died
while en route to the funeral of his fiande, who had succumbed to a similar
syndrome. Both deaths were associated with acute respiratory failure. The dif-
ferential diagnoses for these patients included plague, anthrax, influenza, and toxins
such as paraquat; however, these agents could be neither isolated nor detected.3941
Consultation was initiated among physicians and scientists at the University of
New Mexico Health Sciences Center (UNM HSC), the IHS, the OMI, and the U.S.
Centers for Disease Control and Prevention (CDC) to identify the cause of the
deaths, even as additional suspected cases of the illness were identified over the
subsequent days. The syndrome was initially referred to as unexplained adult
respiratory distress syndrome (UARDS). UARDS was not characteristic of any
previously identified acute infectious disease, but it has similarities to certain
known hemorrhagic fever syndromes, particularly HFRS (Table 1). Most notably,
these similarities included a prodromal phase of fever, chills, and myalgias, fol-
lowed by hernodynamic instability, shock, thrombocytopenia, neutrophilia with
immature differentiation, and atypical lymphocytosis with plasmacytoid forms and
immunoblasts. HPS differed from HFRS primarily in the seventy and prominence
of pulmonary edema, and in the near absence of renal disease and bleeding.
However, it had been appreciated recently that pulmonary disease in HFRS is a
more common manifestation than previously recognized.“* The similarities were
notable enough that an unspecified “hemorrhagic fever virus” was on the list of
three agents initially considered to be the most probable causes of UARDS in this
consultation. The others were influenza and a “new agent”.
One of the first goals, then, was to investigate the serologic reactivity of
patients with UARDS with antigens derived froni the agents of hemorrhagic fever.
It is fortunate that hantavirus antigens, initially prepared by U.S. Army investiga-
tors, were among those available at the CDC for this purpose. This circumstance
is a direct result of the long-standing interest of the U.S. Army in hantaviruses as
a threat to U.S. troops overseas. Several UARDS patients had immunoglobulin
M (IgM) class antibodies reactive to PUU and SEO. The relatively low-titer
antibodies with reactivity to several hantaviruses suggested that UARDS patients
were infected with a heretofore unknown hantavirus. A reverse transcription-
polymerase chain reaction (RT-PCR) assay was then established, using RNA from
the necropsied tissues of hantavirus-seropositive patients as template and consen-
473
TABLE 1
Clinical and Laboratory Similarities and Differences Between
Hantavirus Pulmonary Syndrome (HPS) and Hemorrhagic Fever
With Renal Syndrome (HFRS)
Abnormality HFRS HPS
Prodrome of fevers, chills, myalgias ++++ ++++

Hypotension +++ - ++++ +++ - ++++
Abdominal pain, nausea + - +++ + - +++

Hemorrhage ++ - ++++ +
Retroperitoneal edema ++++ Not reported
Pulmonary edema + - ++ ++++
Renal failure/azoternia ++++ +
Thrombocytopenia +++ - ++++ ++ - +++
Hemoconcentration ++ - +++ ++ - +++
Neutrophilia ++ - +++ ++ - ++++
Immature differentiation ++ - +++ ++ - +++
Infiltration of atypical lymphocytes ++ ++
sus primers derived from the genetic sequence of related hantaviruses.13 Applica-
tion of RT-PCR resulted in the amplification of a small portion of the M genome
(G2 gene) of a hantavirus from several UARDS patients. The sequence of this
genome resembled most closely the sequence of PUU and PH but was distinct from
any previously characterized h a n t a ~ i r u sUARDS
. ~ ~ ~ ~ was thus renamed hantavirus
pulmonary syndrome (HPS).
The rodent host was identified within the next 2 to 3 weeks after an intensive
trapping campaign was conducted in the Four Comers states of Arizona, New
Mexico, and Colorado.45P. maniculatus, P. truei, and brush mice (P. boylii) were
predominant, and approximately 30% were serologically reactive against hantavirus
antigens. Tissue samples from the great majority of seropositive P. maniculatus
were positive for the new virus by RT-PCR. A smaller fraction of samples from
seropositive P. truei and P. boylii were RT-PCR positive. When a small portion of
the M segment of the hantavirus genome from deer mice was compared with that
of HPS-case patients, preliminary analyses suggested that there was close genetic
similarity between the rodent viruses at particular sites and those identified in HPS-
case patients who were likely to have been infected at those
The new virus was originally called Four Comers hantavirus, but political
concerns led to the adoption of the Name Muerto Canyon virus, and later, Sin
Nombre (“no-name”) virus by some workers. Others preferred to maintain the
more straightforward name FC, which we will use herein. The final name will be
decided by the International Committee for the Taxonomy of Viruses in 1996. As
expected from previous work with hantaviruses, FC proved to be difficult to
isolate. Ultimately, FC was propagated in Vero E6 cells by investigators from the
CDC and from the U.S. Army Research Institute for Infectious Diseases
474
(USAMRIID) from P. maniculatus specimens from New Mexico and California,
respecti~ely.~~*~’
Since the outbreak in the spring and summer of 1993, FC has been found to
be enzootic through much of the range of P. rnanicularus, and HPS has been
reported throughout the western U.S. and Canada.48-51It has been diagnosed
retrospectively in patients with HPS-like illness and characteristic clinical findings
in 1959Is4and 1975,52and in deer mouse tissues obtained in 1975Is5and 1983.53-54
All available data indicate that FC can be genetically detected in deer mice and
human (HPS) specimens as far back as well-preserved tissue samples can be

identified. The likely explanation for the sudden emergence of HPS in 1993 in the
southwestern U.S. has been discussed p r e v i o ~ s l y .This
~ ~ . event
~ ~ is probably best
explained by the well-documented rodent population boom in the fall of 1992,55
which in turn has been linked to high levels of precipitation and heavy vegetation
induced by el nifio weather events.
IV. CLINICAL SYNDROMES DUE TO INFECTION WITH

HANTAVIRUSES
A. HFRS
In a 1954 symposium on Korean hemorrhagic fever, the clinical manifestations

of HFRS were described as “numerous, vaned and follow one another in rapid and
confusing sequence”,8 a description that is as appropriate today as it was then.
Clinical manifestations of HFRS include fever, thrombocytopenia, and renal dys-
function characterized by proteinuria and renal i n s u f f i ~ i e n c y ~(reviewed
~~’ in
References 58 to 63). The most severe form of HFRS occurs primarily in autumn
epidemics throughout eastern Asia, with an estimated 100,000 hospitalizations
reported annually in China a10ne.l~Following exposure, the incubation period
averages approximately 2 weeks, with a range of 5 to 42 d. The four phases of
illness are described as febrile, hypotensive, oliguric, and diuretic, although their
boundaries are indistinct. The febrile phase is characterized by abrupt onset of
fevers as high as 40.0°C, chills, and malaise. Headache and generalized aching are
also frequently described. Abdominal complaints, including nausea, vomiting,
anorexia and abdominal pain, are common. Earle noted that “in a few instances
abdominal pain was so severe as to stimulate an acute condition of the abdomen”.*
Following the development of fever in H F R S , a characteristic rash often appears
consisting of a blanching erythematous flushing of the head, neck, and upper torso.
Conjunctival injection may be seen early in the disease course, with conjunctival
petechiae developing later. Petechiae may also develop in the axillary folds, face,
and neck. The severity and duration of this early phase has been correlated with the
severity of the full course of illness. The febrile prodrome lasts an average of 3 to
5 d, followed by the onset of proteinuria, signaling the hypotensive phase.
475
Hypotension ranges in severity from a mild, transient decrease in blood pres-
sure to profound shock and circulatory collapse. Increasing restlessness and con-
tinued myalgias are common at this time. Neurologic abnormalities such as de-
lirium and coma may be seen in seriously ill patients. Laboratory abnormalities at
this stage include thrombocytopenia, hemoconcentration, and leukocytosis with
left shift (see below). In milder cases of both HFRS and HPS, an absolute or
relative bradycardia has been observed in the presence of hypotension and fever,
which may then progress to tachycardia as shock progresses.
As blood pressure returns to normal, an oliguric phase ensues, with the degree
of oliguria roughly proportional to the severity of the illness. A transient hyperten-
sion may occur during this phase. Despite a return of the platelet count to normal,
hemorrhagic complications may appear, including gross hematuria, ecchymosis,
subconjunctival hemorrhage, and upper GI bleeding. Fatal cerebrovascular acci-
dents have occurred in this phase as well. Severe or life-threatening bleeding
complications appear in only a small percentage of patients. The duration of the
oliguric phase is generally 2 to 5 d. Short-term dialysis has been required but is
generally not necessary due to the relative brevity of the course of illness.
Following the oliguric phase, between days 13 to 21 from the start of the
illness, increased urinary output and overall patient improvement are seen. This
diuretic phase is characterized by improved renal function, loss of proteinuria, and
progression toward recovery in most individuals. Electrolyte abnormalities are
common in both the oliguric and diuretic phases of the illness, and deaths due to
electrolyte and volume derangements in this phase are reported. The original
descriptions of HFRS in 1954 included mention of a feared complication of either
the oliguric or diuretic phase: unexplained, fatal pulmonary edema. Giles et al.
described pulmonary complications in 6% of 828 HFRS patients, with death due
to pulmonary complications in 15 patients.@ Another two patients were described
as having unexplained right heart failure and pulmonary edema. These patients
were all in a negative fluid balance, indicating that overhydration was unlikely to
be the cause. The authors also noted that the retroperitoneal edema seen at post-
mortem in patients dying without pulmonary edema was not seen in those with
pulmonary edema. These pulmonary complications appear to be similar to the
pulmonary manifestations of HPS.
In surviving HFRS patients, the convalescent phase may last several weeks to
months. Eventual complete recovery is the norm.
Treatment of HFRS is largely supportive and consists of hospitalization and
close monitoring during the acute phases of the disease, judicious fluid and
electrolyte support, and use of vasopressors to support blood pressure. The use of
vasopressors is particularly critical during the stages of profound capillary leak.
Dialysis may be required, depending on the degree of renal dysfunction. Specific
antiviral pharmacotherapy includes the use of ribavirin, which has strong activity
against hantaviruses in vitro. A prospective, double-blind, concurrent, placebo-
controlled trial of intravenous ribavirin in acute HFRS found a sevenfold reduction
476
in mortality among the ribavirin treatment Vaccine studies are currently
underway, evaluating both inactivated Hantaan virus vaccines and a recombinant
expressed Hantaan envelope glycoprotein (G 1 and G2) subunit vaccine.66The
recombinant G1 and G2 proteins vaccine has recently been shown to induce
protective antibodies in hamsters and is undergoing initial human immunogenicity
trials.
Infection with SEO is associated with a less severe form of HFRS. Nephropathia
epidemica is a mild, often asymptomatic disease due to PUU. Hemorrha,'oic com-
plications in nephropathia epidemica are rare. Proteinuria and thrombocytopenia

are common but generally mild and transient. Mortality is less than 1%.
B. Hantavirus Pulmonary Syndrome

The incubation time for HPS is believed to be between 7 and 14 d, based on very
limited experience with patients who may have had a single, identifiable rodent
exposure. HPS is characterized by a febrile prodrome followed by a phase of rapid
pulmonary deterioration and ultimately death or an equally rapid recovery. The disease
may be relatively mild, requiring supplemental oxygen and in-hospital observation or
may be fulminant, leading to demise as little as 24 h after presentation. Asymptomatic
infection does not appear to be common, although rare cases of antibody
seropositivity without evidence of clinical illness have been noted, including

scientists involved in rodent trapping. Two individuals treated at the UNM HSC
were diagnosed with type II diabetes mellitus, and two cases have been in pregnant
women. However, the majority of patients do not have underlying immuno-
compromising conditions. One possible mild case in a 3-year-old child has been
identified retrospectively from serum samples collected during routine screening.
The case fatality rate overall is 53%; the case fatality rate for 1994 cases was 42%.67
HPS begins with a typical febrile prodrome consisting of fevers up to 40°C
chills, and prominent myalgias, particularly involving the lower back, buttocks,
thighs, and large muscle groups. Myalgias may be so severe that patients volun-
tarily limit movement. Headache without meningeal signs is common. Abdominal
complaints include nausea, vomiting, diffuse or focal abdominal pain, and mild
diarrhea (Table 1). As with HFRS, abdominal pain may be so severe as to mimic
an acute abdominal disease. Preliminary diagnoses in several HPS patients have
included appendicitis and gastroenteritis. Mild pharyngitis may be present. Find-
ings that are not seen and may help exclude HPS include exudative pharyngitis,
mucopurulent sinusitis, meningismus, and cough productive of purulent s p ~ t u m . ~ ~ + ~ ~
There is no rash or significant lymphadenopathy present in HPS. A common
observation is that patients with HPS often feel much worse than what their initial
physical evaluation by medical personnel reveals. Several visits to a health-care
facility before diagnosis have occurred in some cases. This prodromal phase
typically lasts 4 to 5 d, with a range of 2 to 15 d.40
477
Following the prodromal phase, cardiopulmonary deterioration is heralded by
the onset of shortness of breath. Cough may be present late in the prodrome,
followed by an increase in the respiratory rate and hypoxemia. Chest radiographs
in the early stages may be normal despite a falling blood oxygen level, or they may
show faint bilateral symmetrical interstitial prominence in the lung bases on
upright films. All cases have required supplemental oxygenation, with approxi-
mately 70% of patients requiring intubation. Roentgenographic evidence for pul-
monary edema appears rapidly, within hours to a few days after the first respiratory
symptoms. Chest radiographs at this stage of illness reveal pulmonary edema with
alveolar flooding, Kerley’s B lines, peribronchial cuffing, and fluid within the lung
fissures (Figure 2).69Pleural effusions are common and may be either bilateral or
FIGURE 2. Hantavirus pulmonary syndrome. The chest radiograph above is from a 32-
year-old man who presented to University Hospital in Albuquerque, NM, after 4 d of fever
and myalgias, and 1 d of nonproductive cough and increasing dyspnea. There are promi-
nent interstitial markings and Kerley’s B lines, but the cardiac silhouette is normal. The
radiograph below shows the same patient 4 h later. Alveolar flooding is evident, and the
patient required intubation shortly after this radiographic examination.
478
FIGURE 2. (continued)
unilateral. Hemodynamic instability is heralded by hypotension. The seventy of

pulmonary disease and hemodynamic instability are closely correlated. An abso-
lute or relative bradycardia has been observed early in the course of illness in
several patients, with tachycardia noted on progression of shock.
In a series of patients with HPS treated in the Medical Intensive Care Unit at
UNM HSC in 1993, hemodynamic monitoring was performed using a flow-
directed pulmonary artery catheter. A total of nine patients had catheters placed.
Three of the nine died too rapidly for measurements of cardiac performance to be
completed. In the remaining six patients, several consistent findings were noted,
including a low to normal initial pulmonary artery wedge pressure (PAWP), a low
stroke-volume index (SVI), and a marginally normal or low cardiac index (CI) with
an elevated systemic vascular resistance (SVR). In critically ill patients, a falling
SVI and CI were observed in the presence of s h o ~ k . ’ ~Two
J ~ ~patients for whom
479
transthoracic echocardiograms were performed were found to have poor myocar-
dial contractility (low estimated ejection fractions). Pulmonary secretions are
typically thin, nonpurulent, and have protein and LDH levels approaching that of
serum.4oSecretions may be copious, including one patient who required suctioning
of over 20 1 of fluid over a 24-h interval from the endotracheal tube.
In patients with severe pulmonary disease, adequate oxygenation is neverthe-
less possible through maximum ventilatory support, including 100% FIO, and
reverse I:E ratio ~ e n t i l a t i o n . ~Death
~ . ' ~ ~is usually due to shock and myocardial
dysfunction with progression to pulseless electrical activity. Predictors of mortality

include a serum lactate 24 mmol/l, profound hemoconcentration, cardiac index 12,
and persistent hypotension unresponsive to therapy.
When intubation is necessary, the duration is generally short, averaging 3 to
5 d, with rapid recovery. Prolonged intubation is rare, although some individuals
have required supplemental oxygenation for a period of a few weeks. Mild
asymptomatic hepatic transaminase elevations have been noted to persist well into
convalescence. Complaints of fatigue persisting several weeks after hospitalization
have been noted in at least one survivor. Complete short-term recovery is the norm.
Long-term sequelae are unknown.
Renal dysfunction is not common in HPS. Mild increases in BUN and creati-
nine have been seen in severe!y ill patients with hypovolemic instability, and
proteinuria may appear preterminally. There are reports of more atypical cases of
acute febrile illness with serologic evidence of infection where renal dysfunction
has been a more prominent feature of disease, including a case in Florida and a case
under investigation in Arizona.'l It is unclear at this time whether the renal
dysfunction seen in these cases is due to the infection per se or occurs as a
complication of hypoperfusion and shock.
Treatment of acute HPS involves early hospitalization and aggressive inten-
sive care management. Judicious use of fluids, vasopressors, and inotropic support
are often necessary. Extracorporeal membrane oxygenation (ECMO) has been
attempted in two individuals who met the criteria for severe disease with all known
predictors of demise, including profound hypotension unresponsive to fluids,
dopamine, dobutamine, and epinephrine; serum lactate 14 mmol/l; and evidence of
a vascular leak, including hemoconcentration, low albumin, hypoxemia, and pul-
monary edema. ECMO was successful in one patient, who required 72 h of support
followed by eventual recovery, and was unsuccessful in the other patient.
Specific pharmacotherapy is not established. Despite the success of intrave-
nous ribavirin in HFRS, an open label trial of intravenous ribavirin for acute HPS
failed to show convincing evidence of efficacy.67 A placebo-controlled trial is
planned. Broad-spectrum antibiotics are recommended until a firm diagnosis is
established in patients presenting with acute febrile illnesses resembling HPS.
Patients transferred to the UNM HSC for evaluation of possible HPS have been
diagnosed with a wide range of other severe bacterial and viral illnesses, including
septicemic plague, meningococcemia, Cumpylobucter sepsis, miliary tuberculosis,
480
influenza, fulminant endocarditis, and Klebsiella sepsis. For this reason, isolation
precautions, including contact and respiratory isolation, are enforced until a diag-
nosis is clearly established. Although FC RNA has been detected in one of three
samples of endotracheal lavage fluid, there is at present no evidence to support
nosocomial transmission of FC.
V. LABORATORY ABNORMALITIES ASSOCIATED WITH

HANTAVIRUS INFECTION
The total white blood cell counts in HPS are frequently elevated, particularly
in patients with pulmonary capillary leak syndrome, ranging from 6.4 to 45 x 109L
All patients with HPS display an immature myeloid maturation manifested by
circulating myel-ocytes and/or promyelocytes (Figures 3 and 4).41 The absolute
FIGURE 3. Hantavirus pulmonary syndrome. Peripheral blood film. (Wright’s stain; mag-
nification x 400.) Morphologic findings in a patient with fatal HPS are apparent, including
hernoconcentration, thrombocytopenia, leukocytosis with a left shift, and circulating
immunoblasts.
481
FIGURE 4. Hantavirus pulmonary syndrome. Two immunoblasts and a neutrophil are

shown. The immunoblast on the left has plasmacytoid features. Peripheral blood film.
(Wright's stain; magnification x 1000.)
neutrophil count ranges from 5.0 to 37.0 x 109/l. Toxic granulation is generally
mild or absent. Although the absolute lymphocyte counts are usually not high, with
a range of 1.0 to 6.8 x 109/1, the manual lymphocyte differential counts consistently
show greater than 10% immunoblasts. Immunoblasts in HPS are characterized by
a high nuclear-cytoplasmic ratio, variably prominent nucleoli, and basophilic
cytoplasm (Figure 4).
A spectrum of immunoblast morphology is observed, with plasmacytoid fea-
tures as well as azurophilic cytoplasmic granulation. Increased hemoglobin and
hematocrit are often present in patients with severe HPS. The highest levels
(hemoglobin, 23.8 g/dl; hematocrit, 67%) are observed in patients with florid
pulmonary edema. The red blood cell morphology is unremarkable except for the
presence of nucleated erythrocytes and rare spherocytes in some cases.
Microangiopathic changes such as red blood cell fragmentation are not seen.
Thrombocytopenia ( ~ 1 5 x0 109/1) with normal platelet morphology is found in all
cases, with a range of 21 to 155 x 109/1and a median of 64 x 109/l.
The constellation of left shift to the myelocyte stage, >lo% immunoblasts and
plasmacytoid lymphocytes, thrombocytopenia, and (in severe cases) elevated he-
matocrit is highly predictive of HPS. Coagulation studies show no consistent
pattern of abnormality, nor is there evidence of clinical hemorrhage or dissemi-
nated intravascular c~agulopathy."-~~ Although all patients have thrombocytopenia,
482
the platelet counts do not correlate with the clinical seventy of the illness. Pro-
thrombin (PT) and activated partial thromboplastin times (aPTT) are usually
slightly prolonged, with a median and (range) of 13.4 s (1 1.3 to 14.2) and 39 s (3 1
to 40), respectively. Severely increased PT (53 to >I50 s) and aPTT (200 and
356 s) as well as positive assays for plasma fibrinogen D-dimers may occur in the
agonal stage of illness. Plasma fibrinogen is normal, ranging from 213 to 510 g/l.
Hypoproteinemia in conjunction with hemoconcentration reflects the hemody-
namic derangements that occur in HPS. Serum albumin levels are depressed in
terminal patients as well as in those who survive. The mean admission level for
both groups of patients studied at UNM HSC was 2.8 g/l. Lactate dehydrogenase
levels are universally elevated in patients with HPS, and elevated alanine ami-
notransferase levels and lactic acidosis are common.4o
VI. AUTOPSY PATHOLOGY
There are more pathological similarities between HFRS and HPS than are first
apparent. After the nonspecific prodrome, there is an abrupt loss of plasma from
the intravascular space, with hemoconcentration and hypotension. The lung alveoli
and pleural spaces are the exclusive site of this fluid transudation in HPS. By
contrast, the retroperitoneum is the primary site of third-space fluid collection in
H F R S . However, one necropsy study noted a much higher frequency of pulmonary

edema than has been recorded in clinical This feature was largely
confined to the oliguric and diuretic phases of HFRS, and could result from fluid
retention rather than the primary abnormality of the pulmonary vasculature that is
seen in HPS. In both HFRS and HPS, there is a similar infiltration of reticuloen-
dothelial organs by enlarged. atypical mononuclear cells.41.72~73
A. HFRS
Capillary engorgement and focal hemorrhages are widely distributed. In the

renal medulla, it is difficult to distinguish congestion from recent hemorrhage.
Despite these findings, hemorrhagic complications appear to be an uncommon
cause of mortality in HFRS. The areas of red cell extravasation show intense
capillary congestion without vessel wall inflammation or necrosis, and thus do not
represent a true vasculitis. A similar morphology characterizes the hemorrhagic
lesions frequently seen in the renal medulla, serosal surfaces, pituitary, and right
atrial endocardia1 cell^.^'-^^
B. HPS
Sizeable pleural effusions are found in all cases, while the abdominal and
pericardial cavities remain unaffected. The lungs are contracted, poorly aerated,
483
and heavy. Low-power microscopy of the lungs reveal striking accumulations of
edema fluid in the interlobular fissures, often with distention of the associated
lymphatics (Figure 5 ) . The amount of alveolar fluid varies with specimen prepa-
ration, but is extensive in at least some lung fields in all subjects. The airspace
exudate is poorly cellular, consisting mainly of fibrin (Figures 5 to 7). The fibrin
may appear condensed into eosinophilic bands indistinguishable from classic
hyaline membranes, but more commonly appears as a fine meshwork filling the
alveolar space. The interstitium is minimally thickened and contains a mild mono-
nuclear infiltrate. Activated immunoblastic cells similar to those circulating in the

peripheral blood are a consistent component of the infiltrate. At both the light and
electron microscopic levels, the alveolar epithelium appears well preserved, with
little Type I1 pneumocyte activation. Hyaline membrane-like structures have the
ultrastructural appearance of fibrin, without the preponderance of necrotic cellular
debris usually described in classical cases of adult respiratory distress syndrome.
About 50% of cases show significant mononuclear infiltration of the hepatic
portal tracts. Frequent imrnunoblasts are present; otherwise, the triaditis is without
distinguishing features. Similar infiltrates are noted in the lymph node paracortex
and splenic white pulp in most cases.41
FIGURE 5. Hantavirus pulmonary syndrome. An interlobular fissure is enlarged by edema

fluid, including a distended septa1 lymphatic at left. Alveolar structures are well preserved.
In the lower half of the field, alveolar spaces contain fine strands of fibrin. In the upper half,
the fibrin has condensed into thick hyaline membranes. (Lung; magnification x 100.)
484
FIGURE 6. Hantavirus pulmonary syndrome. An intact alveolar wall with type I pneumocyte,
basement membrane, endothelial cell, and circulating red blood cell (curved arrow) are
shown. A fibrin aggregate (arrowhead) lies within the alveolar space and apposed to the
pneumocyte lining. (Lung transmission electron microscopy; original magnification x 4000.)
FIGURE 7 . Hantavirus pulmonary syndrome. There is mild septa1 thickening and mono-
nuclear infiltration. A fibrin meshwork largely fills two adjacent alveoli. There is very little
cellular exudation into the airspaces. (Lung: magnification x 400.)
Particles of the appropriate size and shape for bunyaviruses have been noted
in the cytoplasm of pulmonary endothelial cells during electron microscopic
examination. Hantavirus nucleocapsid antigen is detectable in paraffin sections
using routine immunohistochemical methods (Figure 8).75376The virus localizes
almost exclusively in vascular endothelium, mainly of capillaries. This result is
compatible with in v i m studies demonstrating hantavirus tropism for human
endothelial cells, although some nonendothelial cells are also capable of support-
ing viral r e p l i ~ a t i o n . Occasional
~~.~~ blood lymphocytes and alveolar macrophage
also give positive reactions. Although endothelial cells are positive in heart,
kidney, adrenal, soft tissue, and other organs, the intensity of staining is by far the
greatest in the alveolar capillaries of the lungs. The inflammatory reaction within
the lung interstitium is composed of T-lymphocytes and histiocytes, with a distinct
paucity of B-lymphocytes.
Considered collectively, many features of HFRS and HPS suggest an immu-
nologic basis for pathogenesis. The viruses themselves cause little or no cytopathic
abnormality in tissue culture, nor is there evidence for gross disruption of capillary
FIGURE 8. Hantavirus pulmonary syndrome. The tissue has been stained with a polyclonal
mouse serum reactive (titer 1:16,000) against recombinant FC nucleocapsid protein. The
staining appears within the endothelium of an alveolar capillary. Immune complexes (arrow-
heads) were detected with alkaline phosphatase-conjugated goat anti-mouse secondary
antibody. The arrowheads are in the vessel lumen, where blood elements are apparent. The
plus sign is in the alveolar airspace. (Lung; magnification x 100.)
endothelial cells on histologic studies in patients. Patients with HPS universally
have readily detectable hantavirus-specific serum IgG antibodies on Western blot
by the onset of pulmonary disease. The tissue infiltration of atypical lymphocytes,
with the simultaneous appearance of immunoblasts and pulmonary symptoms, are
also suggestive of an immune pathogenesis.
Abnormal levels of mediators such as tumor necrosis factor and kinins have
been tentatively associated with HFRS.79-sIIf the pathogeneses of HPS and HFRS
are found to have a largely immunologic basis, it could substantially change the
therapeutic options to favor modalities that interrupt or augment the production of

specific immune mediators, or otherwise manipulate the immune response, in
preference to antiviral therapies.
Studies of the pathogenesis of HFRS and HPS are limited by the lack of an
animal model that mimics these human diseases, although a fatal disease that does
not resemble HFRS is induced by HTN in suckling mice after intracerebral
inoculation.82
VII. DEVELOPMENT OF DIAGNOSTIC CAPABILITIES FOR

HANTAVIRUS INFECTION
In the summer of 1993, there existed no capacity for the timely diagnosis of
FC infection in living patients. This *iced was considered urgent, for many rea-
s o n ~ Because
. ~ ~ the clinical syndrome was poorly defined, there was a sizable
influx of patients with HPS as a possible diagnosis presenting to UNM HSC.
Despite the lack of precedent for the nosocomial spread of other hantaviruses, the
predominance of pulmonary attack in HPS meant that the possibility of airborne
spread of FC in the hospital setting could not be excluded. Patients in whom a
diagnosis of H P S was considered were maintained in respiratory isolation. Ribavirin,
a broad-spectrum antiviral drug, was offered in an “open label” (uncontrolled)
clinical trial from June 1993 through August, 1994.67The lack of local capability
for serologic testing (with associated long delays in diagnosis) and lack of homolo-
gous hantavirus antibody tests anywhere inevitably meant that patients with dis-
eases other than HPS would be subjected unnecessarily to this toxic but potentially
therapeutic agent.
Initially, a collaboration between UNM HSC and CDC was established in
which consensus hantavirus RT-PCR primers were applied in amplification of FC
cDNA from the blood components of patients with suspected HPS. This strategy
proved successful. Twenty of 20 seropositive patients who were studied in the
acute phase of infection had detectable FC RNA in their peripheral blood mono-
nuclear cell compartment or in blood clot samples. A smaller fraction, eight of 11
acute serum or plasma samples, had detectable FC RNA. Nine convalescent case-
patients examined 4 weeks or more after hospitalization were negative for FC
mA.84.158
487
Although the RT-PCR assay was helpful diagnostically during the early stages
of the outbreak, a homologous antibody test was necessary both for rapid diagnosis
of acute illness and for diagnosis of past infection. Traditionally, such a test
depended upon the isolation of the causative agent in tissue culture and use of the
cultured virus as antigen source. Isolation of hantaviruses is notoriously inefficient
and uncertain and potentially hazardous to laboratory workers. Because it was
unclear whether and when FC would be propagated in tissue culture, the most
expeditious means for the generation of FC antigens for the detection of serum
hantavirus antibodies was through recombinant DNA-based method^.^^.^^ The

rapid development of homologous, recombinant antigen-based diagnostic capabili-
ties has resulted in a greatly accelerated understanding of the epidemiology and
magnitude of disease due to FC and related agents.
VIII. IMMUNE RESPONSES TO HANTAVIRUS INFECTIONS
Members of the H U ~ ~ U Vgenus ~ ~ Kare

S antigenically distinct from viruses of
other genera within the family B ~ n y a v i r i d a e .Hantavirus
~.~~ nucleocapsid proteins
(N) are highly antigenic and induce antibody responses that cross-react extensively
with heterologous hantavirus N proteins.7*23-2i-88-94 N antibodies do not neutralize
infectious virus in v i m and do not protect laboratory animals from experimental
infection^.^^.^^*^^ In contrast, envelope glycoprotein (G1 and G2) responses tend to

be more virus type specific, and include neutralizing antibodies that block virus
infectivity in vitro and in laboratory animals.'6,23~24.66.86.90~9t.95-101
Humoral immune responses to hantavirus antigens have been characterized
extensively in their usual rodent hosts, in infected humans, and in experimental
animals. Antibody responses to experimental infections, to immunization with
virions and virus-infected cell lysates, and to immunization with hantavirus-
encoded recombinant proteins have been examined. The characterization of mono-
clonal antibodies generated against HTN and PUU in particular have provided
important information about the specificities and biological functions of nucleo-
capsid and glycoprotein antibodies.2J.89-9'.97-g9~'01 Measures of hantavirus antibody
functions have included (1) reactivity with denatured virus proteins in Western blot
assays, (2) reactivity with nondenatured virus proteins in enzyme immunoassays
(EIA), radioimmunoassays (RIA), and radioimmunoprecipitation assays (RIPA),
(3) inhibition of virus glycoprotein-mediated red blood cell agglutination (hemag-
glutination inhibition or HAI), and (4) neutralization of virus infectivity. The
plaque reduction neutralization test (PRNT) is a commonly used measure of virus-
neutralizing activity that detects type-specific antibody r e s p ~ n s e s . ' J ~In
, ~ the
~,~~
PRNT, infectious virions are incubated with test antibodies before plating them
onto a permissive cell line; virus-neutralizing activity is measured as a reduction
in the number of resultant virus plaques.
Hantavirus N proteins are highly antigenic in natural infections and as immu-
nogens. Both IgM and IgG N antibodies are detected in serum at the onset of
488
symptoms in HFRS and in HPS.86J02-io4 N antibodies reach high titers and can be
detectable for d e c a d e ~ . ~ ?Among
J ~ ~ - ~FC-infected
~~ deer mice, strong FC N re-
sponses are detected in Western blot assays.Io7When hantavirus virions have been
used to generate monoclonal antibodies in mice, the vast majority of the antibodies
have been directed against N.89-91
Hantavirus N polyclonal antibody responses are complex and consist of anti-
bodies with different specificitie~.'j.*~.~~ N polyclonal responses include antibodies
that cross-react with the N proteins of related hantaviruses, and the strength of the
cross reactivity vanes with the closeness of the evolutionary relatedness of the
viruses.21~24J08For example, N antibodies generated against a Korean HTN isolate
cross-react strongly with the N protein of a Chinese HTN isolate, less strongly with
a Brazilian SEO isolate, and weakly with a Finnish PUU isolate. In addition to the
cross-reactive N antibodies, N responses also include antibodies with type-specific
reactivitie~.~~~~'J~~
In both human and P. rnanicularus FC infections, an immunodominant region
has been localized within the amino-terminal 59 amino acids of FC N.86.i07Anti-
bodies that react within this region cross-react strongly with PUU N and PH N, and
cross-react weakly with SEO N and HTN N. This portion of the FC N polypeptide
may be homologous to a region of PUU N that was characterized by using
Clethrionomys glareolus monoclonal a n t i b o d i e ~Lundkvist
.~~ and Niklasson dem-
onstrated that bank vole N monoclonal antibodies generated against a Scandina-
vian PUU isolate displayed different patterns of cross-reactivity with heterologous

N proteins but competed with one another for nearby or overlapping e p i t o p e ~ . ~ ~
Monoclonal antibodies that reacted within this region included ( I ) antibodies that
cross-reacted with PH, SEO, and HTN, (2) antibodies that cross-reacted with PH
and not SEO or HTN, and (3) antibodies that cross-reacted with SEO and HTN but
not with two Russian PUU isolates (K-27 and CG-1820). Similarly, Yamada et al.
demonstrated that the monoclonal antibody GB04-BF07 generated against Scan-
dinavian PUU strain 83-223L9Icross-reacted strongly with FC and SEO but did not
cross-react with Russian PUU strain P36O.lo7The cross-reactive FC N epitope
recognized by GB04-BF07 mapped to the immunodominant amino-terminal 59
amino acid residues.
The immunodominant N region is sufficiently conserved that polyclonal anti-
body responses generally cross-react with heterologous N However, in
different PUU isolates, the immunodominant region contains a significant anti-
genic variation.*lOJ1'
The GI and G2 polypeptides form heterodimers in hantavirus-infected cells,
and these glycoproteins together appear to contribute to some conformation-
dependent epitopes.66J00J0iJ I2l1l3 Both G 1 and G2 antibody responses include
Passive transfer of neutraliz-
antibodies that neutralize virus infectivity.66.90~9s-g8~101
ing G I or G2 antibodies to susceptible experimental animals, unlike antibodies to
N, blocks infection on subsequent challenge with infectious virus. Immunization
of susceptible animals with HTN G1 and G2 together blocks HTN infection on
489
subsequent virus challenge, which was determined by the lack of development of
HTN N antibodies. Immunization with either G1 or G2 alone suppresses viral
replication (viral antigens are not detected in the lung at necropsy) but does not
block infection entirely because HTN N antibodies are elicited following virus
challenge.66 Therefore, it appears that G1 and G2 interact to elicit immune re-
sponses that block subsequent viral infections. These protective responses are
generally specific for each virus serotype.
G1- and G2-neutralizing antibodies probably act by blocking virus attachment
to cellular cytoplasmic membranes or by blocking the subsequent fusion of viral

and cellular membranes. G1 and G2 antibodies also block the ability of hantavirus
virions to agglutinate erythrocytes (hemagglutination inhibition). Hemagglutina-
tion results from the attachment of virion membrane glycoproteins to erythrocyte
membranes. For the most part, G1 and G2 antibodies that neutralize virus infec-
tivity also inhibit h e m a g g l ~ t i n a t i o n . ~Most
~ , ~ ~antibodies
.~~ with neutralizing and
HA1 activity react with discontinuous (conformation-dependent) epitopes and do
not react with denatured G1 or G2 proteins. G1 and G2 antibody responses also
include antibodies that react with continuous (or linear) epitopes, but these anti-
bodies generally do not exhibit virus-neutralizing or HA1 activities.
G1 antibodies are generally specific for. a given virus serotype and do not
cross-react with heterologous G1 protein^.^^.^^,^',^^ G2 antibody responses are
intermediate in specificity between serotype-specific G 1 responses and serotype-
common N responses, and generdly cross-react with some but not all related
hanta~iruses.~ Curiously,
~ . ~ ~ . ~ some
~ G 1 monoclonal antibodies that were generated
against native hantavirus proteins display binding with G2, and some G2 mono-
clonal antibodies display binding with G1. This suggests that both G1 and G2
contribute antibody-binding elements to the full epitopes, and that the individual
glycoproteins retain some binding affinity for the antibodies.
Wang et al. analyzed HTN mutants that had escaped the virus-neutralizing
effects of HTN G1 and G2 monoclonal antibodies.lol For G1 monoclonal antibod-
ies (MAbs), specific G1 amino acid changes were detected at positions 217, 304,
and 415, respectively. For G2 mutants, specific G2 amino acid changes were
detected at positions 719 and 795, respectively. In most cases, the mutants were
resistant only to the neutralizing effects of the MAb with which they had been
selected, and remained sensitive to the effects of other neutralizing antibodies.
However, one G1 MAb escape mutant also was found to be resistant to the
neutralizing effects of a G2 MAb, and one G2 MAb escape mutant was found to
be resistant to two G1 MAbs. Further genetic analysis revealed that the G2 MAb
had selected for mutants that contained both a G2 amino acid substitution and a G1
amino acid substitution. The G1 amino acid substitution was in the same position
as a substitution that had been selected by a G1 MAb escape mutant. These
findings support the hypothesis that both the G1 and G2 polypeptides contribute
elements to a conformation-dependent epitope that is recognized by neutralizing
antibodies.
490
In addition, Wang et al. mapped the locations of linear polypeptide segments
recognized by nonneutralizing HTN G1 and G2 MAbs.Ioi The GI MAbs mapped
to an amino-proximal segment of G1, and the G2 MAbs mapped to a carboxy-
proximal segment of G2.
In human PUU infections, GI antibodies are detected in acute and early
convalescent serum samples, lagging somewhat behind N antibody re-
s p o n s e ~ . G2 ~ antibody
~ ~ ~ ~reactivities
~ ~ ~ ~are ~ not
~ ~detected
’ ~ within the first 5
weeks following infection but rise gradually to high titers over subsequent weeks.
N, G1, and G2 antibodies are detected at high titers 2 years following acute
infect ion. i02~104
In HPS, human antibody responses include both IgM and IgG antibodies that
react with linear epitopes of the FC G1 polypeptide.86 FC G1 IgG antibodies are
detected at the onset of disease symptoms, but IgM antibodies are sometimes
present at low or undetectable levels. The human FC G1 antibodies are type
specific and do not cross-react with PUU G1 or PH G1. In contrast, human FC N
antibodies cross-react strongly with PUU N and PH N proteins. A dominant linear
epitope recognized by human FC G1 antibodies has been mapped to an amino-
proximal portion of G1 (between amino acids 58 and 88).
The detection of FC N and FC G1 antibodies in serum is the basis for virus
serotype-specific diagnosis of human FC infections. Hantavirus recombinant pro-
teins have been used commonly as antigen targets in serodiagnostic assays, because
of the difficulty in obtaining adequate amounts of native viral proteins.85.86.114-116 In

the FC Western blot assay, serum samples are tested for the presence of IgG and
IgM antibodies that react with recombinant FC N and G1 proteins. IgG and IgM
antibodies to FC N, and IgG antibodies to FC G1, are present in acute HPS. IgM
antibodies to FC GI are often, but not invariably, detected (Figure 9). The presence
of IgG and IgM antibodies to FC N indicates that the patient is infected with FC
or a closely related hantavirus. FC has been propagated successfully in cell
~ . ~be~ of interest to compare the results of FC type-specific recom-
c u l t ~ r e .It~will
binant Western blot assays to the results of PRNT using native FC virions.
IX. EPIDEMIOLOGY OF HFRS AND HPS
Most cases of human illness associated with hantavirus have resulted from
exposure to wild rodents. No arthropod vector has been implicated in the transmis-
sion of hantaviruses, and most examples of transmission are believed to occur via
the inhalation of aerosolized rodent excreta. A small number of cases are believed
to have occurred in association with rodent bites, or with needles contaminated
with rodent b l ~ o d . ” ~HFRS
- ~ ~ has
~ also resulted from even brief exposure to
infected laboratory rats,i20J2iwith more than I00 laboratory-acquired cases re-
corded in Japan alone.119A laboratory outbreak occurred in Moscow in 1961,
affecting 113 of 186 workers or visitors to a specific laboratory.lZ2Seroconversion
491
FIGURE 9. Hantavirus pulmonary syndrome. FC recombinant western blot assay. Each

panel is a replicate Western blot that contains FC N (N) and FC G1 ( G l ) proteins in separate
lanese6The first two panels were reacted with serum from a patient with a clinical syndrome
consistent with HPS. Separate blots were used to detect IgG antibodies (first panel) and IgM
antibodies (second panel). The serum sample was found to contain strong IgG and IgM
reactivities to FC N, a strong IgG reactivity to FC G1, and a weak IgM reactivity to FC G1.
This pattern is typically seen in patients presenting with acute HPS. Positive and negative
control serum samples, respectively, were tested with blots shown in the last two panels.
has been noted among four individuals working with culture-adapted HTN.159At
least three were asymptomatic; another, who also worked with infected rodents,
may have experienced a mild case of HFRS.
The incidence of HFRS is highest in workers in certain agricultural occupa-
tions, such as threshers.Iz3 There was a male predominance of nearly 2:1, and
nearly all cases occurred in those older than 9 years. Male individuals engaged in
heavy farm work were at highest risk, especially if they slept on the ground. In
studies of HFRS due to PUU in Russia and Sweden, the ratio of male-to-female
cases was 4.6:l and 1.8:1, respectively.124Detailed surveys to try to establish the
relative contributions of Apodemus species as compared with R a m s to HFRS in
China have been ~0nducted.I~ These studies showed that the virus camed by
A. agrurius and A. peninsulae (HTN) in rural areas carries a higher morbidity than
the R. norvegicus virus (SEO) from urban sites.
492
Because HPS is rare, less is known with precision about the nature of expo-
sures that lead to infection by FC and the development of HPS. The demographic
features of HPS patients are roughly similar to those of HFRS patients in Asia and
Europe, although the preponderance of males is less pronounced. Of note is the
absence of HPS among children younger than 11 years, the large preponderance
of patients who reside in rural areas, and the paucity of urban dwellers. HPS
patients range in age from 1 1 to 69 years, with a mean of 35 years. There is a slight
excess of males, and a relative overrepresentation (about 1/3 of cases) of American

Indians among HPS case-patients. Speculations about any inherent predisposition
among Indians should be tempered by recognition that few members of other North
American ethnic groups are engaged in the highly rural lifestyle that is common
among Western Indian tribes.
It is presumed that the risk of HPS is proportional to the extent of exposure to
deer mice or their excreta. A high fraction of HPS case-patients report recent
sightings of rodents or engaging in agricultural activities such as plowing, and
many others report a recent history of cleaning or worhng in closed spaces with
evidence of rodent infestations, such as outbuildings used to store food or ga-
r a g e ~ . Many
' ~ ~ other idiosyncratic activities that are believed to have resulted in
exposure have been reported. Anecdotally, there are specific instances in which FC
was probably contracted during a camping trip,126from (wild) pet rodents,127or
where infected rodents had infested the patient's automobile.160One observation of

relevance to health-care workers is thc absence of documented examples of trans-
mission of hantaviruses among humans, either in the patient care setting or the
laboratory setting.
Preliminary results using the new technology of molecular epidemiology
suggest that valuable clues about the likely sites of patient exposure can be derived
by thorough characterization of FC genotypes among rodents at candidate sites of
exposure, and comparison of those genotypes with those from the tissues of the
case patient.161In four of six such investigations, one or more rodent viral sequence
has been identified with a perfect genetic match to that of the case patient.
Geographidgenetic linkages established from one viral segment are invariably
supported by analyses of a second viral segment. Both worksites and homesites
have been incriminated, but in no case was a perfect match identified at more than
one possible site of exposure. There was a plausible exposure history at the site
from which the matching rodent virus sequence was obtained for each investiga-
tion. It is expected that such molecular investigations will greatly augment the use
of classic epidemiologic investigations in identifying precise modes of transmis-
sion to man, by focusing investigations on those sites with viral genotypes in
circulation that match those of the case patients.
A question that frequently arises concerns the utility and scientific value of
quantitating the extent of shedding of hantaviruses by infected rodent hosts, either
with environmental samples or in laboratory-bred rodents. This issue has been
studied to a limited extent in experimentally infected r o d e n t ~ . ~The ~ ~gold
J~~
493
standard for quantitation of viral infectivity is, of course, viral isolation in tissue
culture or passage into nahe animals. For FC, which required a substantial effort
involving scores of tissue samples before laboratory propagation was accom-
p l i ~ h e d , ~meaningful
~,~' measure of viral excretion will presumably require isola-
tion methods of higher efficiency than those available presently. In a case in which
a recently established colony of 80 P. maniculatus specimens was found to contain
nine seropositive animals, it was noted that no seroconversion could be detected
in the colony after removal of the seropositive specimens.'62This finding suggests
that intracage transmission of FC is not very efficient in a laboratory setting, but

this issue needs to be examined more thoroughly.
Of particular concern are those who may be placed at risk through occupational
exposures. Such events enforce consideration of biosafety precautions that may
prove costly financially or in terms of productivity and comfort. There are several
well-publicized examples, both US. and Canadian, of occurrence of HPS in
persons engaged in field biology, such as ornithologists and mammalogists. At
least one additional case occurred in an electric utility worker who may have
contracted his infection through field activities associated with his
Published guidelines advise against contact with wild rodents, their burrows, or
activities that may aerosolize rodent excreta.I3O Mammalogists and vector biolo-
gists whose work necessitates contact with known hantavirus hosts are advised to
wear protective garments such as surgical gowns, shoe covers, two layers of latex
gloves, and a half-face respirator; a!ternatively, a powered air-purifying respirator

(PAPR) gown may be e m p l ~ y e d . ' ~ ' . ' ~ ~
Although patients who contract HPS can frequently recall significant exposure
to rodents or their excreta, it is clear also that only a minute fraction of persons so
exposed develop HPS. The low case-exposure rate has no adequate explanation at
present. It does not appear that there is a large cohort of individuals who have
undergone asymptomatic seroconversion to FC. The measured hantavirus
seroprevalence among professional mammalogists in North America is slightly
less than 1%,29,30J33 although one study placed the seroprevalence at about 2%.3*
The subjects of these studies included many with years of close exposure to
thousands of rodent of species that are known hosts to hantaviruses. The few
seropositive mammalogists could also have been exposed to any of a number of
hantavirus species other than those used as reagents in the serosurveys (PH and
FC), due to the known cross-reactivity among hantavirus nucleocapsid antigens.
The apparent low attack rate for HPS among individuals with prolonged and
extensive exposure to wild rodents indicates that the concern generated by the rare
but serious infection should be balanced against the societal costs associated with
highly restrictive biosafety practices. Because some knowledge is now available
about events that place people at increased risk for HPS, such as rodent infestations
of homes and outbuildings, the most promising strategies for reducing the inci-
dence of HPS include public education in methods that reduce exposure to
hantavirus-infected rodents and their excreta. Sealing off points of rodent access
494
into buildings, as well as trapping and poisoning campaigns in buildings that are
prone to rodent infestation, should be helpful in reducing exposure risk. Potentially
infectious material (e.g., rodent feces or carcasses) should be disposed of in sealed
containers by individuals wearing gloves and high-efficiency particle (HEPA)
masks, after spraying the material with a 10% bleach or Lysol solution.
X. DIVERSITY OF AGENTS IMPLICATED IN HANTAVIRUS

PULMONARY SYNDROME
As of mid-February 1995, 103 cases of HPS had been reported in 21 U.S.

states, with 3 cases in British Columbia, 4 in Alberta, and 3 in Brazil. All but four
U.S. cases and the Brazilian cases occurred within the habitation range of
P. maniculatus. In the majority of cases of HPS that occurred within the range of
P. maniculatus, there is either genetic evidence or serologic evidence (i.e., sero-
logic reactivity with the FC GI glycoprotein) incriminating FC as the responsible
viral s p e ~ i e s . ~ ~ - ~ *
The UNM HSC database presently includes 67 HPS case patients and two
asymptomatic but seropositive mammalogists studied by serologic and/or PCR
methods from 11 US. states and two Canadian provinces. Twenty-nine of 29
patients with acute HPS from within the range of P. maniculatus studied by RT-
PCR produced a viral amplimer that was clearly derived from FC. In 36 cases,
patients who resided within the range of P. maniculatus were judged to have had
FC on the basis of a compatible clinical history and a positive Western blot assay
(including reactivity to the FC-specific G1 glycoprotein), even in the absence of
genetic verification of FC infection. Some of the latter group were convalescent at
the time that blood was sampled; for others, tissue, blood clot, or anticoagulated
blood samples were not available. Of case patients residing within the range of
P. maniculatus, none lacked detectable serum antibodies to G1. These data support
the notion that FC is responsible for the majority of HPS cases that occur within
the range of P. maniculutus. However, it is not possible to exclude the possibility
that hantaviruses other than FC can produce a small number of HPS cases, even
within the range of P. manicularus. At least six other hantaviruses occur in rodent
hosts with ranges overlapping with that of P. maniculatus; two of the six have been
associated with HPS (see below).
Study of the HPS case-patients who were infected outside of the range of
P. maniculatus has revealed that at least four other hantaviruses can cause HPS.
For two cases, from Louisiana and Brazil, that inference is based solely on the
detection of genetically distinct cDNA sequences from the tissues of HPS patients
at a ~ t o p s y . ' The
~ ~ Jrodent
~ ~ hosts for these genetically novel hantaviruses have not
been identified. The designation Bayou virus (BAY) has been used for the virus
from Louisiana.'34
A nonfatal case of HPS was recognized in southern Florida. but acute-stage
blood samples that might have contained the genetic material of the hantavirus
495
were not saved. Cotton rats (Sigmodon hispidus) were predominant among the
rodents trapped at the likely site of infection and represented the only species with
detectable prevalence for h a n t a ~ i r u s . A
~ ~hantavirus
J~~ called Black Creek Canal
virus (BCC) was isolated from a S. hispidus specimen.136The Florida case-
patient’s antibodies were more strongly reactive with BCC antigens than with FC
(Sin Nombre isolate) antigens. Interestingly, there was slight cross-reactivity be-
tween the G1 antigen of BCC and FC, in Western blot format.i37This result
suggests that BCC and FC are antigenically related hantaviruses.
A young patient died of HPS in Rhode Island in January 1994.138He had

traveled extensively in both New York (urban New York City, Long Island, and
Shelter Island) and Rhode Island, but had not traveled within the habitation range
of P. maniculatus. His antibody response did not include antibodies reactive with
the FC G1 glycoprotein, which strongly suggested that his infection was caused by
an agent distinct from FC. Despite this, the S genome of a virus with fairly close
genetic relationship to FC was amplified from his tissue samples, indicating that
an enzootic of an FC-like agent was present in the northeastern U.S.139The host for
this virus remained elusive until later in 1994, when a virus with nearly complete
genetic identity to that from the case patient was isolated from a white-footed
mouse (P. leucopus) that was trapped on Shelter Island, New Y ~ r k . These ’~~
studies showed that a highly pathogenic, novel hantavirus, designated NY is
enzootic in a widespread and highly successful rodent host that is common in the
eastern U.S.and Canada.
XI. OTHER HANTAVIRUSES INDIGENOUS TO THE AMERICAS
Indigenous New World rodents are host to a diversity of hantavimses (Table 2).
In addition to PH, distinct viruses with genetic similarity to PH have been identi-
fied in two other species of microtine voles, the California meadow mouse Microtus
californicus (Isla Vista virus) and the prairie vole M. ochrogaster (Bloodland Lake
virus).’@It is unknown whether these viruses are pathogenic to man, but they occur
in successful and common rodents that enjoy a wide geographic distribution.
Of greater concern on theoretical grounds are hantaviruses occurring in hosts
of the subfamily Sigmodontinae, family Muridae. These viruses collectively con-
stitute a rnonophyletic lineage. Agents that appear in this group in phylogenetic
analyses include all of the known etiologic agents for HPS: FC, NY, BCC, BAY,
and possibly the Brazilian HPS-associated hantavirus (Figure 10). Two additional
members of this dangerous group have been identified in rodents but have not yet
been demonstrated to have pathogenicity for man. Both are associated with distinct
species of American harvest mice (genus Reithrodontorn~s).’~~.~~~ One, previously
known as HMV-1 but now designated El Moro Canyon virus (ELMC), is associ-
ated with the diminutive western harvest mouse, R. megalotis. ELMC has a
prevalence of about 12 to 15% in R. megalotis and has been identified in at least
five western states and in central Mexico. The second, Rio Segundo virus (RIOS;
496
TABLE 2
Hantaviruses Recognized To Date
Abbrev-
Virus iation Synonyms Type host Distribution of host Disease Ref.
Hantaan HTN A. agrarius Central and E. Asia, Central HFRS 4

and E. Europe
Seoul SEO R. norvegicus Worldwide; commensal rat hosts HFRS 14
Thai THAI B. indica SE Asia, India Unknown 20, 21
DobravdBelgrade DOB BEL A. fla vicollis Asia Minor, Europe, Palestine HFRS 144, 145
Puumala PUU C. glareolus Russia, Europe, Asia Minor HFRS/NE 11
Thottapalayam TPM “S. murinus” Africa, India, S E Asia Unknown 148
Tula TUL M. arvalis Russia, Europe, Asia Minor Unknown 146
Prospect Hill PH M. pennsylvanicus N, E US., Canada, Alaska Unknown 22
Four Corners FC Sin Nombre P. maniculatus Throughout US., W Canada HPS 43,44
El Moro Canyon ELMC HMV-1 R. megalotis W US., Mexico, SW Canada Unknown 141
Rio Segundo RlOS HMV-2 R. mexicanus Mexico, Costa Rica, Ecuador Unknown 142
Black Creek Canal BCC S. hispidus S E U S . to Peru HPS 71, 136
Bloodland Lake BLLL PVV M. ochrogaster Midwestern, E U.S., S Canada Unknown Song W et al.,
unpublished
lsla Vista ILV CMMV M, californicus California, Oregon, Mexico Unknown Song W et al.,
unpublished
New York NY 3-1 P. leucopus NE U.S., SE Canada HPS 139, 140
Bayou BAY Unknown Unknown (Louisiana) HPS 134
Note: The first seven species are associated with indigenous Old World hosts, while the remainder are associated with New World rodent
species. The insectivore (shrew) host for TPM (Suncus murinus) is set in quotations because this species has not been clearly shown
to be the predominant host for TPM.
....................................................................................
-. NOS/Costa-l R. mexicanus
......................................................................................
....................................................................
BAY
M. pennsylvanicus *;
PHJFH-1
- BLLLIMO-46 M. ochrogaster Arvicolinae
IVNC-47 M. califomicus :
M. arvalis
A
i yTUJ4"-76
'1 /-p~~-sotkamo
PUU-P360
1c. glareolus
................................................................................................................
a * .
.........
f' 7 SEO/SR-11 R- nowe@cus
Murinae
..........................................................
10 percent
FIGURE 10. Unweighted rnaximum-parsimony phylogenetic tree depicting relationships

among the N genes of various rodent-borne hantaviruses. Abbreviations are as in Table 2.
The specific allele used to represent each virus species is indicated when appropriate; for
example, the RI-1 (human) allele was used to represent the NY hantavirus. The known or
presumed rodent host species for each taxon is indicated, with dashed balloons used to
indicate rodents confined to a single subfamily. The rodent host for Bayou (BAY) is not known.
previously HMV-2), is known only fiom the prototype genome obtained from an
R. mexicanus specimen from Costa Rica.
Why has human disease by ELMC and RIOS not been recorded? It remains
possible that such cases have occurred but have gone unrecognized. Some cases of
HPS have been identified solely on the basis of immunohistochemical studies or
through serologic examinations that are incapable of distinguishing FC from
ELMC i n f e ~ t i o n . ~Alternatively,
~.'~ the reclusiveness of R. megalotis and its lack
of interaction with humans might make human disease due to ELMC unlikely. It
is also possible that some critical genetic determinant renders FC pathogenic for
humans and ELMC nonpathogenic.
XII. EVOLUTION OF HANTAVIRUSES
In contrast to some other RNA viruses, the evolution of hantaviruses does not
appear to be rapid or chaotic. In fact, hantavirus evolution is best understood if one
498
considers hantaviruses not as free-living parasites, but more as extrachromosomal
genetic elements that are tightly and inexorably associated with their host rodent.
Selection does not operate at the genetic level per se, but at the level of protein
sequence.143For example, FC S genomes detected at sites separated by 3500 or
more km may differ by nearly 20% at the RNA level, yet encode N proteins
differing by only -2.5%. These distances are near the upper limit for genetic
diversity of FC-complex viruses. Similar large distances are observed when FC
sequences from island-bound deer mice are compared with those from the main-
land.137Comparison of hantavirus genomes obtained from different host species

reveals much larger protein sequence distances. For example, FC N proteins differ
by -6.5% from those of allopatric P. leucopus (NY), and by 15% from those of
sympatric ELMC.139
At present, there are at least seven distinct hantaviruses indigenous to Old
World hosts and at least nine associated with New World hosts. Several of the
newer Old World species have recently been studied at the genetic level, and
support the evolutionary inferences developed from study of New World speci-
m e n ~ . ~There ~ . ~ is a~close
~ - correspondence
~ ~ ~ between the imputed phylogeny of
hantaviruses and that of their murid rodent hosts. Thus, hantaviruses of sigmodontine
rodents appear to share a common ancestor, as do hantaviruses of arvicolid
microtine rodents and hantaviruses of the rodent subfamily Murinae. Within a
given rodent subfamily, those hantaviruses that are derived from closely related
host species or genera are themselves closely related (Figure 10).

There are apparent exceptions to this rule, which have complicated and de-
layed an understanding of hantavirus systematics and ecology. The most important
exceptions are hantavirus infections that have been detected in secondary hosts via
“spillover” from the primary hosts. One possible example of this is the isolation of
Thottopalayam (TPM) virus, a virus that closely resembled hantaviruses of murid
rodents, from a shrew (Suncus murinus) in India.21~147,148 It is unclear at present that
TPM is primarily associated with shrews, as opposed to an unknown murid rodent.
There have been other cases in which hantaviruses that are firmly associated with
a particular predominant rodent species have been detected or isolated from
distantly related rodent hosts45 or even from predators that belong to another
taxonomic order.149The epidemiologic importance of these secondary hosts in
human disease is largely unexplored. In one case, evidence was presented impli-
cating the house mouse Mus musculus as a vector for PUU transmission to
humans.150A PUU-like agent was reportedly isolated from a M. musculus in
Leakey, Texas, in 1988,I5l but its extraordinary genetic similarity to the Hallnas-
B1 isolate of PUU, coupled with the lack of supporting evidence for a PUU
enzootic in the Americas, has led to suspicion that the Leakey virus isolate was not
independent.21Laboratory studies suggest that virus serotypes that are specialized
for one rodent host (Apodemus)are less successful in propagating in a heterologous
host ( R ~ t t u s ) , and
~ ~ *vice versa.14
499
XIII. KEY QUESTIONS FOR THE FUTURE
Despite the rapid progress in hantavirus research in recent years, many funda-
mental questions are unanswered.
How common is hantavirus disease, and how many forms of hantavirus

disease exist? Many in the lay community were surprised that a disease of
such severity and distinctiveness as HPS could have occurred unnoticed in
North America since at least 1959. Many more past cases of HPS remain to
be discovered, and others will remain undiscovered because appropriate
pathologic specimens are not retained from all patients who succumb to
explained shock and pulmonary edema. Medical practitioners were not as
surprised to discover that HPS could go unrecognized for so long because
they are more aware of the limitations of the mechanisms for ascertaining
cases of uncommon illnesses that bear superficial resemblance to more
common conditions.
With the recognition that at least nine hantaviruses are indigenous to the
Americas, and seven in the Old World, it remains to be seen whether HPS,
HFRS, chronic renal disease, or other illnesses occur in association with each
of the newly recognized serotypes. There is a remarkable serotype specificity
to the known hantavirus diseases, and also a remarkable variation in disease
severity according to serotype. In addition to the considerable genotypic and

antigenic variation among different hantavirus species, the segmented ge-
nome of hantaviruses makes them capable, in principle, of segment exchange
(genetic reassortment) in nature. Segment reassortment is a potent contributor
to new pandemics of influenza A.153The technology for determining the
strain-specific incidence and sequelae of hantavirus disease is available, but
because hantavirus disease appears to be rare in North America, there has not
been a consensus that such investigations are necessary.
Can we predict hantavirus outbreaks, and intervene appropriately? The most
reasonable explanation for the 1993 outbreak of HPS in Four Comers is the
well-documented increase in rodent population following the unusual weather
patterns of 1992 and 1993. It follows that such weather abnormalities could,
in principle, be monitored and upcoming rodent blooms predicted. This
capability is also probably in existence, requiring only implementation. It
would be particularly appealing if satellite photographic imaging could be
used to determine specific changes in vegetation densities or other envi-
ronmental variables that correlate with an increased incidence of hantavirus
disease. Prediction could lead to education, then to intervention, and thus to
prospective prevention of outbreaks.
Can we intervene in the transmission of hantaviruses from rodent to man?
Major deficiencies in our understanding of both the hantavirus enzootic cycle
and the mode of transmission to man remain. The latter problem is technically
500
challenging in North America because the number of cases is low, and many
patients do not live long enough to recount their recent risk activities. While
it is helpful to consider that some ill-defined exposure to rodent excreta is
important, such a history is not universal, and detailed understanding of what
constitutes a risk activity is lacking. To obtain the maximum return from each
case investigation, molecular epidemiologic studies designed to link viral
genotypes at suspected sites of exposure to those of the patient should be
combined with classic epidemiologic approaches. This is especially critical
in those many cases in which more than one possible site of exposure can be
identified.
4. What is the pathogenesis of hantavirus disease? The outlook for understand-
ing of hantavirus pathogenesis in man is weakened considerably by the
absence of animal models that mimic HFRS or HPS. Without such an
experimental system, correlations can be established but proof of causality
will generally be lacking. That said, the field would be aided greatly by
characterization of T-cell immune responses to hantavirus infection and by
investigations designed to understand the involvement of cytokines and
chemokines in immunopathogenesis. Considerable practical benefit could
come through such investigations. If the concept of an immune pathogenesis
for HFRS and HPS is correct, rationally developed interventions into specific
cytokine or signal transduction pathways could abrogate the full expression
of capillary leak syndrome.
ACKNOWLEDGMENTS
We thank Dr. R. T. Bryan for helpful advice, Drs. G. Mertz and C. Jonsson for
critical comments, and Drs. K. J. Smith and T. Yamada for their contributions
toward the immunohistochemistry study (Figure 8).
REFERENCES
1. Calisher CH. History, classification, and taxonomy of viruses in the family Bunyaviridae. In:
Elliot RM, ed. The bunyaviridae. In press.
2. Elliott RM, Schmaljohn CS. Collett MS. Bunyavirus genome structure and gene expression.
Curr Topics Microbiot Immunol 1991; 169: 9 1- 141.
3. Smorodinstev AA, Kazbintsev LI, Chudakov VG. Virus hemorrhagic fevers. Washington,
DC: National Library of Medicine, 1964.
4. Lee HW, Lee P-W, Johnson KM. Isolation of the etiologic agent of Korean hemorrhagic fever.
J Infect Dis 1978; 137: 298-308.
5. McCormick JB, Palner EL, Sasso DR. et al. Morphological identification of the agent of
Korean hemorrhagic fever (Hantaan virus) as a member of the Bunyaviridae. Lancet 1981; 1:
765-8.
6. Lee H W ,Cho H-J. Electron microscopic appearance of Hantaan virus, the causative agent of
hemorrhagic fever. Lancet 1981; 1: 1070-2.
50 1
7. Schmaljohn CS, Hasty SE, Dalrymple JM, et al. Antigenic and genetic properties of viruses
linked to hemorrhagic fever with renal syndrome. Science 1985; 227: 10414.
8. Earle DP. Symposium on epidemic hemorrhagic fever. Am J Med 1954; 16: 617-709.
9. Yanagihara R, Gajdusek DC. Hemorrhagic fever with renal syndrome: a historical perspective
and review of recent advances. In: Gear JH, ed. Handbook of viral and rickettsial diseases. Pp.
155-81. Boca Raton, CRC Press, 1988.
10. Gajdusek DC. Acute infectious hemorrhagic fevers and mycotoxicoses in the Union of Soviet
Socialist Republics. Washington, DC: Med Sci Pub1 No. 2, Army Medical Service Graduate
School, Walter Reed Army Medical Center, 1953.
1 1. Brummer-KorvenkontioM, Vaheri A, Hovi T, et al. Nephropathia epidemica: detection of antigen

in bank voles and serologic diagnosis of human infection. J Infect Dis 1980; 141: 1314.
12. Niklasson B, LeDuc JW. Isolation of the nephropathia epidemica agent in Sweden. Lancet
1984; 1: 1012-3.
13. Yanagihara R, Goldgaber D, Amyx HL. et al. Propagation of nephropathia epidemica in cell
culture. Lancer 1984; 1: 1013.
14. Lee HW, Baek LJ, Johnson KM. Isolation of Hantaan virus, the etiologic agent of Korean
hemorrhagic fever from wild urban rats. J Infect Dis 1982; 146: 638-44.
15. Chen H-X, Qiu F-X, Dong B-J, et al. Epidemiologic studies on hemorrhagic fever with renal
syndrome in China. J Infect Dis 1986; 154: 394-8.
16. LeDuc JW,Smith GA, Johnson KM. Hantaan-like viruses from domestic rats captured in the
United States. A m J Trop Med Hyg 1984; 33: 992-8.
17. Tsai TF, Bauer SP, Sasso DR, et al. Serological and virological evidence of a Hantaan virus-
related enzootic in the United States. J Infect Dis 1985; 152: 126-36.
18. LeDuc JW, Smith GA, Childs JE, et al. Global survey of antibody to Hantaan-related viruses
among peridomestic rodents. Bull WHO 1986; 64: 139-44.

19. Childs JE, Korch GW, Glass GE, et al. Epizootiology of hantavirus infections in Baltimore:
isolation of a virus from Norway rats, and characteristics of infected rat populations. A m J
Epidemiol 1987; 126: 55-68.
20. Elwell MR, Ward GS, Tingpalapong M, et al. Serologic evidence of Hantaan-like virus in
rodents and man in Thailand. Southeast Asian J Trop Med Public Health 1985; 16:
349-54.
21. Xiao S-Y, LeDuc JW, Chu Y-K, et al. Phylogenetic analysis of virus isolates of the genus
Hantavirus, family Bunyaviridae. Virology 1994; 198: 205-1 7.
22. Lee P-W, Amyx HL, Gajdusek DC, et al. New haemorrhagic fever with renal syndrome-
related virus in indigenous wild rodents in United States. Lancet 1982; 2: 1405.
23. Lee P-W, Gibbs CJ Jr, Gajdusek DC, et al. Serotypic classification of hantaviruses by indirect
immunofluorescent antibody and plaque reduction neutralization tests. J Clin Microbiol 1985;
22: 940-4.
2 4 Chu YK, Lee HW, LeDuc JW,et al. Serological relationships among viruses in the Huntavirus
genus, family Bunyaviridae. Virology 1994; 198: 196-204.
25. Tsai TF, Bauer SP, Sasso DR, et aI. Preliminary evidence that Hantaan or a closely related
virus is enzootic in domestic rodents. N Engl J Med 1982; 307: 6 2 3 4 .
26. Lee P-W, Yanagihara R, Franko MC, et al. Preliminary evidence that Hantaan or a closely
related virus is enzootic in domestic rodents. N Engl J Med 1982; 307: 624-5.
27. LeDuc JW, Smith GA, Bagley LR, et al. Preliminary evidence that Hantaan or a closely related
virus is enzootic in domestic rodents. N Engl J Med 1982; 307: 624.
28. Lee HW, Seong IW,Baek LJ, et al. Positive serological evidence that Hantaan virus, the
etiologic agent of hemorrhagic fever with renal syndrome, is endemic in Canada. Can J
Microbiol 1984; 30: 1137-40.
29. Yanagihara R, Gajdusek DC, Gibbs CJ Jr, et al. Prospect Hill virus: serologic evidence for
infection in mammalogists. N Engl J Med 1984; 310: 1325-6.
30. Yanagihara R, Chin C-T, Weiss MB, et al. Serologic evidence of Hantaan virus infection in
the United States. Am J Trop Med Hyg 1985; 34: 396-9.
3 1. Forthal DN, Bauer SP, McCormick JB. Antibody to hemorrhagic fever with renal syndrome
viruses (hantaviruses) in the United States. Am J Epidemiol 1987; 126: 1210-3.
32. Baek L-J, Yanagihara R, Gibbs CJ Jr, et a]. Leakey virus: a new hantavirus isolated from Mus
musculus in the United States. J Gen Virol 1988; 69: 3129-32.
33. Childs JE, Glass GE. Korch GW, et a]. Evidence of human infection with a rat-associated
Hantavirus in Baltimore, Maryland. Am J Epidemiol 1988; 127: 875-8.
34. Childs JE,Glass GE, Ksiazek TG, et al. Human-rodent contact and infection with lymphocytic
choriomeningitis and Seoul viruses in an inner-city population. Am J Trop Med Hyg 1991; 44:
117-21.
35. Yanagihara R, Daum CA, Lee P-W, et al. Serological survey of Prospect Hill virus infection
in indigenous wild rodents in the USA. Trans R SOC Trop Med Hyg 1987; 81: 42-5.
36. Yanagihara R. Hantavirus infection in the United States; epizootiology and epidemiology. Rev
Infect Dis 1990; 12: 449-57.
37. Glass GE, Watson AJ, LeDuc JW, et al. Domestic cases of hemorrhagic fever with renal
syndrome in the United States. Nephron 1994; 68: 48-51.
38. Glass GE, Watson AJ, LeDuc JW, et al. Infection with a ratborne hantavirus in U.S. residents
is consistently associated with hypertensive renal disease. J Infect Dis 1993; 167: 614-20.
39. Centers for Disease Control and Prevention. Outbreak of acute illness - Southwestern United
States, 1993. Morbid Mortal Wkly Rep 1993; 42: 4 2 1 4 .
40. 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.
41. Nolte KB, Feddersen RM, Foucar K, et al. Hantavirus lymphocyte syndrome in the United
States: a pathological description of a disease caused by a new agent. Hum Parhol 1995; 26:
1 10-20.
42. Linderholm M, Billstrom A, Settergren B, et al. Pulmonary involvement in nephropathia
epidemica as demonstrated by computed tomography. Infection 1992; 20: 263-6.
43. Nichol ST, Spiropoulou CF, Morzunov S, et al. Genetic identification of a novel hantavirus
associated with an outbreak of acute respiratory illness in the southwestern United States.
Science 1993; 262: 914-7.
44. Hjelle B, Jenison S, Torrez-Martinez N, et al. A novel hantavirus associated with an outbreak
of fatal respiratory disease in the southwestern United States: evolutionary relationships to
known hantaviruses. J Virol 1994; 68: 592-6.
45. Childs E, Ksiazek TG, Spiropoulou CF, et al. Serologic and genetic identification of Peromyscus
manicularus as the primary rodent reservoir for a new hantavirus in the southwestern United
States. J Infect Dis 1994; 169: 1271-80.
46. Elliott LH, Ksiazek TG, Rollin PE, et al. Isolation of the causative agent of hantavirus
pulmonary syndrome. Am J Trop Med Hyg 1994; 51: 102-8.
47. Schmaljohn AL, Li D, Negley DL, et al. Isolation and initial characterization of a newfound
hantavirus from California. Virology 1995; 206: 963-72.
48. Spiropoulou CF, Morzunov S, Feldmann H, et al. Genome structure and variability of a virus
causing hantavirus pulmonary syndrome. Virology 1994; 200: 7 15-23.
49. Hjelle B, Jenison S, Mertz G, et al. Emergence of hantavirus disease in the southwestern
United States. West J Med 1994; 161: 467-73.
50. Centers for Disease Control and Prevention. Update: hantavirus disease - United States,
1993. Morbid Mona1 Wkly Rep 1994; 42: 6 1 2 4 .
5 1. Stevens C, Johnson M, Bell A. First reported cases of hantavirus pulmonary syndrome in
Canada. Can Commun Dis Rep 1994; 20-15: 121-5.
52. Wilson C, Hjelle B, Jenison S. A probable case of hantavirus pulmonary syndrome that
occurred in New Mexico in 1975. Ann Intern Med 1994; 120: 813.
53. Nerurkar VR, Song K-J, Gajdusek DC, et al. Genetically distinct hantavirus in deer mice.
Lancet 1993; 342: 1059.
54. Nerurkar VR, Song K-J, Song J-W, et al. Genetic evidence for a hantavirus enzootic in deer
mice (Peromyscus maniculatus) a decade before the recognition of hantavirus pulmonary
syndrome. Virology 1994; 204: 563-8.
55. Parmenter RR, Vigil R. The HARDS epidemic in the southwest: an assessment of autumn
rodent density and population demographics in central and northern New Mexico, October,
1993. Albuquerque: University of New Mexico, Sevilleta LTER Publication No. 45, 1993.
56. Sheedy JA, Froeb HF. Batson HA, et al. The clinical course of epidemic hemorrhagic fever.
Am J Med 1954; 16: 619-28.

57. Tsai TF. Hemorrhagic fever with renal syndrome: clinical aspects. Lab Anim Sci 1987; 37:
4 19-27.
58. Bruno P, Hassell LH, Brown J, et al. The protean manifestations of hemorrhagic fever with
renal syndrome. Ann Intern Med 1990; 113: 385-9 1.
59. Cohen MS. Epidemic hemorrhagic fever revisited. Rev Infect Dis 1982; 4: 992-7.
60. Peters CJ, Johnson KM. California encephalitis viruses, hantaviruses, and other Bunyaviridae.
In: Mandell GL, Bennett JE,Dolin R, eds. Principles and practice of infectious diseases. Pp.
1567-71. New York: Churchill Livingston, 1995.
61. LeDuc JW, Childs JE,Glass GE, et al. Hantaan (Korean hemorrhagic fever) and related rodent
zoonosis. In: Morse SS, ed. Emerging viruses. Pp. 149-58. New York: Oxford University
Press, 1993.
62. Johnson KM. California encephalitis and bunyaviral hemorrhagic fevers. In: Mandell GL,
Douglas RG, Bennett JE, eds. Principles andpractice of infectious diseases. Pp. 1326-9. New
York: Churchill Livingston, 1990.
63. Lee JS, Cho BY, Lee MC, et al. Clinical features of serologically proven Korean hemorrhagic
fever patients. Seoul J Med 1980; 21: 163.
64. Giles RB, Sheedy JA, Ekman CN, et al. The sequelae of epidemic hemorrhagic fever. Am J
Med 1954; 16: 629-38.
65. Huggins JW, Hsiang CM, Cosgriff TM, et al. Prospective, double-blind, concurrent, placebo-
controlled clinical trial of intravenous ribavirin therapy for hemorrhagic fever with renal
syndrome. J Infect Dis 1991; 164: 119-27.
66. Schmaljohn CS, Chu YK, Schmaljohn AL, et al. Antigenic subunits of Hantaan virus ex-
pressed by baculovirus and vaccinia virus recombinants. J Virol 1990; 64: 3162-70.
67. Mertz G , Chapman L. Hantavirus infections in the United States: diagnosis and treatment. In:
Mills J, Corey L, and Volberding P, eds. Antiviral chemotherapy: new directions for clinical
application and research. Vol 4.Englewood Cliffs, NJ: Prendce Hall, in press.
68. Dull SM, Brillman JC, Simpson SQ, et al. Hantavirus pulmonary syndrome: recognition and
emergency department management. Ann Emerg Med 1994; 24: 530-6.
69. Ketai LH, Williamson MR, Telepak RJ, et al. Hantavirus pulmonary syndrome (HPS):
radiographic findings in sixteen patients. Radiology 1994; 191: 665-8.
70. Levy H, Simpson SQ. Hantavirus pulmonary syndrome. Am J Resp Crit Care Med 1994; 149:
1710-3.
71. Centers for Disease Control and Prevention. Newly identified hantavirus - Florida, Morbid
Mortal Wkly Rep 1994; 43: 99, 105.
72. Lukes RJ. The pathology of thirty-nine fatal cases of epidemic hemorrhagic fever. Am J Med
1954; 16: 639-49.
73. Hullinghorst RL, Steer A. Pathology of epidemic hemorrhagic fever. Ann Intern Med 1953;
38: 77-101.
74. Kessler WH. Gross anatomic features found in 27 autopsies of epidemic hemorrhagic fever.
Ann Intern Med 1953; 38: 73-6.
504
75. Poljak M, Zupanc AT. Immunohistochemical detection of Hantaan virus antigen in renal tissue
from patient with hemorrhagic fever with renal syndrome. Nephron 1994; 67: 252.
76. Zaki SR, Greer PW, Coffield LM, et al. Hantavirus pulmonary syndrome: pathogenesis of an
emerging infectious disease. Am J Pathol 1995; 146: 552-79.
77. Yanagihara R, Silverman DJ. Experimental infection of human vascular endothelial cells by
pathogenic and nonpathogenic hantaviruses. Arch Virol 1990; 111: 281-6.
78. French GR, Foulke RS, Brand OA. et al. Korean hemorrhagic fever: propagation of the
etiologic agent in a cell line of human origin. Science 1981; 211: 1046-8.
79. Yang CW, Bang BK. Changes of serum levels of tumor necrosis factor-alpha in patients with
hemorrhagic fever with renal syndrome. J Carholic Med Coll 1992; 45: 819-30.
80. Obukhova GG. Components of the kinin system and inhibitors of proteinases from blood
serum in hemorrhagic fever with renal syndrome. Vopr Med Khim 1980; 26: 118-20.
8 1. Sirotin VZ, Obukhova GG, Mogila TV. Kallikrein-kinin, coagulation and fibrinolytic blood
systems in patients suffering from hemorrhagic fever with renal syndrome. TerArkh 1981; 53:
84-7.
82. Tsai TF, Baner S, McCormick JB, et al. Intracerebral inoculation of suckling mice with
Hantaan virus. Lancer 1982; 2: 503-4.
83. Foucar K, Nolte KB, Fedderson RM, et al. Outbreak of hantavirus pulmonary syndrome in the
southwestern United States: response of pathologists and other laboratorians. Am J CIin Pathol
1994; 101: Sl-S5.
84. Hjelle B, Spiropoulou CF, Torrez-Martinez N, et al. Detection of Muerto Canyon virus RNA
in peripheral blood mononuclear cells from patients with hantavirus pulmonary syndrome. J
Infecr Dis 1994; 170: 1013-7.
85. Feldmann H, Sanchez A, Morzunov S, et al. Utilization of autopsy RNA for the synthesis of
the nucleocapsid antigen of a newly recognized virus associated with hantavirus pulmonary
syndrome. Virus Res 1993; 30: 35147.
86. Jenison S, Yamada T, Moms C, et al. Characterization of human antibody responses to Four
Comers hantavirus infections among patients with hantavirus pulmonary syndrome. J Virol
1994; 68: 3000-6.
87. Kingsford L. Antigenic variance. Curr Top Microbiol Zmmunol 1991; 169: 181-216.
88. Asada H, Tamura M, Kondo K, et al. Cross-reactive immunity among different serotypes of
virus causing hemorrhagic fever with renal syndrome. J Gen Virof 1989; 70: 819-25.
89. Lundkvist A, Fatouros A, Niklasson B. Antigenic variation of European haemorrhagic fever
with renal syndrome virus strains characterized using bank vole monoclonal antibodies. J Gen
Virol 1991; 72: 2097-103.
90. Lundkvist A, Niklasson B. Bank vole monoclonal antibodies against Puumala virus encelope
glycoproteins: identification of epitopes involved in neutralization. Arch Virol 1992; 126: 93-
105.
91. Ruo SL, Sanchez A, Ellion LH, et al. Monoclonal antibodies to three strains of hantaviruses:
Hantaan, R22, and Puumala. Arch Virol 1991; 119: 1-1 1.
92. Sheshberadaran H, Niklasson B, Tkachenko E. Antigenic relationship between hantaviruses
analysed by immunoprecipitation. J Gen Virol 1988; 69: 2645-5 1.
93. Sugiyama K, Morikawa S, Matsuura Y, et a]. Four serotypes of haemorrhagic fever with renal
syndrome viruses identified by polycfonal and monoclonal antibodies. J Gen Viroi 1987; 68:
979-87.
94. Yamanishi K, Dantas JR Jr, Takahashi M, et al. Antigenic differences between two viruses,
isolated in Japan and in Korea, that cause hemorrhagic fever with renal syndrome. J Virol
1984; 52: 231-7.
95. Xu X , Ruo SL, McCormick JB, et al. Immunity to hantavirus challenge in Meriones unguiculatus
induced by vaccinia-vectored viral proteins. Am J Trop Med Hyg 1992; 47: 397404.
505
96. Yoshimatsu K, Yo0 Y-C, Yoshida R, et a]. Protective immunity of Hantaan virus nucleocapsid
and envelope protein studies using baculovirus-expressed proteins. Arch Virol 1993; 130:
365-76.
97. Arikawa J, Schmaljohn AL, Dalrymple JM, et a]. Characterization of Hantaan virus envelope
glycoprotein antigenic determinants defined by monoclonal antibodies. J Gen Virol 1989; 70:
6 15-24.
98. Arikawa J, Yao J-S, Yoshimatsu K, et al. Protective role of antigenic sites on the envelope
protein of Hantaan virus defined by monoclonal antibodies. Arch Virol 1992; 126: 271-81.
99. Dantas JR Jr, Okuno Y, Asada H, et al. Characterization of glycoproteins of viruses causing
hemorrhagic fever with renal syndrome (HFRS) using monoclonal antibodies. Virology 1986;
151: 379-84.
100. Pensiero MN, Jennings GB, Schrnaljohn CS, et al. Expression of the Hantaan virus M genome
segment by using a vaccinia virus recombinant. J Virol 1988; 62: 692-702.
101. Wang M,Pennock DG, Spik KW, et al. Epitope mapping studies with neutralizing and non-
neutralizing monoclonal antibodies to the G1 and G2 envelope glycoproteins of Hantaan virus.
Virology 1993; 197: 757-66.
102. Groen J, Dalrymple J, Fisher-Hoch S, et a]. Serum antibodies to structural proteins of
hantavirus arise at different times after infection. J Med Virol 1992; 37: 283-7.
103. Lundkvist A, Horling J, Niklasson B. The humoral response to Puumala virus infection
(nephropathia epidemica) investigated by viral protein specific immunoassays. Arch Virol
1993; 130: 121-30.
104. Lundkvist A, Bjorsten S, Niklasson B. Immunoglobulin G subclass responses against the
structural components of Puumala virus. J Clin Microbiol 1993; 31: 368-72.
105. Nuti M, Agostini M, Albini E, et al. Hantaan antibody in Italian ex-soldiers who served in the
Balkans. Lilncet 1991; 338: 1277.

106. Settergren B, Ahlm C, Juto P, et al. SpeLific Puumala IgG virus half a century after haemorrhagic
fever with rend syndrome. Lancet 1991; 338: 66.
107. Yamada T, Hjelle B, Lanzi R, et al. Four Comers hantavirus antibody responses in the deer
mouse (Peromyscus rnanicularus):identification of an immunodominant region of the nucleo-
capsid protein. J Virol 1995; 69: 1939-43.
108. Xiao S-Y, Liang M, Schmaljohn CS. Molecular and antigenic characterization of HVI 14, a
hantavirus isolated from a patient with haemorrhagic fever with renal syndrome in China. J
Gen Virol 1993; 74: 1657-9.
109. Wang M, Rossi C, Schmaljohn CS. Expression of non-conserved regions of the S genome
segments of three hantaviruses: evaluation of the expressed polypeptides for diagnosis of
haemorrhagic fever with renal syndrome. J Gen Virol 1993; 74: 11 15-24.
110. Plyusnin A, Vapalahti 0, Ulfves K, et al. Sequences of wild Puumala virus genes show a
correlation of genetic variation with geographic origin of the strains. J Gen Virol 1994; 75:
I 405-9.
11 1. Vapalahti 0, Kallio-Kokko H, Salonen EM, et al. Cloning and sequencing of Puumala virus
Sotkamo strain S and M segments: evidence for strain variation in hantaviruses and expression
of the nucleocapsid protein. J Gen Virol 1992; 73: 829-38.
112. Antic D, Wright KE, Kang CY. Maturation of Hantaan virus glycoproteins GI and G2.
Virology 1992; 189: 324-8.
1 13. RuusaIa A. Person R, Schmaljohn CS, et al. Coexpression of the membrane glycoproteins GI
and G2 of Hantaan virus is required for targeting to the Golgi complex. Virology 1992; 186:
53-64.
114. Zoller LG, Yang S, Gott P, et al. A novel p-capture enzyme-linked immunosorbent assay
based on recombinant proteins for sensitive and specific diagnosis of hemorrhagic fever with
renal syndrome. J Clin Microbiol 1993; 31: 1194-9.
506
115. Zoller LG, Yang S, Gott P, et al. Use of recombinant nucleocapsid proteins of the Hantaan and
nephropathia epidemica serotypes of hantaviruses as immunodiagnostic antigens. J Med Virol
1993; 39: 200-7.
116. Kallio-Kokko H, Vapalahti 0, et al. Puumala virus antibody and immunoglobulin G avidity
assays based on a recombinant nucleocapsid antigen. J Clin Microbiol 1993; 31: 677-80.
1 17. Tsai TF. Hemorrhagic fever with renal syndrome: mode of transmission to humans. Lab Anim
Sci 1987; 37: 428-30.
11 8. Dournon E, Moriniere B, Matheron S, et al. HFRS after a wild rodent bite in the Haute-
Savoie - and risk of exposure to Hantaan-like virus in a Paris laboratory. Lancet 1984; 1:
676-7.
119. Kawamata J, Yamanouchi T, Dohmae K, et al. Control of laboratory acquired hemorrhagic
fever with renal syndrome. Lab Anim Sci 1987; 37: 43 1-6.
120. Umenai T, Lee HW, Lee PW, et al. Korean haemorrhagic fever in staff in an animal laboratory.
Lancet 1979; 1: 1314-6.
121. Lee HW, Johnson KM. Laboratory-acquired infections with Hantaan virus, the etiologic agent
of Korean hemorrhagic fever. J Infect Dis 1982; 146: 645-5 1.
122. Trencseni T, Keleti B, eds. In: Clinical aspects and epidemiology ofhemorrhagicfever with
renal syndrome. Pp. 1-237. Budapest: Akademiai Kiado, 197 1.
123. Xu Z-Y, Guo C-S, Wu Y-L, et al. Epidemiological studies of hemorrhagic fever with renal
syndrome: analysis of risk factors and mode of transmission. J Infect Dis 1985; 152: 137-44.
124. Niklasson B, Hornfeldt B, Mullaart M, et al. An epidemiologic study of hemorrhagic fever
with renal syndrome in Bashkirtostan (Russia) and Sweden. Am J Trop Med Hyg 1993; 48:
670-5.
125. Zeitz PS, Butler JC, Cheek JE,et al. A case-control study of hantavirus pulmonary syndrome
during an outbreak in the southwestern United States. J Infect Dis 1995; 171: 864-70.
126. Flood J, Mintz L, Jay M, et al. Hantavirus infection following wilderness camping in Wash-
ington State and northeastern California. West J Med, in press.
127. Khan AS, Ksiazek TG, Zaki SR, et al. Fatal hantavirus pulmonary syndrome in an adolescent.
Pediatrics 1995; 95: 27680.
128. Lee HW, Lee P-W, Baek LJ, et al. Intraspecific transmission of Hantaan virus, the etiologic
agent of Korean hemorrhagic fever, in the rodent Apodemus agrarius, Am J Trop Med Hyg
1981; 30: 1106-12.
129. Yanagihara R, Amyx HL, Gajdusek DC. Experimental infection with Puumala virus, the
etiologic agent of nephropathia epidemica, in bank voles (Clethrionomys glareolus). J Virol
1985; 55: 34-8.
130. Centers for Disease Control and Prevention. Update: outbreak of hantavirus infection -
southwestem United States, 1993. Morbid Mortal Wkly Rep 1993; 42: 495-6.
131. Centers for Disease Control and Prevention. Hantavirus infection in the southwestern United
States: interim recommendations for risk reduction. Morbid Mortal W l y Rep 1993; 42(RR-
11): 1-13.
132. Mills JN,Yates TL, Childs JE,et al. Guidelines for working with rodents potentially infected
with hantavirus. J Mammal; in press.
133. Armstrong LR, Khabbaz RF, Childs JE, et al. Occupational exposure to hantavirus in mam-
rnalogists and rodent workers. Am J Trop Med Hyg 1994; 51: 28.
134. Morzunov SP, Feldmann H, Spiropoulou CF, et al. A newly recognized virus associated with
a fatal case of hantavirus pulmonary syndrome in Louisiana. J Virol 1995; 69: 1980-3.
135. Khabbaz R. Epidemiology of hantavirus pulmonary syndrome. In: 34th interscience sympo-
sium on antimicrobial agents and chemotherapy. P. 285. Oct 4 to 7, 1994.
136. Rollin PE, Ksiazek TG, Elliott LH, et al. Isolation of Black Creek Canal virus, a new
hantavirus from Sigrnodon hispidus in Florida. J Med Virol 1995; 46: 36-9.
507
137. Hjelle B, Chavez-GilesF, Torrez-Martinez N, et al. Dominant glycoprotein epitope of Four Comers
hantavirus is conserved across a wide geographical area. J Gen Virol 1994; 75: 2881-8.
138. Brackett LE, Rotenberg J, Sherman CB. Hantavirus pulmonary syndrome in New England and
Europe. N Engl J Med 1994; 331: 545.
139. Hjelle B, Krolikowski J, Torrez-Martinez N, et al. Phylogenetically distinct hantavirus impli-
cated in a case of hantavirus pulmonary syndrome in the northeastern United States. J Med
Virol 1995; 46: 21-7.
140. Song J-W, Baek L-J, Gajdusek DC, et al. Isolation of pathogenic hantavirus from white footed
mouse (Peromyscus leucopus). Lancet 1994; 344: 1637.
141. Hjelle B, Chavez-Giles F, Torrez-Martinez N, et al. Genetic identification of a novel hantavirus

of the harvest mouse Reithrodontomys megalotis. J Virol 1994; 68: 67514.
142. Hjelle B, Anderson B, Tonez-Martinez N. et al. Prevalence and geographic genetic variation
of hantaviruses of New World harvest mice (Reithrodontomys): identification of a divergent
genotype from a Costa Rican Reirhrodontomys mexicanus. Virology 1995; 207: 452-9.
143. Hjelle B. Evolution and speciation of New World hantaviruses. In: Morse S S , LeDuc JW, eds.
Hanravimses, new/y emerging viral pathogens. Basel: S . Karker, in press.
144. Gligic A, Dimkovic N, Xiao S - Y , et al. Belgrade virus: a new hantavirus causing severe
hemorrhagic fever with renal syndrome in Yugoslavia. J Infecr Dis 1992; 166: 1 13-20.
145. Xiao S-Y, Diglisic G, Avsic-Zupanc T, et al. Dobrava virus as a new hantavirus: evidenced
by comparative sequence analysis. J Med Virol 1992: 39: 152-5.
146. Plyusnin A, Vapalahti 0, Lankinen H, et al. Tula virus: a newly detected hantavirus carried
by European common voles. J Virol 1994; 68: 7833-9.
147. Tang YW, Xu ZY, Zhu Z-Y, et al. Isolation of HFRS virus from Suncus murinus, an
insectivore. Lancet 1985; 1: 5 1 3 4 .
148. Carey DE, Reuben R, Panicker KN, et al. Thottapalayam virus: a presumptive arbovirus
isolated from a shrew in India. Indian J Med Res 1971; 59: 1758-60.
149. Kim GR, Lee YT, Park CH. A new natural reservoir of hantavirus: isolation of hantaviruses
from lung tissues of bats. Arch Virol 1994; 134: 85-95.
150. Diglisic G, Xiao S-Y, Gligic A, et al. Isolation of a Puumala-like virus from Mus rnusculus
captured in Yugoslavia and its association with severe hemorrhagic fever with renal syndrome.
J Infect Dis 1994; 169: 204-7.
151. Baek LJ, Yanagihara R, Gibbs CJ, et al. Leakey virus: a new hantavirus isolated from Mus
musculus in the United States. J Gen Virol 1988; 69: 3129-32.
152. Kawamura K, Zhang X-K, Arikawa J, et al. Susceptibility of laboratory and wild rodents to
Rattus or Apodemus-type hantaviruses. Acta Virol 1991; 35: 54-63.
153. Palese P, Young JF. Variation of influenza A, B, and C viruses. Science 1982; 215: 1468-74.
154. Hjelle B, Moms C, Jenison SA. Unpublished data, 1994.
155. Sesline D, Ascher M, Hjelle B. Unpublished data.
156. Hallin G, Simpson SQ, Levy H. Personal communication.
157. Foucar K, Scott AA, Kosler FT.Unpublished data. 1995.
158. Hjelle B. Unpublished data, 1994.
159. Schmaljohn CS. Personal communication, 1994.
160. Sarisky J, Enscore R, Hjelle B. Unpublished data, 1994.
161. Hjelle B, Torrez-Martinez N. Song W, et al. Unpublished data.
162. Nestler J. Personal communication.
163. Jay M. Personal communication.
164. Song W, Quintana M, Torrez-Martinez N, et al. Unpublished data, 1995.
508

1995 - Hantaviruses Clinical, Microbiologic, and Epidemiologic Aspects

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

1995 - Hantaviruses Clinical, Microbiologic, and Epidemiologic Aspects

Uploaded by

Copyright:

Available Formats

Crirical Reiiie,vs in Clinical Laboruroy Sciences, 32(5):469-508 ( 1995)

Hantaviruses: Clinical, Microbiologic,

Green, Richard M. Feddersen, and Amy A. Scott'

Referee: H. Arlsob, Laboratory Centre for Disease Control, Ottawa.

II. HISTORICAL CONSIDERATIONS

Hantaviruses first came to the attention of Western medicine in 1951, when a

nephropathy and epidemic hemorrhagic fever, but is now known as hemorrhagic

Baltimore, MD, as well as many other port cities of North In addition

ence that has been supported abundantly in subsequent studies.?(

111. HANTAVIRUS DISEASE IN THE U S .

Throughout the 198Os, a series of serologic surveys for hantavirus infection

Abnormality HFRS HPS

Prodrome of fevers, chills, myalgias ++++ ++++

Abdominal pain, nausea + - +++ + - +++

human (HPS) specimens as far back as well-preserved tissue samples can be

IV. CLINICAL SYNDROMES DUE TO INFECTION WITH

In a 1954 symposium on Korean hemorrhagic fever, the clinical manifestations

plications in nephropathia epidemica are rare. Proteinuria and thrombocytopenia

B. Hantavirus Pulmonary Syndrome

seropositivity without evidence of clinical illness have been noted, including

unilateral. Hemodynamic instability is heralded by hypotension. The seventy of

dysfunction with progression to pulseless electrical activity. Predictors of mortality

V. LABORATORY ABNORMALITIES ASSOCIATED WITH

FIGURE 4. Hantavirus pulmonary syndrome. Two immunoblasts and a neutrophil are

VI. AUTOPSY PATHOLOGY

H F R S . However, one necropsy study noted a much higher frequency of pulmonary

Capillary engorgement and focal hemorrhages are widely distributed. In the

nuclear infiltrate. Activated immunoblastic cells similar to those circulating in the

FIGURE 5. Hantavirus pulmonary syndrome. An interlobular fissure is enlarged by edema

therapeutic options to favor modalities that interrupt or augment the production of

VII. DEVELOPMENT OF DIAGNOSTIC CAPABILITIES FOR

hantavirus antibodies was through recombinant DNA-based method^.^^.^^ The

VIII. IMMUNE RESPONSES TO HANTAVIRUS INFECTIONS

Members of the H U ~ ~ U Vgenus ~ ~ Kare

infection^.^^.^^*^^ In contrast, envelope glycoprotein (G1 and G2) responses tend to

vian PUU isolate displayed different patterns of cross-reactivity with heterologous

to cellular cytoplasmic membranes or by blocking the subsequent fusion of viral

of the difficulty in obtaining adequate amounts of native viral proteins.85.86.114-116 In

IX. EPIDEMIOLOGY OF HFRS AND HPS

FIGURE 9. Hantavirus pulmonary syndrome. FC recombinant western blot assay. Each

excess of males, and a relative overrepresentation (about 1/3 of cases) of American

where infected rodents had infested the patient's automobile.160One observation of

that intracage transmission of FC is not very efficient in a laboratory setting, but

gloves, and a half-face respirator; a!ternatively, a powered air-purifying respirator

X. DIVERSITY OF AGENTS IMPLICATED IN HANTAVIRUS

As of mid-February 1995, 103 cases of HPS had been reported in 21 U.S.

A young patient died of HPS in Rhode Island in January 1994.138He had

eastern U.S.and Canada.

XI. OTHER HANTAVIRUSES INDIGENOUS TO THE AMERICAS

Hantaan HTN A. agrarius Central and E. Asia, Central HFRS 4

FIGURE 10. Unweighted rnaximum-parsimony phylogenetic tree depicting relationships

XII. EVOLUTION OF HANTAVIRUSES

land.137Comparison of hantavirus genomes obtained from different host species

host species or genera are themselves closely related (Figure 10).

How common is hantavirus disease, and how many forms of hantavirus

severity according to serotype. In addition to the considerable genotypic and

of capillary leak syndrome.

1 1. Brummer-KorvenkontioM, Vaheri A, Hovi T, et al. Nephropathia epidemica: detection of antigen

among peridomestic rodents. Bull WHO 1986; 64: 139-44.

Am J Med 1954; 16: 619-28.

Balkans. Lilncet 1991; 338: 1277.

141. Hjelle B, Chavez-Giles F, Torrez-Martinez N, et al. Genetic identification of a novel hantavirus

You might also like