hantavirus pulmonary syndrome radiology

  • 12 min read
  • Feb 07, 2020

SOUTHWEST JOURNAL of PULMONARY & CRITICAL CARE - Pulmonary ...
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1 MD, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil.

2 MD, PhD, Santa Casa de Porto Alegre, Porto Alegre, RS, Brazil.

3 MD, PhD, Faculty of Medicine of Sao Jose do Rio Preto (Famerp) and Ultra X, Sao Jose do Rio Preto, Brazil.

4 MD, PhD, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil.

5 MD, PhD, Federal University of Paraná (UFPR), Curitiba, Brazil.

6 MD, PhD, Federal University of Sao Paulo (Unifesp) and Fleury Group, São Paulo, SP, Brazil.

7 MD, PhD, Faculty of Medicine, University of São Paulo (USP), São Paulo, SP, Brazil.

4 MD, PhD, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil.

The purpose of research is to describe the high-resolution computed
tomography (HRCT) findings in patients with hantavirus pulmonary syndrome
(HPS).

We retrospectively HRCT findings of eight cases of HPS. all
Are male patients aged 19-70 (mean, 41.7) years. established diagnosis
with a serological test (enzyme-linked immunosorbent assay) in all patients. two
Analysis chest radiologists pictures and Decision Reached by
consensus.

Were the dominant HRCT findings ground-glass opacities (GGOs) and smooth
inter and interlobular septal thickening, was found in all eight cases;
However, the crazy-paving pattern was found only in three cases. pleural
peribronchovascular effusion and thickening was observed in five patients.
Is bilateral abnormalities in all patients.

dominant HRCT findings in patients with HPS and smooth Were GGOs
inter and interlobular septal thickening, which may correlate with
Histopathological findings of pulmonary edema.

Describe high computed tomography
Resolution (HRCT) of patients with pulmonary syndrome
Hantavirus.

We retrospectively reviewed the CT findings of eight
patients with hantavirus pulmonary syndrome, all
male and aged 19-70 years (mean 41.7 years). that
Serological diagnosis was established with the assay test
Enzyme-Linked Immunosorbent in all patients. two
chest radiologists analyze the pictures and decide on
consensus.

The predominant HRCT findings ground glass opacities and
inter and interlobular septal thickening was observed in eight patients;
However, the standard-paving is
found only three of them. pleural effusion and thickening
peribronchovascular were observed in five patients. abnormality
They are bilateral in all patients.

Soil glass opacities and interlobular septal thickening between and
HRCT was found predominantly in patients with pulmonary syndrome
hantavirus, which may correlate with the findings
Histopathological pulmonary edema.

Hantavirus pulmonary syndrome (HPS) is an emerging zoonotic disease caused by
hantavirus, RNA viruses belonging to the family Bunyaviridae. In America,
the natural reservoir of the virus of the subfamily are rodents
Sigmodontinae (-). genus
Hantavirus Comprising Some viruses are classified into two
groups, each associated with distinct clinical syndromes: the Old World
hantaviruses that cause hemorrhagic fever with renal syndrome or nephropathia
epidemics; and the New World hantaviruses, HPS related to (-).

Human infection occurred after inhaling aerosols of rodent feces, the Enabling
virus to infect the respiratory epithelium in the lower airways. In HPS, which
spread the virus through respiratory endothelium, pro-inflammatory early
cascade and the immune response results in the destruction of uncontrolled que
respiratory epithelium, microvascular leakage, and pulmonary edema, Affect
Especially peribronchovascular portion of lobule (). HPS clinical presentation usually is
Specifically, with manifestations such as the flu. cough (productive FIRST)
Usually signals the transition to cardiopulmonary phase, where fulminant
capillary leak syndrome can cause rapidly progressive pulmonary edema and
shock ().

Although HPS presumptive diagnosis can be made based on patient history
and clinical and radiological findings, eventually Usually the diagnosis is made by
Serology [enzymelinked immunosorbent assay (ELISA)], whereh identify
specific antibodies of class immunoglobulin (Ig) M and IgG.
Reverse-transcription and polymerase chain reaction (PCR) techniques can also be
used to identify the virus ().
Radiographs of both syndromes (hemorrhagic fever with renal syndrome and HPS) can
showed lung involvement, but the findings more clearly in the HPS, which serves as
interstitial edema with rapid development of the disease airspace. ()

Despite the high resolution computed tomography (HRCT) findings of Old World
hantaviruses have been well described, only three reports of isolated cases (,,) have been described
tomographic aspects of HPS. To our knowledge, no studies have examined HRCT
The findings in a series of patients with HPS. Thus, the limited information available
about CT features of forms of the disease. The purpose of this study was to
explains the HRCT findings in a series of eight patients with HPS confirmed.

Our institutional review board approved this study and waived the requirement for
informed patient consent. All data used in the study anonymously. We
Retrospective review the record of eight adult patients with a confirmed
Hantavirus pulmonary infection. The patients were examined between 2003 and 2014 in
six tertiary hospitals in Brazil. HPS Diagnosis is based on medical history,
clinical course and imaging findings. However, serology (ELISA) is
positive for hantavirus in all patients.

The chest CT examination is done by using various helical scanner, as
different hospitals involved in the study. In the initial examination, HRCT
images obtained at full inspiration with 1-2-mm slice thickness at 5-10 mm
intervals and reconstructed using high spatialfrequency reconstruction algorithm.
The most recent CT examination is performed using a helical acquisition and
reconstructed with a slice thickness of 1-2.5 mm and 1-2-mm intervals using
reconstruction algorithm of high-spatial-frequency. The acquisition time is 0.5-1 s
per rotation, the peak voltage is 120 kVp, modulated tube current is 100-400 mA, pitch
is 1, and the matrix is ​​512 × 512 pixels.

Two chest radiologists with more than 15 years of experience Independent Review
pictures using mediastinum (width, 350-450 HU; level, 10-20 HU) and lungs (width,
HU 1200-1600; level, 2500-2700 HU) settings window. final judgments reached by
consensus. The radiologist blinded to patient demographics, clinical data, and
the final diagnosis. HRCT pattern follows assessed, followed
Fleischner the proposed definition in the Glossary for Thoracic Society
Imaging (): ground-glass
opacity (GGO), which is defined as hazy increased opacity bronchial pulmonary preservation
and the margin of the blood vessels; subtle thickening of the septum, identified as thin linear opacities
Among secondary pulmonary lobule; peribronchovascular thickening, which is defined as
thickening of the connective tissue sheath enclosing the bronchi, lungs
arteries, and lymphatic vessels; small nodules, which are defined as spherical or irregularly
turbidity, well or poorly defined, with a diameter of 2-10 mm; Crazy-paving pattern,
identified as thickened interlobular septa and intralobular line superimposed on
GGO background, resembling irregularly shaped paving stones; and consolidation,
appears as a homogeneous increase in pulmonary parenchymal attenuation
margin obscure vessels and airway wall.

The distribution of axial lesions in the lung parenchyma is classified as a center,
peripheral, or diffuse. Distribution recorded into the current peripheral
The dominant aberration in the outer third of the periphery of the lungs, and central
when abnormalities are dominant in two-thirds of the transverse plane.
In the direction of craniocaudal, lung zone is defined as the upper, middle, and bottom.
The upper zone is defined as being above the level of the aortic arch, the middle
The zone is described between the aortic arch and the carina, and the lower zone
defined as those below the level of the carina. Enlarged lymph nodes and pleura
effusion was also assessed. In addition, the dominance of the findings in the lungs
or symmetrical involvement recorded.

The sample included eight men with an average age of 41.7 (range, 19-70) years. All
patients have reported the risk factors associated with the presence of rats in their homes or
workplace. Four patients died and four survived. The mean time from symptom onset
die was 4 (range, 2-6) days, the average interval from onset of symptoms
to discharge 7.5 (range, 4-10) days, and the average time from onset of symptoms to
HRCT was 3 (range, 2-5) days. HRCT patterns main (), was found in all patients, which GGOs and smooth inter- and
intralobular thickening of the septum (and
). Pleural effusion and
peribronchovascular thickening was observed in five cases (). Four cases presented small nodules (), and only one patient had extensive
consolidation. Crazy-paving pattern was recorded in three patients (). findings shared
bilateral and spreads in all cases; they are in the middle and
the peripheral zone of the lung in seven patients and in the central region in one
patient. Middle zone lungs are involved in all the patients, the upper zone
in five cases, and a lower zone in three cases. Abnormalities are asymmetrical
in seven patients and symmetrical in one patient.

High-resolution computed tomography findings in eight patients with
Hantavirus.

A man 28 years old with fever and rapidly progressive dyspnea.
High resolution computed axial tomography with reconstruction show
bilateral ground-glass opacities. Note also bilateral pleural
effusion.

A man 38 years old with dyspnea, fever, and myalgia, quickly developed to
respiratory failure. Axial computed tomography showed bilateral
ground-glass opacities and smooth thickening of the septum to the center
distribution.

A man 52 years old with fever and rapidly progressive dyspnea. Axial
Computed tomography showed bilateral peribronchovascular
thickening, ground-glass opacities, and bilateral pleural effusion.

A man 58 years old with fever and dyspnea. High resolution computed axial
tomographic images of the above (A) and bottom
(B) lobes showed bilateral areas of ground-glass opacity
and small nodules are not clear.

A man 43 years old with dyspnea, cough, and fever. high resolution
computed tomography with axial (A) and coronal
(B) reconstruction showed bilateral areas of
ground-glass opacities associated with interventricular septum and intralobular
thickening ( “crazy-paving” pattern).

Hantavirus can affect humans after inhalation of an aerosol of virus particles
urine, saliva, or faeces of rodents reservoirs dried (,).
Person-to-person transmission has been reported in a few cases, mostly related
with a particular strain, Andes virus (). In Brazil, 610 cases of HPS were reported from 1993 to
November 2005, mostly in the south and southeast of
country(). in
cases, hantavirus mainly affected young adult males and is associated with
work activities, tourism to rural areas, and flooding (). All the patients in our sample are
young men with positive epidemiological history.

endothelial damage, leading to increased capillary permeability, is key
Pathophysiologic factor in HPS. This process occurs after hantaviruses infect
respiratory epithelium and spread through infected dendritic cells to monocytes and
macrophages in the lymph nodes, and through the respiratory epithelium to
respiratory endothelium ().
infected endothelial cells produce proinflammatory chemokines attract monocytes,
macrophages, and T cells produce additional pro-inflammatory molecules, such as
tumor necrosis factor-α and reactive oxygen / nitrogen species, which is
The main factors that cause heart and blood vessel hyperpermeability
shock(). this process
supports the long-held belief that the induction of an immune uncontrolled
Hantavirus infection and the response to the generation of a cytokine storm, rather than
viral infection per se, cause microvascular leakage and HPS.

The course histopathology of lung inflammation associated with infection
starting with the destruction and exfoliation of the cells of the respiratory, followed by bronchial
septal thickening and interstitial edema and inflammatory activity
cell (). This is called
interstitial pneumonitis often patchy, affecting mainly
peribronchovascular area of ​​lobules. With more severe inflammation,
filling the alveoli with inflammatory exudate, which may be hemorrhagic, and hyaline
the membrane can be formed (). Confirmation
of HPS diagnosis requires viral-specific diagnostic tests, such as
serology (ELISA), reverse transcription, and / or PCR (). Results ELISA for all the patients in
Our samples were positive for hantavirus.

Brazilian literature have reported the importance of imaging exams in the study
lung infection (-). Radio-logical, chest X-ray, although
Specifically, it is important to show the involvement of the lung in HPS; that is, too
important for the monitoring of disease progression. Bilateral typical pattern
diffuse interstitial infiltration occurred at the beginning of a more severe case, at the beginning
fever and dyspnea. This change is growing rapidly along with the worsening
respiratory disorders for lung infiltrates the meeting, so that alveolar
consolidation. Pleural effusions are often reported, and often progresses
bilaterally. Infiltrates increase during the healing period, but can survive
in the lung bases (,).

Ketai et al. () Described series
of 16 patients with HPS seen in New Mexico. All patients presented with various
the degree of opacity interstitials at least one chest X-ray taken during
course of the disease. All seven patients showed extensive involvement of the airspace in the
initial radiographic died. Death occurs within 48 hours of development
Disease vast airspace. Of the nine patients who were still alive, the time to disease
Resolution ranges from 5 days to more than 3 weeks. In a review of chest X-ray
The findings for 20 patients with HPS, Boroja et al. () Identified two distinct patterns of presentation.
First seen in 13/20 patients and associated with fulminant clinical course,
characterized by the rapid development of bilateral interstitial changes to
Bilateral interstitial pattern and airspace consolidation with pleural effusion. Six
patients die within a few days. The second pattern, seen in 7/20 patients, is
characterized by mild clinical symptoms and normal chest radiographic findings or
minimal bilateral abnormalities. All patients recovered. In
Our sample of patients who died showed a consolidation pattern on the first
Chest X-ray examination. Three other showed interstitial opacities, which
progressively evolved to extensive air space consolidation. Two of the four patients
survivors have normal chest radiographs at the time of entry. Others first
showed interstitial opacities, who resigned in overtime. Pleural effusion is
diagnosed on X-rays from three of eight patients. differences findings
can be explained by the modality used for examinations; CT is much more accurate
of chest radiographs, and parenchymal findings are easier to detect
HRCT ().

In our study, the main HRCT findings are GGOs and smooth interlobular septal
thickening was observed in all patients. However, the crazy-paving pattern observed
only three cases. pleural effusion and thickening of the peribronchovascular
observed in five cases. Four patients had small nodules, and only one has a focus on
consolidation. Abnormalities bilateral and spread in all patients. some research
has described the HRCT manifestations of hantavirus infection. Most of the cases reported
describe the symptoms of infection with Old World hantaviruses (hemorrhagic fever with
renal syndrome or nephropathia epidemica). Smooth septum and peribronchovascular
thickening, GGOs center, crazy-paving pattern, consolidation, and bilateral
Pleural effusion is the most common pattern is described. Paakkala et
al. () Reported that
The main HRCT findings in 12 patients with nephropathia epidemica that atelectasis (11
patients), intralobular and interlobular septal thickening (7 patients), GGOs (4
patients), and bronchial wall thickening (2 patients). pleural effusion seen in
9 patients and bilateral in 7. hilar and mediastinal lymphadenopathy seen
in 3 patients. Rasmuson et al. ()
showed that 14/27 patients with confirmed hantavirus infection have an abnormal chest
HRCT findings, with the most common pattern of pulmonary edema and pleural effusion
was found in 11 patients.

We found only three isolated case reports (,,) of the CT findings associated with the New World
hantaviruses (HPS). , Gasparetto et al () described the following HRCT findings of HPS in one patient:
GGOs extensive bilateral, thickened interlobular septa, some poorly defined small
nodules, thickening of the bronchial walls, and small bilateral pleural effusions.
Gonçalves et al. ()
reported that HRCT showed peribronchial cuffing, septal thickening smooth and
GGOs center (producing crazy-paving pattern), the region depends on the
consolidation, and bilateral pleural effusion. Hamam et al. () Describedbilateral alveolar d
consolidation with relative sparing of peripheral areas of the lung, and small pleural
effusion.

We did not find any reference to the crazy-paving pattern in case reports associated with the Old
hantaviruses world. However, Gonçalves et al. () Explained this pattern in patients with HPS, and
we identified in three of eight patients. These findings were observed in two
patients who survived, the second and third days of the disease, respectively, and on
The third day of the disease in patients who died on the seventh day. Gonçalves
et al. () Observed patterns on
The second day of the evolution of patients who died on the fifth day. Thus, crazy
paving pattern appears to have nothing to do with the severity of disease.

Lymphadenopathies have been described in patients infected with Old World
hantaviruses. These findings were observed in 17% (4/24) of the cases analyzed by Rasmuson
et al. (), And in 23% (3/13) of
cases reviewed by Paakkala et al. (). Linderholm et al. () Not describe lymphadenopathy when reported at 19
case, and the findings were not observed in the three cases described HPS
previous(,,). Similarly, none of our eight cases are presented
lymphadenopathy. Five of our patients had pleural effusion, mild in two cases and
is in three. Biochemical studies not conducted because of the pleura
effusion is bilateral and is associated with an underlying disease.

Although our sample was small, the pattern observed on chest X-rays by Boroja et
al. () Looks
reproduced on HRCT. In our study, patients showed a consolidation pattern
died, but three other patients who died just shows GGOs on HRCT. This
The pattern of presentation is important because patients were examined at the beginning
phase of the disease and do not undergo another examination for rapid clinical
soured and morbid results. However, follow-up chest X-ray showed worsening
The findings, by air space disease. In three cases described previously (,,), two patients
with consolidated died, one after the other 10 hours and after 5 days. Patient
which shows only GGOs have a good outcome and was discharged 10 days after symptoms
attack. Thus, the vast air space disease seems related to
more deaths. The diagnosis for these radiological findings widely,
including pulmonary edema, pulmonary hemorrhage, and pneumonia bacteria and viruses.
Clinical history, in combination with laboratory and radiographic findings, perhaps
suggest the diagnosis of HPS. diagnostic tests, however, virus-specific, such as
serological tests, reverse transcription, or PCR, is needed to confirm this
diagnosis(). That
Diagnosis may be difficult with other viral diseases such as dengue fever
fever (-), Influenza A (H1N1) (-), and
even for bacterial infections, such as leptospirosis (-). We
This study has several limitations, including the retrospective observational design and
small sample. Although CT technique varies because of a long study
period and difference in equipment participating agencies, we do not believe
that these variations affect our results.

In conclusion, the dominant HRCT findings in patients with HPS GGOs and
subtle thickening of the septum. In the appropriate clinical setting, these findings have
diagnostic value. pleural effusion and thickening peribronchovascular also
often, but less characteristic findings.

The study, conducted at the Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro,
RJ, Brazil.

,

8600 Rockville Pike, Bethesda
MD, 20 894
United States of America

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