Hantavirus infection chest x ray
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Basir Gill, M.B.B.S, M.D.[2] Furqan M M. M.B.B.S[3]
Overview
On chest x-ray, hantavirus infection may manifest as non-cardiogenic pulmonary edema characterized by bilateral interstitial and alveolar infiltrates with pleural effusions. Chest radiographs are typically normal during the febrile prodrome but evolve rapidly during the cardiopulmonary phase.[1] The presence of infiltrates on chest radiographs is an independent prognostic factor for mortality in New World hantavirus infection (moderate-to-high certainty evidence).[2] A presumptive diagnosis of hantavirus cardiopulmonary syndrome (HCPS) can be made based on pulmonary interstitial edema on chest radiographs in association with leukocytosis, thrombocytopenia, and hemoconcentration.[3]
Chest X-Ray
Hantavirus Cardiopulmonary Syndrome (HCPS)
Prodromal Phase
Chest radiographs are usually normal during the febrile prodrome.[1]
Cardiopulmonary Phase
During the cardiopulmonary phase, bilateral infiltrates develop rapidly — often within hours — with a mixed interstitial and alveolar pattern, accompanied by pleural effusions.[1] In the original 1993 series of 17 patients with confirmed HCPS, the initial chest radiograph showed interstitial or interstitial and alveolar infiltrates in 65% (11/17), fluffy alveolar infiltrates in 12% (2/17), and no abnormalities in 24% (4/17). Subsequently, 94% (16/17) developed rapidly evolving, bilateral, diffuse infiltrates. Pleural effusions were noted during the course of illness in 4 patients.[4]
Key Radiographic Features
Characteristic chest x-ray findings in HCPS include:[1][4][6]
- Diffuse interstitial infiltrates consistent with pulmonary edema
- Kerley B lines indicating interlobular septal thickening
- Thickening of pulmonary fissures
- Normal cardiac silhouette (indicating non-cardiogenic etiology in patients without underlying heart disease)
- Patchy alveolar infiltrates with air bronchograms
- Bilateral pleural effusions
- Some patients may initially present with unilateral pulmonary edema, but findings rapidly progress to bilateral involvement as the disease advances.[1]
Interstitial Edema Predominance — Distinguishing HCPS from ARDS
In a study of 16 confirmed HCPS patients, findings indicative of interstitial edema were present in 88% (14/16), which is far more frequent than typically seen in ARDS (5%). Alveolar flooding subsequently developed in 69% (11/16) and showed a central alveolar filling pattern rather than the peripheral distribution usually seen in ARDS. Autopsy demonstrated a pattern of endothelial leak with minimal epithelial injury, explaining the interstitial edema and central alveolar filling atypical of ARDS.[7]
Non-cardiogenic pulmonary edema is evidenced by chest radiographs showing peribronchial haze and Kerley B lines that subsequently progress to alveolar flooding with proteinaceous fluid.[1]
Radiographic Patterns and Clinical Outcome
Two distinct radiographic patterns have been described that correlate with clinical outcome:[1][7]
- Fulminant form (approximately 65% of patients): Presents with bilateral parenchymal infiltrates or rapid progression from mild bilateral interstitial changes to bilateral interstitial and alveolar infiltrates with pleural effusions. Requires ICU support. Mortality approximately 46%.
- Limited form (approximately 35% of patients): Limited clinical course with only minimal radiographic changes. Limited hospital stay. Mortality 0%.
Hemorrhagic Fever with Renal Syndrome (HFRS)
- Cardiopulmonary involvement with respiratory failure and shock may also occur in HFRS.[1] In European series, more than half of patients with Puumala virus (PUUV) and Dobrava-Belgrade virus (DOBV) infections showed pathological pulmonary radiographs with interstitial infiltrates and pleural effusions.[1] Pulmonary edema may occur during the oliguric phase, associated with hypertension and complications of renal insufficiency.[1][8]
- Virtually all patients with HCPS and more than half of patients with HFRS have respiratory symptoms such as hypoxia and radiological findings on chest X-rays.[1]
Lung Ultrasonography
In a prospective study of 44 HFRS patients, lung ultrasonography (LUS) showed high sensitivity (92.19–100%) and high negative predictive value (95.9–100%) compared with chest CT for diagnosing alveolar-interstitial pattern, lung consolidation, pleural effusion, and pericardial effusion. Both LUS and chest CT scores correlated with disease severity, hospital days, and laboratory profiles. LUS may serve as a useful bedside tool for monitoring pulmonary involvement in hantavirus infection.[9]
Differentiating HCPS from ARDS and Cardiogenic Pulmonary Edema
The following table summarizes key radiographic features that help distinguish HCPS from ARDS and cardiogenic pulmonary edema:[7][1][3]
| Feature | HCPS | ARDS | Cardiogenic Pulmonary Edema |
|---|---|---|---|
| Interstitial edema | Very common (88%) | Uncommon (5%) | Common |
| Alveolar pattern | Central filling (69%) | Peripheral distribution | Perihilar/batwing |
| Cardiac silhouette | Normal | Normal | Enlarged |
| Kerley B lines | Present | Absent | Present |
| Pleural effusions | Common | Less common | Common |
| Vascular redistribution (cephalization) | Absent | Absent | Present |
| Rapidity of progression | Hours | Variable | Variable |
Prognostic Significance
The presence of infiltrates on chest radiographs is an independent prognostic factor for mortality in New World hantavirus infection (moderate-to-high certainty evidence). Other prognostic factors associated with increased mortality include age >18 years, female sex, rural residence, elevated creatinine, increased hematocrit, and signs of bleeding.[2]
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 Vial PA, Ferrés M, Vial C, Valdivieso F, Mertz GJ, Godoy P (2023). "Hantavirus in humans: a review of clinical aspects and management". Lancet Infect Dis. 23 (9): e371–e382. doi:10.1016/S1473-3099(23)00128-7. PMID 37105214 Check
|pmid=value (help). - ↑ 2.0 2.1 Tortosa F, Ragusa MA, Neumann I, Godoy P, Vial PA (2026). "Prognostic factors for mortality in patients infected with New World hantaviruses: a systematic review and meta-analysis". BMJ Open. 16 (1): e096313. doi:10.1136/bmjopen-2024-096313. PMID 41592833 Check
|pmid=value (help). - ↑ 3.0 3.1 Hartline J, Mierek C, Knutson T, Kang C (2013). "Hantavirus infection in North America: a clinical review". Am J Emerg Med. 31 (6): 978–82. doi:10.1016/j.ajem.2013.02.001. PMID 23680331.
- ↑ 4.0 4.1 Duchin JS, Koster FT, Peters CJ, Simpson GL, Tempest B, Zaki SR, Ksiazek TG, Rollin PE, Nichol S, Umland ET (1994). "Hantavirus pulmonary syndrome: a clinical description of 17 patients with a newly recognized disease". N Engl J Med. 330 (14): 949–55. doi:10.1056/NEJM199404073301401. PMID 8189152.
- ↑ "Public Health Image Library (PHIL)".
- ↑ Levy H, Simpson SQ (1994). "Hantavirus pulmonary syndrome". Am. J. Respir. Crit. Care Med. 149 (6): 1710–3. doi:10.1164/ajrccm.149.6.8004332. PMID 8004332.
- ↑ 7.0 7.1 7.2 Ketai LH, Williamson MR, Telepak RJ, Levy H, Koster FT, Nolte KB, Allen SE (1994). "Hantavirus pulmonary syndrome: radiographic findings in 16 patients". Radiology. 191 (3): 665–8. doi:10.1148/radiology.191.3.8078264. PMID 8078264.
- ↑ Jiang H, Zheng X, Wang L, Du H, Wang P, Bai X (2017). "Hantavirus infection: a global zoonotic challenge". Virol Sin. 32 (1): 32–43. doi:10.1007/s12250-016-3899-x. PMID 28120221.
- ↑ Yang H, Zhang Y, Ma C, Hou X, Li J, Wang Y (2023). "Lung ultrasonography versus chest CT in patients with hemorrhagic fever with renal syndrome: a prospective study". BMC Infect Dis. 23 (1): 720. doi:10.1186/s12879-023-08710-z. PMID 37817583 Check
|pmid=value (help).