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__NOTOC__
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{{Hantavirus pulmonary syndrome}}
{{Hantavirus infection}}
 
{{CMG}}; {{AE}} {{ADG}}
{{CMG}}
 
==Overview==
==Overview==
[[Hantavirus]]es belong to the [[bunyavirus]] family of viruses. There are 5 genera within the family: bunyavirus, phlebovirus, nairovirus, tospovirus, and hantavirus. Each is made up of negative-sensed, single-stranded [[RNA]] viruses. All these genera include arthropod-borne viruses, with the exception of hantavirus, which is rodent-borne. The illness mainly goes through two stages, namely the prodromal phase and the cardiopulmonary phase.
Hantavirus is usually transmitted via the inhalation of aerosolized [[viral]] antigens or [[rodent]] bites. The [[incubation period]] of hantavirus infection is of 9 to 33 days. Following inhalation, the virus replicates in pulmonary [[macrophages]] and [[Dendritic cell|dendritic cells]]. The primary target cells of hantavirus infection are [[endothelial cells]] of [[capillaries]]. Infection is followed by impairment of the barrier function of [[endothelial cells]], fluid extravasation, and subsequent [[organ failure]].


==Pathophysiology==
==Pathophysiology==
The prodromal phase of HPS is indistinguishable clinically from numerous other viral infections. Often the only guide to the etiology of the patient's illness is the blood picture, which may show circulating immunoblasts, which appear as large atypical [[lymphocytes]], and [[thrombocytopenia]]. However, unlike other viral infections, HPS patients usually have concurrent left-shifted neutrophilia with circulating [[myelocyte]]s.
===Reservoir===
 
Each Hantavirus species is associated with a specific rodent in a given geographic region. Rodent subfamilies associated with hantaviruses include
In the cardiopulmonary stage of the disease, the patients have a diffuse pulmonary edema. The most frequent cause for such a picture is silent myocardial infarction so it is important to obtain an ECG and echocardiogram early to aid in the assessment. Intensivists at the University of New Mexico, where many of the patients have been managed, have found that a echocardiogram also helps to distinguish these patients from patients with ARDS as cardiac function is depressed to a much greater degree in the HPS patients and cardiac output does not respond to fluid challenge as it tends to with ARDS.  
*Arvicolinae (Europe)
*Murinae (Europe and Asia)
*Sigmodontinae (Americas)
===Transmission===
Hantavirus is usually transmitted via the inhalation of aerosolized viral antigens or rodent bites. Human to human transmission is seen in American Hantaviruses species (Andes virus).


Infections in the immunocompetent which might present with a non-specific prodrome leading to acute cardiopulmonary deterioration as in HPS include leptospirosis, Legionnaire's disease, mycoplasma, Q fever, chlamydia, and in regions where the organisms are present, septicemic plague, tularemia, coccidioidomycosis and histoplasmosis. Non-infectious conditions such as Goodpasture's syndrome should also be considered. Lack of coryza aids the clinical distinction between HPS and Influenza A infection.
===Incubation period===
The [[incubation period]] of hantavirus infection is of 9 to 33 days.<ref name="urlIncubation Period of Hantavirus Cardiopulmonary Syndrome - Volume 12, Number 8—August 2006 - Emerging Infectious Disease journal - CDC">{{cite web |url=https://wwwnc.cdc.gov/eid/article/12/8/05-1127_article |title=Incubation Period of Hantavirus Cardiopulmonary Syndrome - Volume 12, Number 8—August 2006 - Emerging Infectious Disease journal - CDC |format= |work= |accessdate=}}</ref>


It must be remembered that HPS is relatively uncommon and in the immunocompromised PCP, CMV, cryptococcus, aspergillus and graft vs. host disease are far more likely to be the cause of diffuse pulmonary infiltrates than a hantaviral infection.
===Seeding===
Following inhalation, the virus replicates in pulmonary [[Macrophage|macrophages]] and [[Dendritic cells|dendritic cells.]]


==Microbiology==
===Pathogenesis===
Like other members of the bunyavirus family, hantaviruses are enveloped viruses with a genome that consists of three single-stranded RNA segments designated S (small), M (medium), and L (large). All hantaviral genes are encoded in the negative (genome complementary) sense. The S RNA encodes the nucleocapsid (N) protein. The M RNA encodes a polyprotein that is cotranslationally cleaved to yield the envelope glycoproteins G1 and G2. The L RNA encodes the L protein, which functions as the viral transcriptase/replicase. Within virions, the genomic RNAs of hantaviruses are thought to complex with the N protein to form helical nucleocapsids, which circularize due to sequence complementarity between the 5' and 3' terminal sequences of each genomic segment.  
The pathogenesis of hantavirus infection can be described by impairment of the barrier function of [[endothelial cells]], fluid extravasation and subsequent organ
failure.<ref name="pmid23841977">{{cite journal |vauthors=Spiropoulou CF, Srikiatkhachorn A |title=The role of endothelial activation in dengue hemorrhagic fever and hantavirus pulmonary syndrome |journal=Virulence |volume=4 |issue=6 |pages=525–36 |year=2013 |pmid=23841977 |pmc=5359750 |doi=10.4161/viru.25569 |url=}}</ref>
====Impairment of the barrier function of endothelial cells====
* The primary target cells of hantavirus infection are [[endothelial cells]] of capillaries. Most commonly endothelial cells of [[lungs]] and [[heart]] are involved.
* Hantaviruses attach to beta-3 [[integrin]] receptors of endothelial cells and stimulate [[T cells]].<ref name="pmid9618541">{{cite journal |vauthors=Gavrilovskaya IN, Shepley M, Shaw R, Ginsberg MH, Mackow ER |title=beta3 Integrins mediate the cellular entry of hantaviruses that cause respiratory failure |journal=Proc. Natl. Acad. Sci. U.S.A. |volume=95 |issue=12 |pages=7074–9 |year=1998 |pmid=9618541 |pmc=22743 |doi= |url=}}</ref><ref name="pmid12376753">{{cite journal |vauthors=Gavrilovskaya IN, Peresleni T, Geimonen E, Mackow ER |title=Pathogenic hantaviruses selectively inhibit beta3 integrin directed endothelial cell migration |journal=Arch. Virol. |volume=147 |issue=10 |pages=1913–31 |year=2002 |pmid=12376753 |doi=10.1007/s00705-002-0852-0 |url=}}</ref>
* Neutralizing antibody (NAbs) are produced as a result of stimulation and beta-3 [[integrins]] are inactivated.
* Inactivation of virus-bound beta-3-integrins contributes to deregulation of [[Vascular endothelial growth factor receptors|vascular endothelial growth facto]]<nowiki/>r receptor-2 (VEGFR2) and diminished antagonism of [[vascular endothelial growth factor]] (VEGFA).<ref name="pmid12368479">{{cite journal |vauthors=Geimonen E, Neff S, Raymond T, Kocer SS, Gavrilovskaya IN, Mackow ER |title=Pathogenic and nonpathogenic hantaviruses differentially regulate endothelial cell responses |journal=Proc. Natl. Acad. Sci. U.S.A. |volume=99 |issue=21 |pages=13837–42 |year=2002 |pmid=12368479 |pmc=129784 |doi=10.1073/pnas.192298899 |url=}}</ref>
* This leads to impairment of vascular endothelial (VE) cadherin expression and subsequent loss of endothelial barrier function.
* [[Platelet]]<nowiki/>s are consumed in high number in response to the damage to the endothelial layer resulting in [[thrombocytopenia]].


Hantaviruses replicate exclusively in the host cell cytoplasm. Entry into host cells is thought to occur by attachment of virions to cellular receptors and subsequent endocytosis. Nucleocapsids are introduced into the cytoplasm by pH-dependent fusion of the virion with the endosomal membrane. Transcription of viral genes is initiated by association of the L protein with the three nucleocapsid species. In addition to transcriptase and replicase functions, the viral L protein is also thought to have an endonuclease activity that cleaves cellular messenger RNAs (mRNAs) for the production of capped primers used to initiate transcription of viral mRNAs. As a result of this "cap snatching," the mRNAs of hantaviruses are believed to be capped and contain nontemplated 5' terminal extensions. The viral N and L mRNAs are thought to undergo translation at free ribosomes, whereas the M mRNA is translated in the endoplasmic reticulum. G1 and G2 glycoproteins form heterodimers and are then transported from the endoplasmic reticulum to the Golgi complex, where glycosylation is completed. The L protein produces nascent genomes by replication via a positive-sense RNA intermediate. Hantavirions are believed to form by association of nucleocapsids with glycoproteins embedded in the membranes of the Golgi, followed by budding into the Golgi cisternae. Nascent virions are then transported in secretory vesicles to the plasma membrane and released by exocytosis.  
====Fluid extravasation====
 
* Neutralizing antibody (NAbs) also inhibit innate type I [[interferon]] (IFN) responses of endothelial cells.
'''Other Hantaviruses'''
* This results in inhibition of upregulation of CD73 by [[Interferon|IFN-beta]] on endothelial cells and promotes vascular leakage.
 
====Multiorgan failure====
Several members of the hantavirus genus cause different forms of hemorrhagic fever with renal syndrome (HFRS), an ancient disease first described in Russia in 1913. The four viruses that are associated with HFRS, each named for the region from where they were first isolated, have different primary rodent hosts: Apodemus agrarius (the striped field mouse) for Hantaan virus, Rattus norvegicus (the Norway rat) and Rattus rattus (the black rat) for Seoul virus, Clethrionomys glareolus (the bank vole) for Puumala virus, and Apodemus flavicollis (the yellow-necked field mouse) for Dobrava virus. Hantaan virus from Korea and Dobrava virus from Slovenia are associated with a severe form of HFRS characterized by renal failure that can precede pulmonary edema and disseminated intravascular coagulation (DIC), with estimated mortality rates of 5% to 15%. A moderate form of HFRS caused by Seoul virus (which, along with its host, is distributed worldwide) is responsible for thousands of Eurasian cases annually. Serologic evidence for infection with Seoul-like hantaviruses has been found in rodents in major cities of the United States, and this virus was recently implicated in human cases of HFRS in Baltimore. One report has also associated Seoul virus with chronic renal disease. A mild form of HFRS, caused by Puumala virus, is responsible for nephropathia epidemica in Scandinavia, with an estimated mortality rate of 1% to 3%.
* Hantaviruses demonstrated to have an immunoreceptor tyrosine-based activation motif (ITAM) on their G1 envelope glycoproteins.
 
* Immunoreceptor tyrosine-based activation motif along with local T-cell [[cytokine]] production results in cellular downstream and immune cell dysfunction.<ref name="pmid9878011">{{cite journal |vauthors=Mori M, Rothman AL, Kurane I, Montoya JM, Nolte KB, Norman JE, Waite DC, Koster FT, Ennis FA |title=High levels of cytokine-producing cells in the lung tissues of patients with fatal hantavirus pulmonary syndrome |journal=J. Infect. Dis. |volume=179 |issue=2 |pages=295–302 |year=1999 |pmid=9878011 |doi=10.1086/314597 |url=}}</ref>
== Genetics ==
* Attachment of hantavirus to beta-2 integrin receptors on [[neutrophils]] also induces the release of neutrophil extracellular traps.
''Sin nombre virus sequencing''
* Sensitized mononuclear cells infiltrate the [[lung]], myocardial interstitium, and [[spleen]] to produce [[cytokines]], particularly [[TNF-alpha]] and [[interferon-gamma]], resulting in [[pulmonary edema]] and [[myocarditis]]
[[Image:53 ov.jpg|left|Polymerase chain reaction (PCR) flow chart]]
The entire genomic sequence of SNV has subsequently been determined by using RNA extracted from autopsy material as well as RNA extracted from cell culture-adapted virus. The L RNA is 6562 nucleotides (nt) in length; the M RNA is 3696 nt long; and the S RNA is 2059 to 2060 nt long. Interestingly, when the prototype sequence (NMH10) of SNV detected in tissues from an HPS case was compared with the sequence of the SNV isolate (NMR11; isolated in Vero E6 cells from P. maniculatus trapped in the residence of the same case), only 16 nucleotide changes were found, and none of these changes resulted in alterations in amino acid sequences of viral proteins. It had been assumed that in the process of adaptation to cell culture, selection of SNV variants which grow optimally in cell culture would occur, and selected variants would differ genetically from the parental virus. Though NMH10 and NMR11 are identical in protein sequence, nucleotide substitutions in nontranslated regions of the genome could be responsible for altered viral phenotypes, as could changes in protein glycosylation or virus membrane components.
 
The nested RT-PCR assay developed during the initial HPS outbreak provided a rapid method for the genetic characterization of novel hantaviruses that did not require a virus isolate. Numerous new hantaviruses have been detected by RT-PCR in rodent tissues but have yet to be associated with human disease. These include El Moro Canyon virus associated with the western harvest mouse (Reithrodontomys megalotis), Tula virus with Microtus arvalis and M. rossiaemeridionalis, Rio Segundo virus with the Mexican harvest mouse (R. mexicanus), Isla Vista virus with the California vole (M. californicus), and Prospect Hill-like viruses in Microtus species.
 
''Phylogenetic Analysis''
 
Phylogenetic analysis of Old World and American hantaviruses indicates that the relationship among hantaviruses corresponds with the phylogeny of their rodent hosts. Viruses of rodents belonging to the subfamily Murinae are monophyletic as are hantaviruses of arvicoline and sigmodontine rodents, suggesting that long-term virus-rodent coevolution is taking place. Hantavirus evolution is best understood as co-evolution within specific lineages in the rodent family Muridae. The apparent coupling between hantaviruses and their rodent hosts suggests that viruses of sigmodontine rodents share a common ancestor, as do viruses of the subfamily Arvicolinae and Murinae. This coupling also has a geographic and clinical correlate: viruses found in Old World murine rodents, including Hantaan virus (HTNV), Seoul virus (SEOV) and Dobrava virus, are associated with HFRS in Eurasia.  By contrast, viruses carried by New World sigmodontine rodents, including SNV Black Creek Canal virus (BCCV) and Bayou virus (BAYV), are associated with HPS in the Americas. This distinction can narrow the search for a rodent host for newly discovered HPS-like diseases and suggest disease implications for the various new viruses being genetically amplified from rodents.
 
''Sequence Divergence''
 
Detection and characterization of Sin Nombre-like viruses in P. maniculatus and P. leucopus populations have shown that multiple phylogenetic lineages of SNV exist in North America, and in some cases similar viruses are detected in both Peromyscus species. Sequence divergence among SNV genes has been shown to be as high as 23% nucleotide dissimilarity and 7% amino acid dissimilarity. Comparison of SNV sequences with those of other hantaviruses provides no obvious explanation as to why SNV and related viruses cause HPS while other hantaviruses are associated with HFRS. The development of a reverse genetics system for manipulation of virus genomes and an animal model for studying pathogenesis will be necessary to define the molecular mechanism(s) of SNV pathogenicity.
 
Genomic reassortment by RNA viruses with segmented genomes is well documented and has the potential to produce viruses with altered biological activity, host range, and disease potential. For example, segment reassortment among influenza virus strains (antigenic shift) is thought to be responsible for influenza pandemics. Genomic reassortment among SNV variants is known to occur in nature, but the precise role of genomic reassortment in the epidemiology of HPS and HFRS is unknown.


== References ==
== References ==
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Latest revision as of 21:57, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Overview

Hantavirus is usually transmitted via the inhalation of aerosolized viral antigens or rodent bites. The incubation period of hantavirus infection is of 9 to 33 days. Following inhalation, the virus replicates in pulmonary macrophages and dendritic cells. The primary target cells of hantavirus infection are endothelial cells of capillaries. Infection is followed by impairment of the barrier function of endothelial cells, fluid extravasation, and subsequent organ failure.

Pathophysiology

Reservoir

Each Hantavirus species is associated with a specific rodent in a given geographic region. Rodent subfamilies associated with hantaviruses include

  • Arvicolinae (Europe)
  • Murinae (Europe and Asia)
  • Sigmodontinae (Americas)

Transmission

Hantavirus is usually transmitted via the inhalation of aerosolized viral antigens or rodent bites. Human to human transmission is seen in American Hantaviruses species (Andes virus).

Incubation period

The incubation period of hantavirus infection is of 9 to 33 days.[1]

Seeding

Following inhalation, the virus replicates in pulmonary macrophages and dendritic cells.

Pathogenesis

The pathogenesis of hantavirus infection can be described by impairment of the barrier function of endothelial cells, fluid extravasation and subsequent organ failure.[2]

Impairment of the barrier function of endothelial cells

  • The primary target cells of hantavirus infection are endothelial cells of capillaries. Most commonly endothelial cells of lungs and heart are involved.
  • Hantaviruses attach to beta-3 integrin receptors of endothelial cells and stimulate T cells.[3][4]
  • Neutralizing antibody (NAbs) are produced as a result of stimulation and beta-3 integrins are inactivated.
  • Inactivation of virus-bound beta-3-integrins contributes to deregulation of vascular endothelial growth factor receptor-2 (VEGFR2) and diminished antagonism of vascular endothelial growth factor (VEGFA).[5]
  • This leads to impairment of vascular endothelial (VE) cadherin expression and subsequent loss of endothelial barrier function.
  • Platelets are consumed in high number in response to the damage to the endothelial layer resulting in thrombocytopenia.

Fluid extravasation

  • Neutralizing antibody (NAbs) also inhibit innate type I interferon (IFN) responses of endothelial cells.
  • This results in inhibition of upregulation of CD73 by IFN-beta on endothelial cells and promotes vascular leakage.

Multiorgan failure

  • Hantaviruses demonstrated to have an immunoreceptor tyrosine-based activation motif (ITAM) on their G1 envelope glycoproteins.
  • Immunoreceptor tyrosine-based activation motif along with local T-cell cytokine production results in cellular downstream and immune cell dysfunction.[6]
  • Attachment of hantavirus to beta-2 integrin receptors on neutrophils also induces the release of neutrophil extracellular traps.
  • Sensitized mononuclear cells infiltrate the lung, myocardial interstitium, and spleen to produce cytokines, particularly TNF-alpha and interferon-gamma, resulting in pulmonary edema and myocarditis

References

  1. ↑ "Incubation Period of Hantavirus Cardiopulmonary Syndrome - Volume 12, Number 8—August 2006 - Emerging Infectious Disease journal - CDC".
  2. ↑ Spiropoulou CF, Srikiatkhachorn A (2013). "The role of endothelial activation in dengue hemorrhagic fever and hantavirus pulmonary syndrome". Virulence. 4 (6): 525–36. doi:10.4161/viru.25569. PMC 5359750. PMID 23841977.
  3. ↑ Gavrilovskaya IN, Shepley M, Shaw R, Ginsberg MH, Mackow ER (1998). "beta3 Integrins mediate the cellular entry of hantaviruses that cause respiratory failure". Proc. Natl. Acad. Sci. U.S.A. 95 (12): 7074–9. PMC 22743. PMID 9618541.
  4. ↑ Gavrilovskaya IN, Peresleni T, Geimonen E, Mackow ER (2002). "Pathogenic hantaviruses selectively inhibit beta3 integrin directed endothelial cell migration". Arch. Virol. 147 (10): 1913–31. doi:10.1007/s00705-002-0852-0. PMID 12376753.
  5. ↑ Geimonen E, Neff S, Raymond T, Kocer SS, Gavrilovskaya IN, Mackow ER (2002). "Pathogenic and nonpathogenic hantaviruses differentially regulate endothelial cell responses". Proc. Natl. Acad. Sci. U.S.A. 99 (21): 13837–42. doi:10.1073/pnas.192298899. PMC 129784. PMID 12368479.
  6. ↑ Mori M, Rothman AL, Kurane I, Montoya JM, Nolte KB, Norman JE, Waite DC, Koster FT, Ennis FA (1999). "High levels of cytokine-producing cells in the lung tissues of patients with fatal hantavirus pulmonary syndrome". J. Infect. Dis. 179 (2): 295–302. doi:10.1086/314597. PMID 9878011.

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