Domestically Acquired Seoul Virus Causing Hemophagocytic Lymphohistiocytosis—Washington, DC, 2018

Abstract

Seoul orthohantavirus (SEOV) infections, uncommonly reported in the United States, often result in mild illness. We report a case of hemophagocytic lymphohistiocytosis secondary to SEOV infection that was domestically acquired in Washington, DC.

Hemorrhagic fever with renal syndrome presenting as leukemoid reaction and hemophagocytic lymphohistiocytosis

“…So far, there are only five cases of HFRS presenting with secondary HLH. [6][7][8][9][10] Interestingly, cytopenia, characterized by decreased two or three cell lines, is very common in HLH. However, in our case, the patient manifested as LR, thus it is unique for this case.…”

Notes from the Field: First Reports of Locally Transmitted Seoul Hantavirus Infection — District of Columbia, May 2018–December 2018

“…In May 2018, patient A, a previously healthy man aged 30 years, was evaluated at a District of Columbia (DC) health care facility for a 4-day history of chills, diarrhea, fever (103°F [39.5°C]), headache, sore throat, and vomiting. Despite symptomatic treatment with antipyretics, he subsequently experienced hemoconcentration (hematocrit = 60.4% [normal = 38.8%–50%]), thrombocytopenia (<10,000 platelets/ μ L [normal = 150,000–450,000]), and acute kidney injury (blood urea nitrogen [BUN] = 95 mg/dL [normal = 9–20] and creatinine = 4.95 mg/dL [normal = 0.66–1.50]) over several days ( 1 ). Approximately 1 week later, he experienced signs consistent with hemophagocytic lymphohistiocytosis, a potentially fatal systemic inflammatory syndrome, including elevated ferritin, triglycerides, and interleukin-2 levels, and hemophagocytosis cells on bone marrow biopsy ( 2 ).…”

“…Additional tests sent to CDC returned with hantavirus IgG and IgM titers >1:6,400, confirming recent infection with Seoul hantavirus (SEOV). Virus isolation was unsuccessful ( 1 ). Comprehensive testing for other infectious etiologies returned negative results.…”

“…SEOV is a type of hantavirus previously associated with hemorrhagic fever-renal syndrome. * Patient A is believed to have had the first case of hemophagocytic lymphohistiocytosis related to hantavirus infection reported in the United States and the second worldwide ( 1 , 3 ). Past studies have documented that Norway rats serve as the reservoir species for SEOV in the United States ( 1 , 4 ), and previous cases of hantavirus infection have been linked to wild or pet rodents ( 4 , 5 ).…”

“…* Patient A is believed to have had the first case of hemophagocytic lymphohistiocytosis related to hantavirus infection reported in the United States and the second worldwide ( 1 , 3 ). Past studies have documented that Norway rats serve as the reservoir species for SEOV in the United States ( 1 , 4 ), and previous cases of hantavirus infection have been linked to wild or pet rodents ( 4 , 5 ). Humans can become infected with SEOV through aerosol exposure to virus shed in rodent feces, saliva, or urine.…”