Puumala Virus Infections Associated with Cardiovascular Causes of Death

Anne-Marie Connolly-Andersen, Kristin Ahlm, Clas Ahlm

, and Jonas Klingström

Author affiliations: Author affiliations: Umeå University, Umeå, Sweden (A.-M. Connolly-Andersen, K. Ahlm, C. Ahlm); Swedish Institute for Communicable Disease Control, Solna, Sweden (J. Klingström); Karolinska Institutet, Stockholm, Sweden (J. Klingström)

Abstract

We studied the causes of death of patients in Sweden with diagnoses of hemorrhagic fever with renal syndrome (HFRS) during 1997–2009. Cardiovascular disorders were a common cause of death during acute-phase HFRS and were the cause of death for >50% of those who died during the first year after HFRS.

Hantaviruses cause 2 acute diseases: hemorrhagic fever with renal syndrome (HFRS) and hantavirus cardiopulmonary syndrome (HCPS). HFRS is caused by the prototypic hantavirus Hantaan and by Dobrava virus, Puumala virus (PUUV), and Seoul virus in Eurasia; HCPS is caused by Andes virus, Sin Nombre virus and related hantaviruses in the Americas. Case-fatality rates differ: <10% for HFRS and <40% for HCPS (1). PUUV causes HFRS in Europe; >225,000 cases of HFRS have been reported (2). One of the largest PUUV outbreaks recorded occurred in northern Sweden; an incidence of 313 cases per 100,000 persons was reported (3). The case-fatality rate for HFRS is 0.4% overall in Sweden and reaches 6% among elderly persons (4).
HFRS can cause pulmonary complications and HCPS can cause renal signs and symptoms, suggesting that these 2 diseases might have more in common than previously believed (5,6). However, as indicated by their respective names, HFRS is mainly considered a hemorrhagic fever with affected renal functions, and HCPS is characterized by severe cardiac and respiratory signs and symptoms (1). The primary causes of death during HCPS are known to be associated with cardiopulmonary failure (7). However, less is known regarding causes of death during the acute phase of HFRS and those that occur after HFRS related to possible sequelae of the illness. To explore patterns of death among persons who died during and after HFRS, we reviewed all causes of death of persons infected with PUUV in Sweden during 1997–2009.