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{{Taxobox
* '''Cytomegalovirus treatment'''<ref>{{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy 2014 | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2014 | isbn = 978-1930808782 }}</ref>
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:* 1. '''Immunocompetent patients'''
| name = ''Hantavirus''
::* 1.1 '''Mononucleosis syndrome'''
| image = Sin Nombre hanta virus TEM PHIL 1136 lores.jpg
:::* Preferred regimen: supportive therapy
| image_caption = Transmission electron micrograph of the Sin Nombre Hantavirus
::* 1.2 '''CMV in pregnancy'''
| virus_group = v
:::* Preferred regimen: Hyperimmune 200 IU/kg of maternal weight as single-dose during pregnancy
| familia = ''[[Bunyaviridae]]''
:* 2. '''Immunocompromised patients'''
| genus = '''''Hantavirus'''''
::* 2.1 '''Retinitis'''
| subdivision_ranks = Species
:::* Preferred regimen (1): [[Ganciclovir]] intraocular implant {{plus}} [[Valganciclovir]] 900 mg PO bid for 14-21 days {{then}} [[Valganciclovir]] 900mg PO qq for maintenance therapy - for immediate sight-threatening lesions
| subdivision =  
:::* Preferred regimen (2): [[Valganciclovir]] 900 mg PO bid for 14-21 days {{then}} [[Valganciclovir]] 900 mg PO qq for maintenance therapy - for peripheral lesions
''[[Andes virus]]'' (ANDV)<br />
:::* Alternative regimen (1): [[Foscarnet]] 60 mg/kg IV q8h {{or}} [[Foscarnet]] 90 mg/kg IV q12h for 14-21 days {{then}} [[Foscarnet]] 90-120 mg/kg IV q24h
''Bayou virus'' (BAYV)<br />
:::* Alternative regimen (2): [[Cidofovir]] 5 mg/kg IV for 2 weeks {{then}} [[Cidofovir]] 5 mg/kg IV every other week - each dose should be admnistered with IV saline hydration and probenecid
''Black Creek Canal virus'' (BCCV)<br />
:::* Alternative regimen (3): [[Ganciclovir]] 5 mg/kg IV q12h for 14-21 days {{then}} [[Valganciclovir]] 900 mg PO bid
''Cano Delgadito virus'' (CADV)<br />
:::* Alternative regimen (4): [[Fomivirsen]] intravitreal injection - for relapses
''Choclo virus'' (CHOV)<br />
:::* Note: keep a maintenance dose of [[Valganciclovir]] 900 mg PO qd until CD4 >100/mm³
''Dobrava-Belgrade virus'' (DOBV)<br />
::* 2.2 '''Transplant patients'''
''Hantaan virus'' (HTNV)<br />
:::* Preferred regimen: [[Valganciclovir]] 900 mg PO bid {{or}} [[Ganciclovir]] 5 mg/kg IV q12h for at least 2-3 weeek
''Isla Vista virus'' (ISLAV)<br />
:::* Note: Use [[Valganciclovir]] 900 mg PO qd for 1-3 months if high dose of immunosuppression.  
''Khabarovsk virus'' (KHAV)<br />
::* 2.3 '''Colitis, esophagitis, gastritis'''
''Laguna Negra virus'' (LANV)<br />
:::* Preferred regimen: [[Ganciclovir]] 5 mg/kg/dose IV q12h for 3-6 weeks weeks for induction. There is no agreement on the use of maintenance.
''Muleshoe virus'' (MULV)<br />
:::* Alternative regimen: [[Cidofovir]] 5 mg/kg IV for 2 weeks, then 5 mg/kg every other week; each dose should be administered with IV saline hydration and oral probenecid 2 g PO 3h before each dose and further 1 g doses after 2h and 8h.
''New York virus'' (NYV)<br />
:::* Note: Switch to oral [[Valganciclovir]] when PO tolerated & when symptoms not severe enough to interfere with absorption.  
''Prospect Hill virus'' (PHV)<br />
::* 2.4 '''Pneumonia'''
''[[Puumala virus]]'' (PUUV)<br />
:::* Preferred regimen: [[Valganciclovir]] 900 mg PO bid for 14–21 days, then 900 mg PO qd for maintenance therapy
''Rio Mamore virus'' (RIOMV)<br />
:::* Alternative regimen for retinitis: [[Ganciclovir]] 5 mg/kg IV q12h for 14–21 days, then [[Valganciclovir]] 900 mg PO qd
''Rio Segundo virus'' (RIOSV)<br />
:::* Note: In bone marrow transplant patients, combine therapy with CMV immune globulin.
''[[Seoul virus]]'' (SEOV)<br />
::* 2.5 '''Encephalitis, ventriculitis'''
''[[Sin Nombre virus]]'' (SNV)<br />
:::* Note: Treatment not defined, but should be considered the same as retinitis. Disease may develop while taking [[Ganciclovir]] as suppressive therapy.  
''Thailand virus'' (THAIV)<br />
::* 2.6 '''Lumbosacral polyradiculopathy'''
''Thottapalayam virus'' (TPMV)<br />
:::* Preferred regimen: [[Ganciclovir]], as with retinitis
''Topografov virus'' (TOPV)<br />
:::* Alternative regimen: [[Foscarnet]] 40 mg/kg IV q12h another option
''Tula virus'' (TULV)<br />
:::* Alternative regimen: [[Cidofovir]] 5 mg/kg IV for 2 weeks, then 5 mg/kg every other week; each dose should be administered with IV saline hydration and oral probenecid 2 g PO 3h before each dose and further 1 g doses after 2h and 8h.
''Bakau virus'' <br />
:::* Note (1): Switch to [[Valganciclovir]] when possible.
}}
:::* Note (2): Suppression continued until CD4 remains >100/mm³ for 6 months.  
 
::*2.7 '''Peri/postnatal severe CMV infection in very low birth weight infants'''
{{SI}}
:::*Preferred regimen: [[Ganciclovir]] 6 mg/kg/dose IV q12h for 3 weeks<ref name="pmid25243446">{{cite journal| author=Josephson CD, Caliendo AM, Easley KA, Knezevic A, Shenvi N, Hinkes MT et al.| title=Blood transfusion and breast milk transmission of cytomegalovirus in very low-birth-weight infants: a prospective cohort study. | journal=JAMA Pediatr | year= 2014 | volume= 168 | issue= 11 | pages= 1054-62 | pmid=25243446 | doi=10.1001/jamapediatrics.2014.1360 | pmc=PMC4392178 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25243446  }} </ref>
 
 
==Overview==
'''Hantaviruses''' belong to the '''[[bunyaviridae]]''' family of [[virus]]es. There are 5 genera within the bunyaviridae family: bunyavirus, [[phlebovirus]], [[nairovirus]], [[tospovirus]], and hantavirus. Each is made up of negative-sensed, single-stranded [[RNA virus]]es. All these genera include [[arthropod]]-borne viruses, with the exception of hantavirus, which is a genus of [[rodent]]-borne agents.
 
The word ''hantavirus'' is derived from the Hantan River, where the Hantaan virus (the etiologic agent of Korean hemorrhagic fever) was first isolated by Dr. Lee Ho-Wang. The disease associated with Hantaan virus is called '''Korean hemorrhagic fever''' (a term that is no longer in use)  or '''hemorrhagic fever with renal syndrome''' (HFRS), a term that is accepted by the World Health Organization.
 
==History==
The Hantaviruses constitute a relatively newly discovered class of virus; the disease entity HFRS was first recognized by Western medicine during the Korean War in the early 1950s. In 1993, a newly-recognized species of hantavirus was found to be behind the '''Hantavirus cardiopulmonary syndrome''' (HCPS, also called HPS) caused by the [[Sin Nombre virus]] (Spanish for "nameless virus") in New Mexico and other Four Corners states. In addition to Hantaan virus and Sin Nombre virus, several other hantaviruses have been implicated as etiologic agents for either HFRS or HCPS.
 
==Geographic distribution and epidemiology==
Regions especially affected by HFRS include China, the Korean Peninsula, Russia (Hantaan, Puumala and Seoul viruses), and northern and western Europe ([[Puumala virus|Puumala]] and Dobrava viruses). Regions with the highest incidences of HCPS include Patagonian Argentina, Chile, Brazil, the United States, Canada, and Panama, where a milder form of disease that spares the heart has been recognized. The two agents of HCPS in South America are [[Andes virus]] (also called Oran, Castelo de Sonhos, Lechiguanas, Juquitiba, Araraquara, and Bermejo viruses, among many other synonyms), which is the only hantavirus that has shown (only in a few clusters of cases) an interpersonal form of transmission, and Laguna Negra virus, an extremely close relative of the previously-known Rio Mamore virus. In the U.S., minor causes of HCPS include New York virus, Bayou virus, and possibly Black Creek Canal virus.
 
As of July of 2007, six states had reported 30 or more cases of Hantavirus since 1993 - New Mexico (69), Colorado (49), Arizona (46), California (43), Texas (33), and Washington (30).  Other states reporting a significant number of cases include Montana (25), Idaho (19), and Utah (24).  With only 7 cases, Oregon has a notably lower attack rate overall and relative to population, compared to other Western states.
 
==Virology==
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 [[glycoprotein]]s G1 and G2. The L RNA encodes the L protein, which functions as the viral transcriptase/replicase. Within [[virion]]s, the genomic RNAs of hantaviruses are thought to complex with the N protein to form helical nucleocapsids, the RNA component of which circularizes due to sequence complementarity between the 5' and 3' terminal sequences of each genomic segment.
 
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 must be 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 capped and contain nontemplated 5' terminal extensions. The G1 (aka Gn) and G2 (Gc) glycoproteins form [[hetero-oligomers]] 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. Hantavirus virions are believed to assemble 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 [[vesicle]]s to the [[plasma membrane]] and released by [[exocytosis]].
 
==Symptoms==
====Hemorrhagic Fever with Renal Syndrome (HFRS)====
 
Hantavirus has an [[incubation time]] of 2-4 weeks in humans, before symptoms of infection occur. These symptoms can be split into five phases:
 
* '''Febrile phase''': Symptoms include [[fever]], chills, [[malaise]], [[headache]]s, [[nausea]], [[abdominal]] and back [[Pain and nociception|pain]], [[respiratory]] problems such as the ones common in the [[influenza]] [[virus]], as well as gastro-intestinal problems. These symptoms normally occur for 3-7days.
 
* '''Hypotensive phase''': This occurs when the blood platelet levels drop and symptoms can lead to [[tachycardia]] and [[hypoxemia]]. This phase can last for 2 days.
 
* '''Oliguric phase''': This phase lasts for 3-7 days and is characterised by the onset of [[renal]] failure and [[proteinuria]] occurs.  
 
* '''Diuretic phase''': This is characterized by [[diuresis]] of 3-6L per day, which can last for a couple of days up to weeks.
 
* '''Convalescent phase''': This is normally when recovery occurs and symptoms begin to improve.
 
====Hantavirus (Cardio-)Pulmonary Syndrome (HPS or HCPS)====
 
Hantavirus pulmonary syndrome (HPS) is a deadly disease transmitted by infected rodents through urine, droppings, or saliva. Humans can contract the disease when they breathe in aerosolized virus. HPS was first recognized in 1993 and has since been identified throughout the United States. Although rare, HPS is potentially deadly. Rodent control in and around the home remains the primary strategy for preventing hantavirus infection.
 
These symptoms, which are very similar to HFRS, include [[tachycardia]] and [[tachypnoea]]. Such conditions can lead to a cardiopulmonary phase, where [[cardiovascular]] shock can occur, and hospitalization of the patient is required.
 
==Treatment==
 
* Hanta virus treatment<ref>{{citeweb|title=|http://www.cdc.gov/hantavirus/technical/hps/treatment.html|=}}</ref>
:* Supportive therapy
::* ICU management should include careful assessment, monitoring and adjustment of volume status and cardiac function, including inotropic and vasopressor support if needed.
::* Fluids should be administered carefully due to the potential for capillary leakage.
::* Supplemental oxygen should be administered if patients become hypoxic.  
::* Equipment and materials for intubation and mechanical ventilation should be readily available since onset of respiratory failure may be precipitous.
:* Note (1): There is no specific treatment or cure for hantavirus infection.  
:* Note (2): Treatment of patients with HPS remains supportive in nature.
:* Note (3): Patients should receive appropriate, broad-spectrum antibiotic therapy while awaiting confirmation of a diagnosis of HPS. Care during the initial stages of the disease should include antipyretics and analgesia as needed.
:* Note (4): If there is a high degree of suspicion of Hantavirus pulmonary syndrome, patients should be immediately transferred to an emergency department or intensive care unit (ICU) for close monitoring and care.
:* Note (5): if the individual is experiencing fever and fatigue and has a history of potential rural rodent exposure, together with shortness of breath, would be strongly suggestive of Hantavirus pulmonary syndrome.
 
 
==External links==
*[http://www.tulane.edu/~dmsander/WWW/335/Hantaviruses.html "Hantaviruses, with emphasis on Four Corners Hantavirus"] by Brian Hjelle, M.D., Department of Pathology, School of Medicine, University of New Mexico
*[http://www.cdc.gov/ncidod/diseases/hanta/hps/noframes/phys/technicalinfoindex.htm CDC's Hantavirus Information page]
* Kruger DH, Ulrich R, Lundkvist A (2001) "Hantavirus infections and their prevention", Microbes And Infection 3 (13): 1129-1144
 
 
[[Category:Viral diseases]]
[[Category:Bunyaviruses]]
[[Category:Hemorrhagic fevers]]
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{{WikiDoc Sources}}
 
==References==
{{reflist|2}}

Revision as of 15:02, 10 August 2015

  • Cytomegalovirus treatment[1]
  • 1. Immunocompetent patients
  • 1.1 Mononucleosis syndrome
  • Preferred regimen: supportive therapy
  • 1.2 CMV in pregnancy
  • Preferred regimen: Hyperimmune 200 IU/kg of maternal weight as single-dose during pregnancy
  • 2. Immunocompromised patients
  • 2.1 Retinitis
  • Preferred regimen (1): Ganciclovir intraocular implant PLUS Valganciclovir 900 mg PO bid for 14-21 days THEN Valganciclovir 900mg PO qq for maintenance therapy - for immediate sight-threatening lesions
  • Preferred regimen (2): Valganciclovir 900 mg PO bid for 14-21 days THEN Valganciclovir 900 mg PO qq for maintenance therapy - for peripheral lesions
  • Alternative regimen (1): Foscarnet 60 mg/kg IV q8h OR Foscarnet 90 mg/kg IV q12h for 14-21 days THEN Foscarnet 90-120 mg/kg IV q24h
  • Alternative regimen (2): Cidofovir 5 mg/kg IV for 2 weeks THEN Cidofovir 5 mg/kg IV every other week - each dose should be admnistered with IV saline hydration and probenecid
  • Alternative regimen (3): Ganciclovir 5 mg/kg IV q12h for 14-21 days THEN Valganciclovir 900 mg PO bid
  • Alternative regimen (4): Fomivirsen intravitreal injection - for relapses
  • Note: keep a maintenance dose of Valganciclovir 900 mg PO qd until CD4 >100/mm³
  • 2.2 Transplant patients
  • 2.3 Colitis, esophagitis, gastritis
  • Preferred regimen: Ganciclovir 5 mg/kg/dose IV q12h for 3-6 weeks weeks for induction. There is no agreement on the use of maintenance.
  • Alternative regimen: Cidofovir 5 mg/kg IV for 2 weeks, then 5 mg/kg every other week; each dose should be administered with IV saline hydration and oral probenecid 2 g PO 3h before each dose and further 1 g doses after 2h and 8h.
  • Note: Switch to oral Valganciclovir when PO tolerated & when symptoms not severe enough to interfere with absorption.
  • 2.4 Pneumonia
  • Preferred regimen: Valganciclovir 900 mg PO bid for 14–21 days, then 900 mg PO qd for maintenance therapy
  • Alternative regimen for retinitis: Ganciclovir 5 mg/kg IV q12h for 14–21 days, then Valganciclovir 900 mg PO qd
  • Note: In bone marrow transplant patients, combine therapy with CMV immune globulin.
  • 2.5 Encephalitis, ventriculitis
  • Note: Treatment not defined, but should be considered the same as retinitis. Disease may develop while taking Ganciclovir as suppressive therapy.
  • 2.6 Lumbosacral polyradiculopathy
  • Preferred regimen: Ganciclovir, as with retinitis
  • Alternative regimen: Foscarnet 40 mg/kg IV q12h another option
  • Alternative regimen: Cidofovir 5 mg/kg IV for 2 weeks, then 5 mg/kg every other week; each dose should be administered with IV saline hydration and oral probenecid 2 g PO 3h before each dose and further 1 g doses after 2h and 8h.
  • Note (1): Switch to Valganciclovir when possible.
  • Note (2): Suppression continued until CD4 remains >100/mm³ for 6 months.
  • 2.7 Peri/postnatal severe CMV infection in very low birth weight infants
  1. ↑ Gilbert, David (2014). The Sanford guide to antimicrobial therapy 2014. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808782.
  2. ↑ Josephson CD, Caliendo AM, Easley KA, Knezevic A, Shenvi N, Hinkes MT; et al. (2014). "Blood transfusion and breast milk transmission of cytomegalovirus in very low-birth-weight infants: a prospective cohort study". JAMA Pediatr. 168 (11): 1054–62. doi:10.1001/jamapediatrics.2014.1360. PMC 4392178. PMID 25243446.
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