Hantavirus infection differential diagnosis

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

Overview

Hemorrhagic fever caused by hantavirus can be differentiated from other disease such as dengue, malaria and Ebola. The hantavirus cardiopulmonary syndrome can be differentiated from other diseases like histoplasmosis, coccidioidomycosis, brucellosis, tuberculosis and aspergillosis.

Differentiating Hantavirus infection from other Diseases

Hemorrhagic fever caused by hantavirus can be differentiated from other disease such as dengue, malaria and Ebola. The hantavirus cardiopulmonary syndrome can be differentiated from other diseases like histoplasmosis, coccidioidomycosis, brucellosis, tuberculosis and aspergillosis.

Differentiating Hantavirus infection from other causes of Hemorrhagic fever

Disease	Incubation period	Vector	Symptoms							Physical signs		Lab findings		Other findings	Treatment
			Fever	Cough	Rash	Joint pain	Myalgia	Diarrhea	Common hemorrhagic symptoms	Characterestic physical finding	Icterus	Plasma Creatine kinase	Confirmatory test
Leptospirosis	2 to 30 days	Rodents Domestic animals	Fever last for 4-7 days, remission for 1-2 days and then relapse	+	Present over legs Hemorrhagic rash	+	+ (Severe myalgia is characteristic of leptospirosis typically localized to the calf and lumbar areas)	+	Conjunctival hemorrhage, Hemoptysis	Conjunctival suffusion	+	Elevated	Microscopic agglutination test of urine	History of exposure to soil or water contaminated by infected rodents Recent history travel to tropical, sub tropical areas or humid areas	NSAIDs
Dengue	4 to 10 days	Aedes mosquito	Fever last for 1-2 days, remission for 1-2 days and then relapse for 1-2 days (Biphasic fever pattern)	-	Over legs and trunk pruritic rash May be hemorrhagic	+	+	-	Upper gastrointestinal bleeding	Painful lymphadenopathy	-	Normal	Serology showing positive IgM or IgG	Recent travel to South America, Africa, Southeast Asia	Supportive care Avoid aspirin and other NSAIDs
Malaria	Plasmodium falciparum: 9-14 days Plasmodium vivax: 12-18 days Plasmodium ovale: 18-40 days	Female Anopheles	Fever present daily or on alternate day or every 3 days depending on Plasmodium sps.	-	No rash	-	+	-	Bloody urine	Hepatosplenomegaly	+	Normal	Giemsa stained thick and thin blood smears	Recent travel to South America, Africa, Southeast Asia	Anti malarial regimen
Ebola	2 to 21 days.	No vector Human to human transmission Air born disease	+	+	Maculopapular non-pruritic rash with erythema Centripetal distribution	+	+	+ May be bloody in the early phase	Epistaxis Mucosal bleeding	Sudden onset of high fever with conjunctival injection and early gastrointestinal symptoms	-	Normal	RT-PCR	Recent visit to endemic area especially African countries	Isolation of the patient, supportive therapy
Influenza	1-4 days	No vector Air born disease	+	+	+/-	+	+	+	-	Fever and upper respiratory symptoms	-	Normal	Viral culture or PCR	Health care workers Patients with co-morbid conditions	Symptomatic treatment Oseltamivir or zanamivir
Yellow fever	3 to 6 days	Aedes or Haemagogus species mosquitoes	+	+	-	-	+	-	Conjunctival hemorrhage, Hemoptysis	Relative bradycardia (Faget's sign)	+	Normal	RT-PCR, Nucleic acid amplification test, Immuno-histochemical staining	Recent travel to  Africa, South and Central America, and the Caribbean. Tropical rain forests of south America	Symptomatic treatment, Anti-inflammatory drugs
Typhoid fever	6 to 30 days	No vector Air born disease	+	-	Blanching erythematous  maculopapularlesions on the lower chest and abdomen	+	+	+	Intestinal bleeding	Rose spots	-	Normal	Blood or stool culture showing salmonella typhi sps.	Residence in endemic area Recent travel to endemic area	Fluoroquinolones, Third generation cephalosporins, Azithromycin

Differentiating Hantavirus infection on the basis of Cardiopulmonary involvement

The hantavirus cardiopulmonary syndrome can be differentiated from other diseases like histoplasmosis, coccidioidomycosis, brucellosis, tuberculosis and aspergillosis.

Disease	Geographic distribution	High risk Groups	Differentiating features		Microscopic findings
			Physical exam	Laboratory findings
Histoplasmosis	Mississippi and Ohio River valleys	Cave dwellers Soil that contains bird or bat dropping	Palate and oral ulcers Splenomegaly	Pancytopenia Urine antigen testing	Yeast are typically smaller, with narrow-based budding, found intracellularly within macrophages
Coccidioidomycosis	Southwestern US region	Opportunistic infection seen in AIDS	Rash on upper body or legs Night sweats	Serologic tests (enzyme immune assay) more sensitive	Characteristic spherule appearance
Aspergillosis	Ubiquitous	Cystic fibrosis or asthma. tuberculosis. Immunocompromised	Wheezing Stuffiness, runny nose Hemoptysis Weight loss	Cell wall detection using galactomannan antigen detection, Beta-D-glucan detection test.	Septated hyphae with acute angle branching
Anthrax	Ubiquitous	Live stock handlers	Painless skin ulcer with a black center Bloody diarrhea	Thrombocytopenia Hyponatremia ↑ BUN Hypoalbuminemia ↑ Troponin.	Nonmotile, Gram-positive, aerobic or facultatively anaerobic, endospore-forming, rod-shaped bacterium
Tuberculosis	Asia,Africa	Ill contact individuals	Night sweats Hemoptysis	Hypercalcemia Elevated alkaline phosphatase levels fluorescence microscopy (auramine-rhodamine staining)+ for baccilli.	Aerobic, non-encapsulated, non-motile, acid-fast bacillus
Listeriosis	Ubiquitous	Pregnant women Adults > 65 Immunocompromised.	Pregnancy can lead to miscarriage, stillbirth, premature delivery Non-pregnant : headache, stiff neck, confusion, loss of balance, and convulsions	Elevated titers of listeriolysin O CSF analysis :Pleocytosis lymphocytes ↑CSF protein ↓ CSF glucose	flagellated, catalase-positive, facultative intracellular, anaerobic, nonsporulating, Gram-positive bacillus
Brucellosis	Mexico, South and Central America	People who take unpasteurized dairy products	Arthritis Testicular and scrotal swelling Endocarditis	Antibody production againstlipopolysaccharide and bacterial antigens Relative lymphocytosis and thrombocytopenia.	Gram-negative bacteria,non-motile, encapsulated coccobacilli.
Coxsackie A virus	−	Children attending day care	Painful blisters in the mouth, palms and on the feet. Rash, appears after episode of high fever.	Clinically diagnosed	−