667. Novel Clinical and Pathologic Findings in a Heartland Virus-Associated Death
Session: Poster Abstract Session: Oh, Those Pesky Viruses!
Thursday, October 27, 2016
Room: Poster Hall
Posters
  • Fill_IDWeekPoster_HRTV.pdf (962.0 kB)
  • Background: Heartland virus (HRTV) is an emerging tickborne phlebovirus. Clinical characteristics of infection include leukopenia, thrombocytopenia, and fever. In 2013, the first reported HRTV-associated death occurred in a man aged 80 years with multiple comorbidities. HRTV antigen has previously been detected in bone marrow and postmortem lymph node and splenic tissue. We describe an HRTV-associated death in Tennessee in 2015 with novel clinical and pathology findings.

    Methods: We performed a chart review. Pathology specimens collected at autopsy were sent to the Centers for Disease Control and Prevention’s Infectious Disease Pathology Branch for testing.

    Results: A man aged 68 years with past medical history of small intracerebral hemorrhage (with no deficits), stage T2b melanoma (resected in 2013), remote peptic ulcer disease, and hypertension was hospitalized with altered mental status, nausea, vomiting, and fever. He developed septic shock, acute respiratory distress syndrome requiring mechanical ventilation, disseminated intravascular coagulation, renal failure, and atrial fibrillation. Despite maximum medical therapy, the patient died on hospital day 6; an autopsy was performed. Notable laboratory findings included hyperferritinemia (46,789 ng/mL), leukocytosis (31.1 x 103/μL), increased creatine kinase (7,361 IU/L), and increased lactate dehydrogenase (5,093 U/L). Despite extreme hyperferritinemia, the patient did not meet diagnostic criteria for hemophagocytic lymphohistiocytosis. Notable autopsy pathology findings included detection of HRTV antigen by immunohistochemistry in brain (thalamus, associated with remote infarct), liver, pancreas, heart (Figure 1A), lung, large and small bowel, kidney (Figure 1B), testes (Figure 1C), and skin lesion, in addition to previously described bone marrow, lymph nodes, and spleen.

    Conclusion: HRTV can cause rapidly fatal, widely disseminated infection with severe shock, and multisystem organ failure in a patient without notable preexisting comorbidities. We identified viral antigen in organ tissues where it had been undetected previously. Clinicians should consider this diagnosis, and pursue testing, in cases with compatible clinical and laboratory findings.

    Mary-Margaret Fill, MD1,2, Margaret Compton, MD3, Abelardo Moncayo, PhD2, John Dunn, DVM, PhD2, William Schaffner, MD, FIDSA, FSHEA4, Timothy F. Jones, MD, FIDSA2 and Wun-Ju Shieh, MD, MPH, PhD5, (1)Division of Scientific Education and Professional Development, Centers for Disease Control and Prevention, Atlanta, GA, (2)Division of Communicable and Environmental Diseases and Emergency Preparedness, Tennessee Department of Health, Nashville, TN, (3)Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, (4)Vanderbilt University School of Medicine, Nashville, TN, (5)National Center for Emerging and Zoonotic Infectious Diseases, Infectious Diseases Pathology Branch, Centers for Disease Control and Prevention, Atlanta, GA

    Disclosures:

    M. M. Fill, None

    M. Compton, None

    A. Moncayo, None

    J. Dunn, None

    W. Schaffner, None

    T. F. Jones, None

    W. J. Shieh, None

    Findings in the abstracts are embargoed until 12:01 a.m. CDT, Wednesday Oct. 26th with the exception of research findings presented at the IDWeek press conferences.