International Notes Hemorrhagic Fever with Renal Syndrome - - France

In France, the first two autochthonous cases of hemorrhagic fever with renal syndrome (HFRS) were recognized in November 1982 and June 1983 (1,2). Since then, in collaboration with CDC laboratories, France has identified six additional cases; others have identified five more cases (3), confirming the existence of a Hantaan virus-related disease in France.

The clinical illness in all eight patients was characterized by fever, acute renal insufficiency (serium creatinine over 300 uM/l in six patients), proteinuria (over 1.5 gm/dl), headache, and lumbar and abdominal pain. Five patients had severe renal insufficiency with serum creatinine over 500 uM/l and were admitted to an intensive-care unit. Two patients had mild hemorrhagic manifestations. All recovered without sequelae after 2 or 3 weeks. The diagnosis was confirmed serologically at CDC by immunofluorescent antibody testing, and in selected cases, a plaque-reduction neutralization test against Hantaan virus strain 76-118 (4).

The patients ranged in age from 14 to 38 years; seven were male. All had histories of possible exposure to wild rodents within 4 weeks before onset of disease. For three patients, the incubation period was known exactly because of single exposures: 14 days for one patient who developed HFRS after being bitten by a wild rodent; and 17 and 20 days for two patients, living in Paris, who had a single, indirect exposure to wild rodents in the same place (1,2).

The eight infections were contracted in four different geographical areas: for two patients--120 km northeast of Paris; for four patients--70 km north of Paris; for one patient--500 km south of Paris; for one patient--30 km northwest of Paris.

Epidemiologic investigations are in progress to further assess the extent of HFRS in France. Reported by E Dournon, MD, B Moriniere, MD, PM Girard, MD, Laboratoire Central, Institut de Medecine et d'Epidemiologie Tropicales, Hopital Claude Bernard, JP Gonzalez, MD, Office de le Recherche Scientifique et Technique Outre-Mer, Paris, PY Lallement, MD, E Kaloustian, MD, Centre Hospitalier, Compiegne, B Schlemmer, MD, CMC Foch, Suresnes, E Bouvet, MD, Direction Generale de la Sante, Ministere des Affaires Sociales et de la Solidarite Nationale, Paris, France; Special Pathogens Br, Div of Viral Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Hemorrhagic fever with renal syndrome begins abruptly with fever, chills, weakness, and dizziness. Headache, myalgia, and lumbar pain are usually prominent. The severe form of the disease, occurring primarily in Asia, may result in thrombocytopenia with petechiae and hemorrhage, while the milder form exhibits little or no hemorrhage. Both forms may result in acute renal failure. Although hemorrhagic fever with renal syndrome was known in Asia before World War II, it was first reported in the English literature during the Korean War, when United Nations' troops became ill with the disease.

Improved tissue-culture replication of Hantaan virus (4,5) has resulted in the identification and isolation of Hantaan-related viruses in rodents in diverse areas of the world, including North America and Asia (6-9). Parallel to this has been the discovery of human infection and, in France, significant numbers of HFRS cases associated with these infections, as illustrated in this report.

These reports suggest that HFRS is an important cause of serious, hospitalizable disease in France. The trapping of clethrionomys rodents in areas associated with acute disease in France suggests that HFRS there is an extension of the disease already known in Scandinavia and Eastern Europe and probably represents the milder form of disease reported in the western Union of Soviet Socialist Republics and China. The geographic diversity of cases in France suggests that surrounding countries should be aware of the situation and search for the disease in their own populations. In any countries where the virus has been identified in wild rodents, such as the United States, the potential exists for human disease and warrants a search for such cases.

References

1. Mery JP, Dard S, Chamouard JM, et al. Mucoid virus nephropathies (Letter to the Editor). Lancet 1983;II:845-6.

2. Dournon E, Brion N, Gonzalez JP, McCormick JB. Further case of haemorrhagic fever with renal syndrome in France (Letter to the Editor). Lancet 1983;II:1419.

3. Chanard J, Melin JP, Milcent T, et al. Focus of muroid virus nephropathy in France (Letter to the Editor). Lancet 1984;I:98.

4. McCormick JB, Palmer EL, Sasso DR, Kiley MP. Morphological identification of the agent of Korean haemorrhagic fever (Hantaan virus) as a member of the Bunyaviridae. Lancet 1982;I:765-8.

5. French GR, Foulke RS, Brand OA, Eddy GA, Lee HW, Lee PW. Korean hemorrhagic fever: propagation of the etiologic agent in a cell line of human origin. Science 1981;211:1046-8.

6. Tsai TF, Bauer, SP, Sasso DR, et al. Preliminary evidence that Hantaan or a closely related virus is enzootic in domestic rodents (Letter to the Editor). N Engl J Med 1982;307:623-4.

7. LeDuc JW, Smith GA, Bagley LR, Hasty SE, Johnson KM. Preliminary evidence that Hantaan or a closely related virus is enzootic in domestic rodents (Letter to the Editor). N Engl J Med 1982;307:624.

8. Tao H, Se-Mau X, Gan S, et al. Viruses of classical and mild forms of haemorrhagic fever with renal syndrome isolated in China have similar Bunyavirus-like morphology (Letter to the Editor). Lancet 1983;I:589-91.

9. Kitamura T, Morita C, Komatsu T, et al. Isolation of virus causing hemorrhagic fever with renal syndrome (HFRS) through a cell culture system. Japanese J Med Sci Biol 1983;36:17-25.

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