Approach

Empirical antimicrobial therapy of sepsis is appropriate until the diagnosis of hantavirus cardiopulmonary syndrome (HCPS) is made. Analgesia and antipyretics are given while awaiting confirmation of diagnosis. Antibiotics are discontinued once diagnosis is made, and treatment is supportive care thereafter.

Patients in the cardiopulmonary phase of the disease can rapidly deteriorate; close monitoring in an intensive care unit (ICU) is warranted with initiation of mechanical ventilation as needed to treat respiratory failure. Fluids should be carefully given along with pressors (i.e., dobutamine and noradrenaline [norepinephrine]) to maintain blood pressure. A falling cardiac index with evidence of cardiovascular collapse is an indication for extracorporeal membrane oxygenation (ECMO) support.[46]

ICU management

HCPS can progress rapidly to cardiogenic shock and death and must be managed in an ICU.[43]

  • Empirical antimicrobial therapy of sepsis is appropriate until the diagnosis of HCPS is made.

  • Supplemental oxygen and intubation for respiratory support may be required.

  • Fluid management should be careful to avoid volume overload.

  • Inotropic therapy may be required for cardiogenic shock.

ECMO

Findings associated with a 100% mortality in the absence of ECMO include:[61]

  • Cardiac index <2.5 L/minute/m²

  • Serum lactate >4 mmol/L

  • Ventricular fibrillation, tachycardia, or pulseless electrical dissociation

  • Shock refractory to fluids and vasoactive therapy.

Published experience suggests that up to 72% of HCPS patients with high mortality risk supported with ECMO have survived to hospital discharge.[46][62]

In a single case report ECMO was successful in supporting a pregnant patient with severe HCPS.[63]

Therapies without proven benefit

Intravenous ribavirin does not seem effective against HCPS when given during the cardiopulmonary phase. Once the cardiopulmonary phase begins, the rate of disease progression and death are too rapid for ribavirin to be of benefit. Administration of ribavirin during the prodrome phase has not been studied, mainly due to difficulty in enrolling participants during this phase.[64] An analysis of open-label ribavirin use for HCPS did not find that it was effective and also noted that 71% of ribavirin recipients became anaemic, with 19% requiring transfusion.[65] Thus, treatment with intravenous ribavirin is probably not effective.

One randomised, double-blind controlled study of high-dose intravenous methylprednisolone for Andes virus-associated HCPS in Chile found no treatment benefit.[66]

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