Hantavirus Infection in Istanbul, Turkey

To the Editor: More than 20 serotypes of hantavirus have been identifi ed, and 11 infect humans. Puumala virus (PUUV), Dobrava virus (DOBV), and Seoul virus cause different forms of hemorrhagic renal syndrome (1,2). DOBV is endemic to Turkey and countries in the Balkan region. Approximately 10,000–12,000 cases of infection with PUUV and DOBV occur in European Russia each year (3). Initial case reports identifi ed a hantavirus epidemic (laboratory con-fi rmed) in February 2009 that involved 12 persons in Bartin and Zonguldak in western Turkey near the Black Sea. The hantavirus responsible for this epidemic was a PUUV subtype (4). We report a man infected with DOBV in Turkey who died 2 days after admission to an intensive care unit (ICU). The patient was a 22-year-old man who lived near Istanbul, Turkey. He was admitted to the Silivri State Hospital in March 2010 because of fatigue , diffuse pain, nausea, and vomiting. Approximately 2 hours after admission , ecchymotic rashes developed on his upper extremities and spread to other areas. His general condition worsened, and 15 hours later, he was transferred to the ICU of the Emergency Service of Gulhane Military Medical Academy Haydarpasa Training Hospital. His medical history did not include exposure to rodents or any travel. At admission to the ICU, his general condition was poor, and his speech was garbled and incoherent. He had a body temperature of 37.2°C, a pulse of 140 beats/min, an arterial blood pressure of 90/60 mm Hg, diffuse hemor-rhagic foci, and a disseminated ec-chymotic rash. Laboratory test results showed the following: 13,200 leuko-cytes/mm 3 , 92% polymorphonuclear leukocytes, hemoglobin 11.6 mg/dL, 385,000 platelets/mm 3 , alanine ami-notransferase 62 IU/mL, aspartate aminotransferase 170 IU/mL, creatine phosphokinase 2,115 IU/L, lactate de-hydrogenase 1,109 IU/L, urea 65 mg/ dL, creatinine 3.78 mg/dL, prothrobin time 24.8 s, activated partial throm-boplastin time 116.3 s, potassium 2.9 mEq/L, C-reactive protein 326 mg/ dL, and erythrocyte sedimentation rate 132 mm/h. Subsequently, urinary output decreased and respiratory functions worsened. He then lost consciousness and was subjected to mechanic ventilation. Lumbar puncture was not performed because of risk for bleeding (high international normalized ratio values for blood coagulation and thrombocytopenia). Cranial computed tomographic scan did not show any pathologic changes. Treatment with ceftriaxone, 4 g/day intravenously, was initiated, and the dose was adjusted according to creatinine clearance because of suspected meningococce-mia. A single dose of prednisolone, 80 mg intravenously, was given …