A Hidden Cause of MERS and HLH in a Girl: Unusual Presentation of Hantaviruses Infection

A 6-year-old girl was hospitalized with fever, headache, and hallucinations. A corpus callosum lesion was detected on magnetic resonance imaging (MRI; [Fig. 1]). She developed hemophagocytic lymphohistiocytosis (HLH [Fig. 2]). A diagnosis of hemorrhagic fever with renal syndrome (HFRS) was made on the basis of hantaviruses antibody positivity. Hypotensive shock, oliguria, and polyuria were absent. Immunotherapy led to rapid recovery. MRI showed disappearance of the corpus callosum lesion, consistent with the observations for a mild encephalitis/encephalopathy with reversible splenial lesion (MERS; [Fig. 3]).

Fig. 1 Axial brain MRI showed a high signal on T2-WI and D-WI, while the ADC MRI showed a low signal in the splenium of the corpus callosum. ADC, apparent diffusion coefficient; D-WI, diffusion-weighted; MRI, magnetic resonance imaging; T2-WI, T2-weighted.

Fig. 2 Bone marrow smear results revealed a prominent hemophagocytosis in macrophagocyte (arrows)(captured using immersion oil microscopy, Wright–Gram's staining, 100).

Fig. 3 The corpus callosum lesion disappeared on follow-up MRI on day 79 of onset. MRI, magnetic resonance imaging.

HFRS, caused by hantaviruses, is an endemic zoonosis, with almost 90% of cases occurring in China.[1] Complications of MERS or HLH in HFRS have rarely been reported and there are no reports of concurrent HFRS, MERS, and HLH.[2] [3] Imaging features of MERS include a lesion in the splenium of the corpus callosum with a high signal intensity on T2-weighted and diffusion-weighted imaging and hyposignal on apparent diffusion coefficient (ADC). Most patients with MERS show complete clinical and MRI recovery.[4]

Our case illustrates the etiological diversity of MERS and clinical heterogeneity of HFRS in children, indicating that more attention is required when evaluating the cause of MERS and clinical course of HFRS in children.

Financial Disclosure

None.

^* These authors contributed equally to this article.

• References

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