LETTERS

Hantavirus 385,000 platelets/mm3, alanine ami- Meningococcemia, acute hem- notransferase 62 IU/mL, aspartate orrhagic fever, and Crimean-Congo Infection in aminotransferase 170 IU/mL, creatine hemorrhagic fever were considered Istanbul, Turkey phosphokinase 2,115 IU/L, lactate de- in the differential diagnosis for the hydrogenase 1,109 IU/L, urea 65 mg/ patient. Other diseases were excluded To the Editor: More than 20 dL, creatinine 3.78 mg/dL, prothrobin by biochemical, serologic, and micro- serotypes of hantavirus have been time 24.8 s, activated partial throm- biologic test results. Hantavirus infec- identifi ed, and 11 infect humans. boplastin time 116.3 s, potassium 2.9 tion was diagnosed in this patient on Puumala virus (PUUV), Dobrava vi- mEq/L, C-reactive protein 326 mg/ the basis of criteria recommended by rus (DOBV), and Seoul virus cause dL, and erythrocyte sedimentation rate the European Network for Diagnostics different forms of hemorrhagic renal 132 mm/h. of Imported Viral Diseases (5). On the syndrome (1,2). DOBV is endemic Subsequently, urinary output second day of treatment, the patient to Turkey and countries in the Balkan decreased and respiratory functions died of cardiopulmonary arrest. region. Approximately 10,000–12,000 worsened. He then lost conscious- The patient had worked as a se- cases of infection with PUUV and ness and was subjected to mechanic curity guard in a new prison located DOBV occur in European Russia each ventilation. Lumbar puncture was not in an area that had contained oak and year (3). Initial case reports identifi ed performed because of risk for bleed- hornbeam forests. DOBV is carried a hantavirus epidemic (laboratory con- ing (high international normalized ra- by rodents (Apodemus fl avicollis), fi rmed) in February 2009 that involved tio values for blood coagulation and and the habitat of this rodent in Eu- 12 persons in Bartin and Zonguldak in thrombocytopenia). Cranial computed rope is open oak or beech forest. In western Turkey near the Black Sea. tomographic scan did not show any a fi eld study performed in rural areas The hantavirus responsible for this ep- pathologic changes. Treatment with of Turkey near the Black Sea and Ae- idemic was a PUUV subtype (4). We ceftriaxone, 4 g/day intravenously, gean Sea, hantavirus was detected in report a man infected with DOBV in was initiated, and the dose was adjust- Microtus spp. voles (6). In another Turkey who died 2 days after admis- ed according to creatinine clearance study performed in regions near the sion to an intensive care unit (ICU). because of suspected meningococce- Aegean Sea, DOBV was detected in The patient was a 22-year-old mia. A single dose of prednisolone, 80 7 (3.5%) of 200 patients with acute man who lived near Istanbul, Turkey. mg intravenously, was given concom- or chronic renal failure (7). However, He was admitted to the Silivri State itantly. Bacterial growth was not ob- information about specifi c regions in Hospital in March 2010 because of fa- served in cultures of urine and blood Turkey in which hantavirus is endem- tigue, diffuse pain, nausea, and vomit- samples. ic is limited. ing. Approximately 2 hours after ad- The Hanta Profi le 1 EUROLINE Hantavirus infections, which were mission, ecchymotic rashes developed Test (Euroimmun, Luebeck, Germany) fi rst identifi ed in northwestern Turkey on his upper extremities and spread was used to detect immunoglobulin in 2009 and subsequently in Istanbul, to other areas. His general condition (Ig) G and IgM against 3 hantavirus should be considered in the diagnosis worsened, and 15 hours later, he was serotypes (PUUV, DOBV, and Han- of patients who have fever and bleed- transferred to the ICU of the Emer- taan virus). Results of a hantavirus ing. Because of recent emergence of gency Service of Gulhane Military IgM immunoblot test were positive for hantavirus in Turkey, areas to which Medical Academy Haydarpasa Train- DOBV. The QIAamp viral RNA Mini this virus is endemic and where risk ing Hospital. His medical history did Extraction Kit (QIAGEN, Hilden, for infection is highest have not been not include exposure to rodents or any Germany) was used for extraction of identifi ed. Therefore, all inhabitants at travel. viral RNA. PUUV and DOBV RNA in high risk for infection (forest workers, At admission to the ICU, his gen- serum and urine samples were inves- military personnel, farmers, persons eral condition was poor, and his speech tigated by using an in-house real-time living in or near a forest, persons han- was garbled and incoherent. He had a PCR (Rotorgene; QIAGEN). DOBV dling wood) should be informed about body temperature of 37.2°C, a pulse of RNA was detected in urine samples by this risk. 140 beats/min, an arterial blood pres- PCR (Table). sure of 90/60 mm Hg, diffuse hemor- rhagic foci, and a disseminated ec- Table. Detection of Dobrava virus in 22-year-old patient, Turkey* chymotic rash. Laboratory test results Hantavirus Real-time PCR showed the following: 13,200 leuko- immunoblot Serum Urine cytes/mm3, 92% polymorphonuclear Test IgM IgG DOBV PUUV DOBV PUUV leukocytes, hemoglobin 11.6 mg/dL, Result Pos Neg Neg Neg Pos Neg *Ig, immunoglobulin; DOBV, Dobrava virus; PUUV, Puumala virus; pos, positive; neg; negative.

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 2, February 2011 303 LETTERS

Oral Oncul, Yunus Atalay, Maternal–Fetal www.cdc.gov/EID/content/17/2/302- Yalcin Onem, Vedat Turhan, Ali appF.htm). The fi rst stomach chamber Acar, Yavuz Uyar, Transmission of contained two 3.5 cm × 2.5 cm raised, Dilek Y. Caglayik, Sezai Ozkan, Cryptococcus gattii centrally umbilicated ulcers and sev- and Levent Gorenek in Harbor Porpoise eral embedded anisakid nematodes. Author affi liations: Gulhane Military Medi- The uterus was gravid in the right cal Academy Haydarpasa Training Hospi- To the Editor: We report mater- horn with a mid-term fetus. No other tal, Istanbul, Turkey (O. Oncul, Y. Atalay, nal–fetal transmission of Cryptococ- gross lesions were identifi ed. Micro- Y. Onem, V. Turhan, A. Acar, S. Ozkan, L. cus gattii and death in a wild porpoise. scopically, the lung lesions correlated Gorenek); and Refi k Saydam National Pub- Cryptococcus neoformans and C. gat- with granulomatous to pyogranuloma- lic Health Agency, Ankara, Turkey (Y. Uyar, tii are 2 environmental, encapsulated tous infi ltrates, often with a myriad of D.Y. Caglayik) yeasts that cause invasive, potentially yeasts. life-threatening infections in humans The male fetus (length 30 cm, DOI: 10.3201/eid1702.100663 and animals (1). C. neoformans causes weight 2.4 kg), was examined sepa- disease in immunocompromised hosts, rately at a different facility than the References and C. gattii is also pathogenic in im- dam. It appeared grossly normal ex- 1. Tang YW, Li YL, Ye KL, Xu ZY, Ruo munocompetent hosts (2). Since 1999, ternally and was at a gestation of ≈5–6 SL, Fisher-Hoch SP, et al. Distribution of cryptococcosis caused by C. gattii months. Mediastinal lymph nodes had hantavirus serotypes Hantaan and Seoul has appeared on southern Vancouver mild granulomatous infl ammation and causing hemorrhagic fever with renal syn- drome and identifi cation by hemaggluti- Island (British Columbia, Canada) contained numerous yeasts morpho- nation inhibition assay. J Clin Microbiol. and nearby surrounding areas (2,3). logically consistent with Cryptococ- 1991;29:1924–7. Spread beyond Vancouver Island has cus spp. (online Appendix Figure, 2. Khan AS, Ksiazek TG, Peters CJ. Han- been documented along the Pacifi c panel B). The lymph nodes were par- tavirus pulmonary syndrome. Lancet. 1996;347:739–41. DOI: 10.1016/S0140- Northwest Coast, but the mechanism tially replaced with intracellular and 6736(96)90082-3 remains undetermined (4). extracellular mulilobulated yeast ag- 3. Klempa B, Tkachenko EA, Dzagurova A pregnant, dead, stranded, har- gregates (length 8–20 μm) with pale TK, Yunicheva YV, Morozov VG, Oku- bor porpoise (Phocoena phocoena) eosinophilic central regions and a thin lova NM, et al. Hemorrhagic fever with renal syndrome caused by 2 lineages of was reported on February 22, 2007, refractile wall peripherally bound by a Dobrava hantavirus, Russia. Emerg In- on western Whidbey Island, in Puget 5-μm nonstaining capsule. Around the fect Dis. 2008;14:617–25. DOI: 10.3201/ Sound, Washington State (48.2833°N, periphery of these aggregates, there eid1404.071310 122.7283°W). The carcass was iced were small numbers of macrophages 4. Ertek M, Buzgan T; Refi k Saydam Na- tional Public Health Agency; Ministry and necropsy was performed on Feb- and lymphocytes and fewer neutro- of Health, Ankara, Turkey. An outbreak ruary 24. Sampled tissues from the phils. Specifi c staining showed a caused by hantavirus in the Black Sea re- adult and fetus were divided: half prominent mucicarminophilic capsule gion of Turkey, January–May 2009. Euro fi xed in 10% formalin for histopatho- consistent with Cryptococcus spp. Surveill 2009;14: pii:19214. 5. European Network for Diagnostics of Im- logic analysis, and half frozen for an- Yeasts were found in the amniotic ported Viral Diseases (ENIVD) diagnosis cillary studies. fl uid and interspersed within the chori- criteria [cited 2010 Sep 22]. http://www. For histologic analysis, tissues oallantoic villi and submucosal vascu- enivd.de/FS/fs_encdiseases.htm were embedded in paraffi n, sectioned lature of the placenta. Mild multifocal 6. Laakkonen J, Kallio-Kokko H, Oktem MA, Blasdell K, Plyusnina A, Niemi- to 3–5 μm, and stained with hema- nonsuppurative myocarditis was de- maa J, et al. Serological survey for viral toxylin and eosin. Selected sections tected. However, no yeasts were seen pathogens in Turkish rodents. J Wildl Dis. were stained with mucicarmine. The in infl amed areas. There were no overt 2006;42:672–6. adult porpoise (length 177 cm, weight lesions in the remaining organs. 7. Oktem MA. Hantavirus and tick-borne en- cephalitis infections [in Turkish]. Ankem ≈57.7 kg) was in poor condition (re- Maternal and fetal tissues were Derg. 2009;23(Suppl 2):245–8. duced blubber layer). Both lungs were cultured for fungi, and diagnosis was exposed, extensively scavenged, fi rm, based on Gram stain (budding yeast- Address for correspondence: Vedat Turhan, and nodular; a sectioned surface exud- like cells), India ink stain (positive for Department of Infectious Diseases and Clinical ed clear to slightly opaque gelatinous encapsulated cells), hydrolysis of urea Microbiology, Gulhane Military Medical to mucinous discharge. Mediastinal (positive), and fi nal confi rmation by Academy Haydarpasa Training Hospital, lymph nodes were grossly enlarged, using API 20C Aux V3.0 (bioMérieux, Uskudar, Istanbul 34668, Turkey; email: multinodular, and fi rm with large num- Marcy l’Etoile, France). Canavanine- [email protected] bers of yeasts visible by microscopy glycine-bromthymol blue agar was (online Appendix Figure, panel A, used to differentiate between C. gattii

304 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 2, February 2011