On March 20, 2009, a Chinese-born male resident of Milwaukee, Wisconsin, 36 years of age, sought medical attention with a 3-day history of headache, fever, chills, fatigue, myalgias, and a nonproductive cough. The patient had returned from a month-long trip to Shenyang, in northeastern China, 1 month before illness onset. In Shenyang, where he felt well, he spent time only in urban areas, he denied rodent contact during his visit, and had no reported contact with ill persons. At the time of illness onset, he had resided in the United States for 18 months. He is a research scientist who works with laboratory rats; although he was not involved in animal care, he was exposed to rat excreta. His work entails implanting transducers in rat colons and then conducting necropsies of rat organs. His most recent rat contact was 3 days before illness onset.
On examination, the patient was drowsy; his temperature was 38.9°C; pulse 62 bpm; blood pressure 123/86; and pulse oximetry was 93% (room air). He had conjunctival suffusion but no other focal findings. Initial abnormal laboratory test results () included white blood cell count 8,600/mm3 (normal 3,800–11,000/mm3) with 32% bands, decreased platelet count, and elevated alanine aminotransferase (ALT) and aspartate aminotransferase (AST); total bilirubin 1.7 mg/dL (normal, 0.1–1.3 mg/dL), ferritin 38,394 ng/mL, lactate dehydrogenase > 2,400/μL, and partial thromboplastin time elevated to 54 seconds. Serum creatinine was normal, but urinalysis showed 2 + proteinuria. Serologic tests for hepatitis A, B, and C viruses, Epstein-Barr virus, human immunodeficiency virus, and leptospira; polymerase chain reaction (PCR) for cytomegalovirus; Rickettsia antibody panel; blood cultures and peripheral smears for malarial parasites were all negative.
Liver function (AST and ALT) test results and platelet count from a Seoul virus-infected patient during his hospitalization in a Milwaukee, WI hospital, by hospital day, March 2009
The patient was febrile during hospital Days 1 and 2, and his ALT and AST peaked on hospital Day 3 when his hypoxia worsened to 90% saturation on room air. A chest computerized tomography examination showed bilateral moderate-sized pleural effusions but no consolidation. His serum creatinine increased to 1.53 mg/dL, but urine output remained normal. Liver tissue obtained by transvenous liver biopsy showed acute hepatitis with lobular necrosis without viral inclusions, atypical cells, vasculitis, or fibrosis ().
Transvenous liver biopsy, obtained on Day 6 of the patient's hospital stay, showed acute hepatitis with focal necrosis without viral inclusions, atypical cells, or vasculitis or fibrosis.
His hypoxia and fever subsided on Day 5 and his liver enzymes and platelet count normalized. He was discharged from the hospital on Day 9. One week later, he reported only mild fatigue, and laboratory tests showed near-normal liver transaminases and serum creatinine of 1.15 mg/dL. His chest x-ray on that day showed resolution of the pleural effusions.