Atypical severe Puumala hantavirus infection and virus sequence analysis of the patient and regional reservoir host

Nephropathia epidemica (NE) caused by Puumala hantavirus (PUUV) is a mild variant of haemorrhagic fever with renal syndrome, which is endemic in Germany. We describe the case of a 67-year-old man initially presenting with acute bilateral angle-closure glaucoma, an atypical clinical presentation of PUUV infection. Subsequently, the patient developed a severe course of disease additionally complicated by profound hepatitis and interstitial nephritis, both phenomena which are rarely described in association with hantavirus infection. Serologic diagnosis was complicated by delayed antibody production until the 10th day of illness; however, PUUV RNA was detectable early in disease. To further analyse this unusual case, sequencing of the PUUV S segment was performed from the patient and regional reservoir host which showed a close relation.