# Hemorrhagic fever with renal syndrome

> Clinical form of Eurasian hantavirus diseases, primarily affecting the kidneys. Global incidence is 60,000 to 150,000 cases per year, the vast majority in China.

Canonical source: https://hantatracker.fr/en/glossary/hfrs/

**Aliases**: HFRS, FHSR, Korean hemorrhagic fever

**Hemorrhagic fever with renal syndrome** (HFRS, FHSR for *fièvre hémorragique avec syndrome rénal* in French) is the main clinical form of Eurasian hantavirus diseases. Unlike hantavirus pulmonary syndrome found in the Americas, HFRS primarily affects the kidneys and may be accompanied by hemorrhagic manifestations. It is a zoonosis endemic in East Asia and present in Northern Europe.

## Epidemiology

### Global distribution

The estimated worldwide annual incidence is between **60,000 and 150,000 cases**. China accounts for 70 to 90% of these cases, with between 12,000 and 20,000 reported cases per year. Russia and South Korea (300 to 600 cases per year) follow. In Europe, cases are mainly linked to Puumala virus and concentrated in Scandinavia, Germany and eastern France, generally in a milder clinical form.

### Strains involved

The main hantaviruses responsible for HFRS are Old World hantaviruses: **Hantaan** (East Asia), **Seoul** (worldwide via the black rat *Rattus norvegicus*), **Puumala** (Europe), **Dobrava-Belgrade** (Balkans). Severity varies: case fatality below 1% for Puumala, up to 15% for Hantaan.

## Clinical presentation

### Five successive phases

The classic form evolves through five phases: **febrile** (3 to 7 days, with fever, headache, myalgia, abdominal pain), **hypotensive** (2 to 3 days, possible hypovolemic shock), **oliguric** (3 to 6 days, acute renal failure), **polyuric** (up to several weeks, recovery polyuria) and **convalescence** (up to several months). Hemorrhagic complications (purpura, mucosal bleeding, hemorrhagic shock) are more common with Asian strains.

### Nephropathia epidemica

The European form caused by Puumala virus is called *nephropathia epidemica*. Milder, it manifests as fever, thrombocytopenia and transient renal involvement, most often without significant hemorrhage. Case fatality is below 1%.

## Management and prevention

### Treatment

Care is mainly symptomatic: fluid and electrolyte balance, hemodynamic support, dialysis in cases of severe acute renal failure. Intravenous ribavirin has shown partial benefit for Hantaan and Puumala strains when given early, but it is not used systematically.

### Available vaccines

Inactivated vaccines against Hantaan and Seoul strains have been produced and used in China and South Korea since the 1990s. They are not licensed in the European Union or the United States. No vaccine currently exists for the New World hantaviruses (Andes, Sin Nombre).