TWO CASES OF HANTAVIRUS PULMONARY SYNDROME IN RANDOLPH COUNTY, WEST VIRGINIA: A COINCIDENCE OF TIME AND PLACE? JULIE R. SINCLAIR,* DARIN S. CARROLL, JOEL M. MONTGOMERY, BORIS PAVLIN, KATHERINE MCCOMBS, JAMES N. MILLS, JAMES A. COMER, THOMAS G. KSIAZEK, PIERRE E. ROLLIN, STUART T. NICHOL, ANGELA J. SANCHEZ, CHRISTINA L. HUTSON, MICHAEL BELL, AND JANE A. ROONEY Centers for Disease Control and Prevention, Atlanta, Georgia; Virginia Department of Health, Christiansburg, Virginia; West Virginia Department of Health and Human Resources, Charleston, West Virginia Abstract. Hantavirus pulmonary syndrome (HPS) is caused by an infection with viruses of the genus Hantavirus in the western hemisphere. Rodent hosts of hantaviruses are present throughout the United States. In July 2004, two HPS case-patients were identified in Randolph County, WV: a wildlife science graduate student working locally and a Randolph County resident. We interviewed family members and colleagues, reviewed medical records, and conducted environmental studies at likely exposure sites. Small mammals were trapped, and blood, urine, and tissue samples were submitted to the Centers for Disease Control and Prevention for laboratory analyses. These analyses confirmed that both patients were infected with Monongahela virus, a Sin Nombre hantavirus variant hosted by the Cloudland deer mouse, Peromyscus maniculatus nubiterrae. Other than one retrospectively diagnosed case in 1981, these are the first HPS cases reported in West Virginia. These cases emphasize the need to educate the public throughout the United States regarding risks and prevention measures for hantavirus infection. INTRODUCTION Hantavirus pulmonary syndrome (HPS) is a rodent-borne viral disease first identified in the Four Corners region of the southwestern United States in 1993. 1–3 HPS often results from infection with one of multiple pathogenic viruses (i.e., Sin Nombre virus [SNV], Bayou virus, and Black Creek Canal virus in the United States), all members of the genus Han- tavirus. After identification of SNV as the viral agent respon- sible for the 1993 HPS outbreak, ∼30 new Hantavirus geno- types have been identified throughout North, Central, and South America. 4–8 Although the majority of US cases of HPS are identified in the Western states, rodent reservoirs of han- taviruses are present, and HPS cases occur throughout the United States. 9–11 Before the incidents presented in this pa- per, only one hantavirus infection had been reported from West Virginia. That infection was retrospectively diagnosed in a wildlife biologist working in Randolph and Tucker Coun- ties, who became ill in 1981. The deer mouse (Peromyscus maniculatus) and the white-footed mouse (P. leucopus), both known to carry SNV (including Monongahela and New York variants), inhabit West Virginia. 9–11 Persons coming into con- tact with rodents or rodent excreta through work-related, rec- reational, or peridomestic activities are at risk for infection. 12 In this report, we present the results of an investigation to identify the virus, the associated rodent reservoir, and the circumstances surrounding two HPS cases occurring within 1 week and 12 miles of each other in Randolph County, WV, in July 2004. CASE REPORTS Patient 1. A man, 32 years of age, who was a wildlife sci- ence graduate student, had spent June 2004 and the summer of 2003 live-trapping small mammals with other university students and faculty in a research forest in Randolph County, WV. The graduate student was reported to have not used personal protective equipment (i.e., respirator, gloves, gown, or coveralls) while handling rodents and to have eaten food without washing his hands after handling animals. On July 5, 2004, the graduate student (Patient 1) visited a Blacksburg, VA, emergency department (ED) complaining of fever, cough, and weakness. His medical history included chest pain, presumably from sneezing and coughing intermittently for ∼1 month. Vital signs indicated a fever (102.7°F/39.2°C) and tachycardia (pulse, 117 bpm). A chest radiograph showed a faint infiltrate in the right lung. Initial blood work revealed a normal white blood cell count (5,600/mm 3 ), with a slight left shift (87% neutrophils) and no bands and a lymphopenia (400/mm 3 ). The platelet count (195,000/mm 3 ) and hematocrit (48.9%) were both normal. Physical exam findings were con- sistent with pneumonia. Patient 1 received intravenous fluids, nonsteroidal anti-inflammatory drugs, and oral quinolone an- tibiotic therapy in the ED. Approximately 4 hours later, Pa- tient 1 was released at his own request. While attempting to leave the ED parking lot, Patient 1 became nauseated and vomited and was readmitted to the ED; 12 hours later, he had acute respiratory failure requiring intubation and mechanical ventilation. He remained febrile with worsening hypotension. Chest radiographs on June 6 showed severe bilateral pulmo- nary edema. Blood work on June 6 revealed a mild throm- bocytopenia (115,000/mm 3 ), a normal white blood cell count, with left shift consistent with blood work on admission, but with bands (28%) now present, a normal hematocrit (50.5%), and a slightly increased prothrombin time (12.8 seconds). Multiple scratch wounds were noted on Patient 1’s arms, and his graduate advisor suggested possible hantavirus infection to his physicians. Possible diagnoses considered included pneumococcal pneumonia, pulmonary tularemia, and HPS. Despite aggressive therapy and empirical antimicrobial treat- ment, Patient 1 died on July 8. Patient 2. A man, 41 years of age, residing in Randolph County, spent the first weekend of July 2004 at his family’s log cabin. He and other family members had been renovating the cabin over the past year. The Randolph County man (Patient 2) had multiple exposures to rodents while working at the cabin during the 2 months preceding this weekend stay. As an example of such exposures, on the evening of July 2, Patient * Address correspondence to Julie R. Sinclair, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Mailstop E-73, At- lanta, GA 30333. E-mail: bwg5@cdc.gov Am. J. Trop. Med. Hyg., 76(3), 2007, pp. 438–442 Copyright © 2007 by The American Society of Tropical Medicine and Hygiene 438