Central nervous system involvement of hantaviruses: clinical presentations, neuroimaging findings, and current implications

Because of their involvement in outbreaks, hantaviruses as emerging zoonotic diseases have been regarded a public health issue. Recent reports have identified CNS symptoms of hantavirus infection, although the data are still relatively sparse and inconsistent, especially for Andes orthohantavirus (ANDV) and to a lesser extent Puumala virus (PUUV). Reported neurological features include headache, dizziness, altered mental state, seizures, focal deficits, and peripheral neuropathy, possibly accompanied by ocular symptoms such as impaired vision and photophobia. The results of neuroimaging have been inconsistent and nonspecific, ranging from hemorrhagic or edematous changes to thalamic or brainstem abnormalities and splenial lesions. Evidence could suggest that endothelial dysfunction, capillary leak, inflammatory damage, and, in certain situations, potential intrathecal immunological responses or direct viral presence may all contribute to CNS involvement. However, most evidence stems from case reports or case series, and causative neuroinvasion may not have been fully demonstrated. Recent studies, especially the recent ANDV-associated outbreak, may emphasize the necessity for rigorous neurological examination. A better understanding of the neurological range of hantavirus infection may enhance detection, risk stratification, and supportive therapy.