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Introduction: Hantavirus pulmonary syndrome (HPS) is a rare and sometimes fatal respiratory disease in humans. The infection is acquired mainly through inhalation of aerosolized rodent secretions which serves as the reservoir for the virus. HPS cases are mostly reported from the American continent. In this article we describe a case of fulminant HPS in a 47 years old man who had traveled with his family on vacation to the southwestern region of the United States. The patient was hospitalized one month after his return to Israel and the diagnosis of hantavirus infection (species Sin Nombre Virus), was performed on samples sent to the CDC's Viral Special Pathogens Branch. Clinicians should be aware of this special entity and consider HPS in the differential diagnosis of patients with respiratory failure and fever, when there is a history of travel to the endemic area.

The use of TNFalpha blockers is associated with reactivation of tuberculosis. The Israeli Association of Rheumatology nominated a committee to determine guidelines for the prevention of tuberculosis in patients taking TNFalpha blockers. The risk of reactivation of tuberculosis is higher with monoclonal antibodies to TNFalpha (infliximab, adalimumab) in comparison with the soluble receptor of TNFalpha (etanercept). All patients who are candidates to receive TNFalpha blockers should be screened for active or latent tuberculosis. The screening includes: Tuberculin Skin Test (TST), chest X-ray and a questionnaire about possible exposure to tuberculosis. Two-step screening should be used as recommended by the Ministry of Health. The reaction elicited in the second test (if applied) should be used. In the general population latent tuberculosis is diagnosed when the TST response is 15 mm. or above; a reaction of 10 mm. or above is positive in populations with a history of definite or probable exposure to TB and 5 mm. is the threshold for populations who are immunosuppressed or if chest radiography reveals old tuberculosis without clear documentation of previous treatment. Patients with a TST less than 5 mm. should be questioned about prior exposure to tuberculosis. Latent tuberculosis should be treated with a 9 month course of isoniazid (300mg/d) or a 4 month course of rifampicin (600mg/d) or for 3 months with a combination of 300 mg. isoniazid and 600 mg. rifampicin daily. The committee recommends postponing treatment with TNFalpha blockers until completion of anti-tuberculosis therapy. If the clinical condition requires the urgent use of TNFalpha blockers, these may be initiated one month after starting treatment for latent tuberculosis.

On November 2002, 305 cases of atypical pneumonia appeared in southern China. In February 2003, cases were reported in Hong Kong and from there the disease spread to many other countries, mainly, China, Hong Kong, Singapore, Vietnam and Toronto in Canada. The syndrome was defined as Severe Acute Respiratory Syndrome SARS), and a person is suspected of having SARS if he/she became ill after November 1 2002, has a fever exceeding 38 degrees C, has symptoms of a respiratory disease and was in a risk area or in close contact with a SARS patient within ten days prior the appearance of symptoms. The World Health Organization has received reports of 4,836 cases, of which 293 persons have died. Most were family members or medical staff treating the patient, persons who came into close and prolonged contact with the patient. The estimated incubation period is two days to one week. Symptoms of the disease include fever, shortness of breath and cough. Ten percent of patients afflicted with SARS require artificial breathing. The mortality rate is 6-7%. A novel coronavirus is associated with this outbreak, and the evidence indicates that this virus has an etiologic role in SARS. Infection is transmitted from person to person through direct or close contact with airborne droplets or personal objects of an infected person. Patients must be isolated and treated by contact and airborne isolation. Treatment consists of support care and artificial respiration when required. The use of anti-viral medications has not yet proven effective.