Beyond the Kidney and Lung: Cutaneous and Mucosal Clues to Human Hantavirus Disease

Hantaviruses are rodent-borne viruses that cause two overlapping vascular syndromes in humans: hemorrhagic fever with renal syndrome, including nephropathia epidemica, and hantavirus pulmonary/cardiopulmonary syndrome. Although dermatologists are rarely central to hantavirus care, early visible abnormalities may occur on the skin, mucosa, and ocular surface. This narrative review synthesizes the dermatologic and mucocutaneous manifestations of human hantavirus disease, with emphasis on signs that should prompt diagnostic suspicion in dermatology, emergency, travel-medicine, and infectious-disease settings. The dermatologic signal is strongest in hemorrhagic fever with renal syndrome, where facial or upper-torso flushing, conjunctival and pharyngeal injection, petechiae, purpura, ecchymoses, and mucosal bleeding may appear during the febrile or hemorrhagic phases. These findings are not pathognomonic, but their diagnostic value increases when they occur with rodent or outbreak exposure, thrombocytopenia or coagulopathy, and renal abnormalities such as proteinuria, hematuria, or acute kidney injury. In hantavirus pulmonary/cardiopulmonary syndrome, particularly infections caused by New World hantaviruses, visible cutaneous involvement is less prominent and may be absent despite severe pulmonary endothelial disease. We propose a practical dermatology-oriented trigger for suspicion based on exposure history, abrupt febrile illness, nephro-pulmonary involvement, thrombocytopenia, and vascular mucocutaneous findings. Hantavirus should be considered when otherwise unexplained vascular skin or mucosal signs occur in a febrile patient with thrombocytopenia, renal involvement, hypoxemia, or compatible exposure. The skin rarely diagnoses hantavirus alone, but it may shorten time to testing, supportive care, and public-health notification.