In this article, we report on a rare case of acute respiratory distress syndrome (ARDS) caused by the Puumala orthohantavirus (PUUV), which is typically associated with hemorrhagic fever with renal syndrome (HFRS). This is the first documented case of PUUV-associated ARDS in Southeast Europe. The diagnosis was confirmed by serum RT-PCR and serology and corroborated by phylogenetic analysis and chemokine profiling. The patient was a 23-year-old male from Zagreb, Croatia, who had recently traveled throughout Europe. He presented with fever, headache, abdominal pain, and sudden onset of ARDS. Treatment involved high-flow nasal cannula oxygen therapy and glucocorticoids, which resulted in a full recovery. A systematic literature review identified 10 cases of hantavirus pulmonary syndrome (HPS) caused by PUUV in various European countries and Turkey between 2002 and 2023. The median age of patients was 53 years (range 24–73), and six of the patients were male. Most patients were treated in intensive care units, but none received antiviral therapy targeting PUUV. Eight patients survived hospitalization. The presented case highlights the importance of considering HPS in the differential diagnosis of ARDS, even in areas where HFRS is the dominant form of hantavirus infection.

SARS-CoV-2 has been implicated in many cardiac pathologies, manifesting mainly as acute. However, acute purulent pericarditis is exceedingly rare in the antibiotic era. Though, few studies have associated it with long-COVID, prompt recognition and treatment are crucial. A 61-year-old immunocompetent woman presented with a left lower limb pitting oedema 1 month after COVID-19 pneumonia. Following clinical, laboratory, and imaging work-up, the patient was found to have deep vein thrombosis of the anterior and posterior tibial and gastrocnemius veins. Owning to persistent sinus tachycardia, an additional work-up was performed, which revealed a large pericardial effusion. Pericardiocentesis drained the frank pus, and subsequently, empirical antibiotics therapy was initiated. Pericardial fluid cultures showed methicillin-sensitive Staphylococcus aureus (MSSA). Following the antibiotic treatment with cloxacillin 6 × 2 g IV for 6 weeks, the patient fully recovered. Herein, we report a rare case of bacterial pericarditis caused by MSSA 1 month after COVID-19 pneumonia. Additionally, this condition may arise as a result of immunosuppressive treatment with glucocorticoids during and after COVID-19 pneumonia. However, the causal association has not yet been confirmed.

Background: Balkan nephropathy (BEN) is an environmental form of aristolochic acid nephropathy (AAN) strongly associated with upper urinary tract urothelial carcinoma (UTUC). Clinical diagnosis remains challenging, and misclassification is frequent. The study reassessed BEN diagnoses in kidney transplant recipients from rural farming areas who did not undergo prophylactic bilateral nephroureterectomy and evaluated post-transplant outcomes. Methods: In this retrospective single-centre study, we analysed 12 kidney transplant recipients from rural Balkan farming regions. BEN diagnoses were reevaluated according to international consensus criteria. Key endpoints included patient and graft survival, post-transplant clinical course, and UTUC characteristics. Results: Upon reassessment, three of the six patients initially diagnosed with BEN were reclassified as having BEN. Among the remaining six patients, four were reclassified as having sporadic BEN. Overall, only 33% of patients had a diagnosis concordant with their admission records. During a median follow-up of 6.8 years (IQR 2.1–15.8), UTUC developed in seven out of 12 patients. The UTUC cases were predominantly high-grade and multifocal, and they were identified as the leading cause of death. Five-year patient and graft survival rates were 71% and 100%, respectively. Conclusions: BEN is frequently misdiagnosed or misclassified in kidney transplant candidates from rural farming areas. Despite excellent graft survival, the high incidence of post-transplant urothelial carcinoma underscores the necessity of accurate diagnosis and the consideration of prophylactic bilateral nephroureterectomy. Lifelong intensive surveillance is essential not only for patients from established BEN regions but also for individuals from other rural farming areas at risk for sporadic BEN.