Fatal Case of Heartland Virus in the Mid-Atlantic

Heartland virus is an emerging tick-borne infection that can lead to severe illness and death. Although most cases have been reported in the Midwest and southern United States, investigators have now documented a fatal Heartland virus infection acquired in the Mid-Atlantic region.

In their article “Fatal Case of Heartland Virus Disease Acquired in the Mid-Atlantic Region, United States,” Liu and colleagues describe the case of a man in his 60s who likely acquired the Heartland virus in either Maryland or Virginia.

Heartland Virus Case Presentation

The patient was admitted to the hospital in November 2021 with fever, diarrhea, dyspnea, myalgias, and malaise that had persisted for five days.

His medical history included splenectomy, hypertension, remote trauma, and coronary artery disease.

Importantly, the patient did not recall a tick bite and had no erythema migrans rash.

“The range of Heartland virus could be expanding in the United States.”

Delayed Diagnosis of Heartland Virus

Clinicians initially suspected an arboviral illness. However, diagnosis was delayed because commercial testing for many tick-borne viruses remains limited.

“An arboviral disease was the leading diagnostic consideration, but limited availability of commercial diagnostic testing for tickborne diseases delayed diagnosis,” wrote Liu and colleagues.

The patient was treated empirically with doxycycline for a suspected tick-borne infection.

Two days later—seven days after symptom onset—he returned to the emergency department with confusion, an unsteady gait, and new fecal and urinary incontinence.

His illness progressed to encephalopathy, hyponatremia, abnormal liver function tests, and worsening fatigue.

Fatal Outcome of Heartland Virus Infection

The patient’s condition rapidly deteriorated.

“He had acute respiratory failure, renal failure, and a cardiac arrest. He was transitioned to comfort care and died on day 13 after symptom onset,” wrote Liu et al.

An autopsy revealed that the heart, spleen, kidney, and liver were positive for Heartland virus.

The Virginia Department of Health later collected ticks from the patient’s property, identifying 193 Lone Star ticks. None of the ticks tested positive for Heartland virus.

Tick-Borne Diseases Identified by the CDC

The Centers for Disease Control and Prevention (CDC) recognizes numerous tick-borne diseases in the United States. These include:

1. Anaplasmosis
2. Babesiosis
3. Borrelia mayonii
4. Borrelia miyamotoi
5. Bourbon virus
6. Colorado tick fever
7. Ehrlichiosis
8. Heartland virus
9. Lyme disease
10. Powassan virus
11. Rocky Mountain spotted fever (RMSF)
12. STARI (Southern tick-associated rash illness)
13. Tick-borne relapsing fever
14. Tularemia
15. 364D rickettsiosis