Although usually less severe and sometimes overlooked, pulmonary symptoms are common in European HFRS caused by Puumala virus (PUUV). Frequent clinical findings include cough, dyspnoea, interstitial lung infiltrates, pleural effusion and impaired pulmonary function [10] [11] [12] . Pronounced lung involvement in HFRS has previously been reported [13] [14] [15] [16] . However, none of those reported patients had a fatal outcome that could be attributed to the acute infection, and there is no description of histopathological findings.