Clinical features and patient management of Lujo hemorrhagic fever.
BACKGROUND
In 2008 a nosocomial outbreak of five cases of viral hemorrhagic fever due to a novel arenavirus, Lujo virus, occurred in Johannesburg, South Africa. Lujo virus is only the second pathogenic arenavirus, after Lassa virus, to be recognized in Africa and the first in over 40 years. Because of the remote, resource-poor, and often politically unstable regions where Lassa fever and other viral hemorrhagic fevers typically occur, there have been few opportunities to undertake in-depth study of their clinical manifestations, transmission dynamics, pathogenesis, or response to treatment options typically available in industrialized countries.


RESULTS
We describe the clinical features of five cases of Lujo hemorrhagic fever and summarize their clinical management, as well as providing additional epidemiologic detail regarding the 2008 outbreak. Illness typically began with the abrupt onset of fever, malaise, headache, and myalgias followed successively by sore throat, chest pain, gastrointestinal symptoms, rash, minor hemorrhage, subconjunctival injection, and neck and facial swelling over the first week of illness. No major hemorrhage was noted. Neurological signs were sometimes seen in the late stages. Shock and multi-organ system failure, often with evidence of disseminated intravascular coagulopathy, ensued in the second week, with death in four of the five cases. Distinctive treatment components of the one surviving patient included rapid commencement of the antiviral drug ribavirin and administration of HMG-CoA reductase inhibitors (statins), N-acetylcysteine, and recombinant factor VIIa.


CONCLUSIONS
Lujo virus causes a clinical syndrome remarkably similar to Lassa fever. Considering the high case-fatality and significant logistical impediments to controlled treatment efficacy trials for viral hemorrhagic fever, it is both logical and ethical to explore the use of the various compounds used in the treatment of the surviving case reported here in future outbreaks. Clinical observations should be systematically recorded to facilitate objective evaluation of treatment efficacy. Due to the risk of secondary transmission, viral hemorrhagic fever precautions should be implemented for all cases of Lujo virus infection, with specialized precautions to protect against aerosols when performing enhanced-risk procedures such as endotracheal intubation.
Internal Medicine, Morningside MediClinic, Johannesburg, South Africa; Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa.
Nivesh H
NH
Sewlall
Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa.
Guy
G
Richards
Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa.
Adriano
A
Duse
Department of Medicine, University of Pretoria, Pretoria, South Africa.
Robert
R
Swanepoel
National Institute of Communicable Disease, Sandringham, South Africa.
Janusz
J
Paweska
National Institute of Communicable Disease, Sandringham, South Africa.
Lucille
L
Blumberg
Centers for Disease control and Prevention, Atlanta, Georgia, United States of America.
Thu Ha
TH
Dinh
Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America.
Daniel
D
Bausch
D000111:Acetylcysteine / Q000627:therapeutic use; D000328:Adult; D000998:Antiviral Agents / Q000627:therapeutic use*; D001117:Arenaviridae Infections / Q000188:drug therapy / Q000453:epidemiology / Q000473:pathology* / Q000821:virology; D003428:Cross Infection / Q000188:drug therapy / Q000453:epidemiology / Q000473:pathology* / Q000821:virology; D004196:Disease Outbreaks; D015942:Factor VIIa / Q000627:therapeutic use; D017809:Fatal Outcome; D005260:Female; D006482:Hemorrhagic Fevers, Viral / Q000188:drug therapy / Q000453:epidemiology / Q000473:pathology* / Q000821:virology; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D007835:Lassa Fever / Q000473:pathology; D007836:Lassa virus / Q000302:isolation & purification; D063927:Lujo virus / Q000187:drug effects / Q000302:isolation & purification*; D008297:Male; D008875:Middle Aged; D011994:Recombinant Proteins / Q000627:therapeutic use; D012254:Ribavirin / Q000627:therapeutic use; D013019:South Africa / Q000453:epidemiology
D000998:Antiviral Agents; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D011994:Recombinant Proteins; D012254:Ribavirin; C103587:recombinant FVIIa; D015942:Factor VIIa; D000111:Acetylcysteine