Abstract:
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.
METHODS AND FINDINGS : 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.
