Lassa fever is one of the viral hemorrhagic fevers (VHF) endemic in West Africa, posing a great public health challenge in the region. This is a case of a 50-year-old female farmer who presented with signs and symptoms semblance of Lassa fever disease. She was commenced on supportive therapy without antiviral drugs pending the confirmation of the VHF assessment result by RT-PCR. Early presentation, a high index of suspicion, prompt diagnosis, and early commencement of supportive therapy in managing patients suspected of Lassa fever are encouraged in states with high cases of viral hemorrhagic infections. She was referred to Alex Ekwueme Federal University Teaching Hospital Abakaliki due to unavailability of ribavirin and for continuation of care.

• Lassa fever

• Viral hemorrhagic fever

• Ebonyi State

• Nigeria

• Index case

Edoiseh EF (2024) Index Case of Lassa Fever in David Umahi Federal University Teaching Hospital Uburu, Ebonyi State, Nigeria: A Case Report. JSM Clin Case Rep 12(5): 1251.

Lassa fever is an acute viral illness caused by an enveloped, bi-segmented single-stranded RNA virus belonging to the Arenaviridae family of viruses [1,2]. It is a neglected tropical disease that is endemic in West Africa and has important global health implications given that it is the most exported of all the viral haemorrhagic fevers (VHFs), including Ebola [3-5].

The infection causes 300,000-500,000 cases annually with approximately 5000 deaths [6]. Outbreaks of Lassa fever occur in Sierra Leone, Guinea, Liberia, Central African Republic, and Nigeria, and it is also believed that human infections also exist in the Democratic Republic of Congo, Mali and Senegal [7].

The natural host of the Lassa virus is a multimammate rat called mastomys natalensis, which transmits the virus through its excreta or urine. At-risk individuals can contract the virus through direct or indirect contact with excreta or urine of infected rodents deposited on surfaces such as floors or beds, or in food or water. Infection can also occur through inhalation of tiny droplets (aerosols) of the virus [8,9]. Secondary spread of Lassa fever (person-to-person) transmission occurs mainly through contact with body fluids or droplets of infected persons [9]. The risk level for secondary transmission depends on the closeness and duration of contact, the type of activity by medical staff, as well as people handling or preparing the body of a person infected by Lassa fever, and the type of personal protective equipment used. Aerosolization of body fluid can particularly occur during invasive procedures like endotracheal suction or bronchoscopy, leaving healthcare workers involved in such procedures at increased risk if not properly protected [10,11].

Identified local practices that fuel Lassa fever infection and further transmission include exposure to food or surfaces contaminated with droppings or urine of infected rodents often the result of open drying of grains, processing of infected rats for consumption, and direct human-human transmission through close contact in community settings with prevailing poor infection, prevention and control (IPC) measures [12,13]. Outbreaks occur frequently with a peak during the dry season months of November to April.

On the 25th of February, 2024, a 50-year-old female farmer from a monogamous family who hails from Onicha Local Government Area of Ebonyi State, Nigeria presented to the Accident and Emergency Department of our facility with complaints of fever, sore throat, inability to swallow, cough, chest pain, generalized body weakness and irrational talking.

She was well until one week before the hospital visit when she started having intermittent, high grade fever. A sore throat was noticed about the same day with pain and inability to swallow. The associated cough was unproductive of sputum and had no hemoptysis. Subsequently, she developed generalized body weakness and irrational talks and on account of the above, she was rushed to a private hospital where she received care and medications unknown to the relative. Before her presentation, there was a history of strange deaths in her community due to undiagnosed febrile ailments. She also had a traditional uvulectomy and tonsillectomy (removal of her uvular and tonsils done in a traditional setting) on account tonsillar enlargement four days prior to presentation. Her condition started deteriorating hence her presentation to this facility for expert care.

There was no history of consumption of bush meat, bleeding from orifices, diarrhoea, headache, muscle pain or facial swelling. However, there was a history of fever and feeling of unwell from two of her siblings before the onset of her symptoms. On examination, she was chronically looking ill, lethargic, febrile, pale moderately dehydrated, acyanosed and with no pedal oedema. The pulse rate was 116 bpm, blood pressure 110/90 mmHg, Heart Sound- S1 and S2 heard, Respiratory rate- 28 cpm, SPO2 94% (room air), Random Blood Sugar- 681mg/dL. She was conscious but confused, pupil-PERL? with no neck stiffness. The abdomen was full with generalized abdominal tenderness. Some of the requested laboratory examinations were not carried out due to lack of money and this posed a challenge in ruling out or increasing the high suspicion of viral hemorrhagic fever (VHF).

The patient was thereafter admitted into the isolation ward of our facility querying hyperglycemic crisis, viral hemorrhagic fever (VHF), septicemia and severe malaria. The following laboratory examinations were requested: Full Blood Count, Malaria Parasite, Eletrolytes, Urea & Creatinine, urinalysis, urine Microscopy/Cultilure/Sensitivity, Chest X-ray, clotting profile, Livee Function Test, Retroviral Screening Test, HBsAg and Hepatitis C Virus antibody. A clinical microbiologist was contacted for VHF assessment and samples were collected and sent to the Virology Centre at Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AEFUTHA), Ebonyi State, Nigeria for RT PCR. The following medications were administered pending the result of the VHF assessment: Intravenous fluids, Intravenous Paracetamol, IV Co-amoxiclav, IV flagyl, soluble insulin (until RBG ≤ 250mg/dL), Intramuscular diclofenac. All protective protocols were ensured while awaiting test results. Intravenous insulin was discontinued upon attainment of 116 mg/dL RBG. Viral hemorrhagic fever was confirmed by a polymerase chain reaction at AEFUTHA. The patient was consequently, referred to Alex Ekwueme Federal University Teaching Hospital Abakaliki for further treatment on account of the non-availability of intravenous ribavirin, the approved antiviral treatment of Lassa fever disease.

The hospital upon receipt of the positive VHF status of the patient immediately commenced contact tracing of her staff who were at one point or the other involved in the management of the patient. Furthermore, the Department of Community Medicine organized an awareness campaign on Lassa fever, infection prevention, and control practices among staff to improve their readiness to case finding and combat the spread of the disease.

We report an index case of Lassa fever in David Umahi Federal University Teaching Hospital, (DUFUTH), Uburu, Ebonyi State, Nigeria, which presented in the hospital on the 25th of February, 2024 by a 50-year-old female farmer. The importance of early hospital presentation cannot be overemphasized in the successful management of Lassa fever disease [14]. In the current case, the patient could be adjudged to have presented early enough to the hospital but her management was challenged by the unavailability of funds to carry out requested laboratory investigations which would have increased the Lassa fever virus suspicion pending the outcome of RT-PCR test result. This further emphasized the importance of early presentation, high index of suspicion by the health workers, commencement of supportive therapy, and prompt diagnosis of Lassa fever [15].

Upon PCR confirmation of Lassa fever virus, our facility could not continue the case management due to the unavailability of ribavirin, hence the patient was referred to AEFUTHA. Patient was then managed successfully and was discharged home after 3 weeks on admission in fertha.

There was a report of a pregnant woman with Lassa fever disease who presented in a hospital at the early stage of the infection and with supportive therapy she improved clinically [15]. However, surviving Lassa fever without antiviral treatment has been documented but rare [16]. It is therefore important that cases of febrile illnesses should be taken to the nearest health facility for medical attention. The government at all levels should, therefore, ensure the availability of the required diagnostic tools and treatments for VHF in health facilities especially in endemic regions to ensure a high level of success in the fight against VHFs.

A combination of factors may improve the survival of individuals with this infection hence reducing the mortality rate associated with Lassa fever disease. Some of the factors include but are not limited to early presentation, a high index of suspicion among health workers, prompt diagnosis (availability of rapid diagnostic kit), and conservative management of symptoms and their complications [15].

The increasing cases of Lassa fever disease in Nigeria across ethnic and geopolitical divides call for urgent attention to disease surveillance, improved diagnosis and availability of antiviral therapy. Training and retraining of health workers in infection prevention and control strategies for viral hemorrhagic fevers should be encouraged.

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