718

INTERNATIONAL REPORTS

Treatment of Bolivian Hemorrhagic Fever with Intravenous Ribavirin

Paul E. Kilgore, Thomas G. Ksiazek, Pierre E. Rollin,
James N. Mills, Mario R. Villagra, Mario J. Montenegro,
Maria A. Costales, Luis C. Paredes, and C. J. Peters
From the Division of Viral and Rickettsial Diseases, National Center for
Infectious Diseases and the Epidemiology Program Office, Centers for
Disease Control and Prevention, Atlanta, Georgia, USA; the National
Health Secretary for Bolivia, the German Busch Hospital, and the
Japanese Maternal-Infant Hospital, Trinidad, Bolivia; and Viedma

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Hospital, Cochabamba, Bolivia

Bolivian hemorrhagic fever (BHF) is a potentially severe febrile illness caused by Machupo virus
(family Arenaviridae). Initial symptoms include headache, fever, arthralgia, and myalgia. In the later
stages of this illness, patients may develop hemorrhagic manifestations including subconjunctival
hemorrhage, epistaxis, hematemesis, melena, and hematuria, as well as neurological signs including
tremor, seizures, and coma. During the BHF epidemics of the 1960s, convalescent-phase immune
plasma from survivors of BHF was administered to selected patients infected with Machupo virus.
However, there is currently a paucity of survivors of BHF who can donate immune plasma, and
there is no active program for collection and storage of BHF immune plasma; therefore, we had
the opportunity to offer intravenous ribavirin to two of three patients with this potentially life-
threatening infection. One patient with laboratory-confirmed Machupo virus infection who received
ribavirin recovered without sequelae, as did a second patient with suspected BHF whose epidemiolog-
ical and clinical features were similar to those of the first patient. This report describes the first use
of intravenous ribavirin therapy for BHF in humans, and the results suggest the need for more
extensive clinical studies to assess the usefulness of ribavirin for treating BHF.

Bolivian hemorrhagic fever (BHF) was first described in
1959, and there were multiple outbreaks of this infection in
the communities of northern Bolivia throughout the 1960s [1].
The etiologic agent is Machupo virus (family Arenaviridae),
whose reservoir is the sigmodontine rodent Calomys callosus
[2]. Human infections are believed to occur after exposure to
Machupo virus in aerosolized secretions or excretions from
infected rodents. In 1971, a nosocomial outbreak of BHF that
involved five persons occurred in Cochabamba, Bolivia; the
investigation of this outbreak suggested that the virus may
sometimes be transmitted person-to-person by exposure to
fomites, droplets, or aerosols from infected patients [3].
Since the 1960s, the treatment of BHF has consisted of
supportive care or, in a small number of cases, the administra-
Received 12 March 1996; revised 16 September 1996.
This work was presented in part at the 35th Interscience Conference on
Antimicrobial Agents and Chemotherapy held on 17-20 September 1995 in
San Francisco.
Informed consent was obtained from patients, and the guidelines for human
experimentation of the U.S. Department of Health and Human Services and/
or those of the authors' institutions were followed in the conduct of this study.
Financial support: This work was supported in part by the U.S. Agency for
International Development, La Paz, Bolivia.
Reprints or correspondence: Dr. C. J. Peters, Mailstop A-26, National Center
for Infectious Diseases, Centers for Disease Control and Prevention, 1600
Clifton Road, N.E., Atlanta, Georgia 30333.
Clinical Infectious Diseases 1997; 24:718-22
CD 1997 by The University of Chicago. All rights reserved.
1058-4838/97/2404-0024$02.00
tion of convalescent-phase immune plasma obtained from sur-
vivors of BHF [4]. Previous studies have shown that ribavirin
(ICN Pharmaceuticals, Costa Mesa, CA) is effective in the
treatment of Lassa fever in humans and other arenavirus infec-
tions in animal models; however, ribavirin has not been studied
for the treatment of Machupo virus infection in humans [5, 6].
Patients infected with Junin virus, a closely related arenavirus
that causes Argentine hemorrhagic fever (AHF), have received
intravenous ribavirin in limited trials; some of these patients
recovered clinically after receiving this therapy [7].
In September 1994 and October 1994, three patients living in
northern Bolivia were identified as having signs and symptoms
consistent with BHF. A Centers for Disease Control and Pre-
vention (CDC) medical team that was in Bolivia during Sep-
tember 1994 was dispatched to evaluate the use of ribavirin
therapy in patients 1 and 2, while Bolivian physicians evaluated
and treated patient 3 in October 1994. The results suggest that
more-extensive trials may be warranted to assess the role of
ribavirin in the treatment of BHF.
Case Reports
Patient 1. On 28 August, a previously healthy 34-year-old
butcher from Magdalena, Beni Department, Bolivia, developed
pyrexia, rigors, and hip arthralgia, followed by widespread
myalgia, headaches, and a fever (temperature, 39.2°C). On pre-
sentation to the local hospital, his blood pressure was 110/88
mm Hg, and his heart rate was 78; physical examination
CID 1997;24 (April) Ribavirin for Bolivian Hemorrhagic Fever 719
showed conjunctival injection and pharyngeal mucosal conges-
tion. Laboratory studies documented a declining total WBC
count (count on 29 August, 10,900/mm 3 ; on 30 August,
6,000/mm 3 ; and on 31 August, 4,000/mm 3 ). Four days after
the onset of his symptoms, physical examination revealed a
diffusely inflamed pharynx with isolated whitish plaques. Be-
cause of deterioration in his condition, he was admitted to a
tertiary care center in Cochabamba on 3 September for further
evaluation and treatment.
On admission to the tertiary care center, laboratory investiga-
tions revealed a hemoglobin level of 14.5 g/dL, a hematocrit
of 44%, and a total WBC count of 4,200/mm 3 . Urinalysis re-
vealed the following values: specific gravity, 1.03; pH, 5; albu-
min, 2+; hemoglobin, 2+; 30 WBCs per high-power field; and
20-30 RBCs per high-power field.
On the third day after admission, the patient developed gross
hematemesis and fecal incontinence, followed by generalized
seizures requiring treatment with intravenous diazepam. The
next day he remained unresponsive and incontinent, and he
passed grossly bloody stools. He died later that day after devel-
oping oliguria and persistent upper gastrointestinal bleeding
followed by shock. The diagnosis of BHF was not considered
until the latter portion of his hospitalization. BHF was con-
firmed after the patient's death by detection of antigens with
an ELISA and by isolation of virus from serum specimens.
Patient 2. A 52-year-old agricultural worker from San Ra-
mOn, Mamore Province, Beni Department, was well until 2
September, when he noted the onset of epistaxis accompanied
by fatigue, melena, and hematuria. He was seen by a physician
in Trinidad, Bolivia, who admitted him to the hospital on 11
September for evaluation of progressive fatigue and inability
to ambulate without assistance. On 12 September, regional
public health authorities notified the visiting CDC medical
team, who traveled to examine this patient with suspected BHF.
Physical examination performed on 13 September while the
patient was supine revealed generalized malaise and hypotension
(blood pressure, 80/48 mm Hg and heart rate, 72). The mucosa
was hyperemic with evidence of recent epistaxis, and both sclera
appeared severely injected. The neurological examination showed
involuntary left-forearm flexion to 60° as well as a mild resting
tremor of the hands, with evidence of global hyperreflexia. Exami-
nation of the patellar tendon showed 3+ reactivity, with bilateral
spreading to the quadriceps. A finger-nose test showed a gross
intention tremor and past-pointing. Initial laboratory studies
showed a total WBC count of 1,200/mm 3 , and analysis of a urine
sample revealed 2+ protein and 3+ hemoglobin (table 1).
On 13 September, the patient's neurological status continued
to deteriorate despite supportive care, and ribavirin therapy was
initiated 12 days after the appearance of the first symptoms.
On the second day of therapy, he developed a cough and expec-
torated yellowish-brown sputum. Radiographic equipment was
unavailable, and he was treated presumptively for pneumonia
with amoxicillin. On 21 September he developed a fever (tem-
perature to 39°C) and chills coincident with the presence of
hematuria from 18 September to 22 September.
Although laboratory facilities for performing cultures were
unavailable, we believed that a nosocomial infection of the
urinary tract or bronchopulmonary tract represented the most
likely source of the pyrexia. The remainder of the patient's
hospital course was marked by prolonged hematuria and slow
resolution of the neurological signs, even after an 8-day course
of therapy. At the conclusion of ribavirin therapy on 23 Septem-
ber, the hematuria had markedly cleared, and he was afebrile
and ambulatory. The diagnosis of BHF was confirmed by detec-
tion of serum viral antigen and isolation of virus from his
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serum.
Patient 3. A 57-year-old agricultural worker who lived and
worked with patient 2 in San Ram& was well until 25 Septem-
ber, when he developed generalized malaise, an intense head-
ache, anorexia, and dysphagia. He presented to a physician in
Trinidad on 7 October, and laboratory studies performed that
day showed a depressed total WBC count (1,450/mm 3 ) (table
2). From 7 October to 10 October, his condition worsened with
the onset of photophobia, diffuse arthralgia and myalgia, fever,
and hand tremors.
On admission to the hospital on 10 October, physical exami-
nation revealed fever (temperature, 39.2°C) and hypotension
(heart rate, 76, and blood pressure, 80/50 mm Hg). The large
joints of the upper and lower extremities were tender to palpa-
tion and on movement around the articulations. A neurological
examination showed bilateral resting hand tremors, dysarthria,
and an unstable, wide-based gait.
Given that the epidemiological characteristics of this patient
were similar to those of patient 2 and that neurological signs
had become progressive, consistent with a diagnosis of BHF,
ribavirin therapy was initiated on 10 October. During the first
week of ribavirin therapy, the patient reported gradual resolu-
tion of the headache, arthralgia, and myalgia, which was ac-
companied by a transient decrease in the platelet count (nadir,
57,600/mm' on 12 October) and microscopic hematuria. By
day 10 of ribavirin therapy, he was afebrile (temperature, 37°C)
with a heart rate of 75 and a blood pressure of 90/70 mm Hg,
and he had no evidence of swallowing dysfunction or speech
impairment.
At the end of a 10-day course of intravenous ribavirin ther-
apy, the patient could ambulate without assistance, but exami-
nation showed his gait to be slightly wider-based than normal.
No clinical complications were noted while he was receiving
ribavirin, but anemia was noted on the final day of therapy and
during a follow-up visit on 4 November. Clinical specimens
could not be made available to the Centers for Disease Control
and Prevention for laboratory confirmation of Machupo virus
infection.
Discussion
Our recent clinical experience in Bolivia reaffirms the fact
that BHF is a life-threatening condition that may mimic other
endemic illnesses (e.g., dengue fever and malaria) during its
initial phases. Two of the cases described in this report repre-
720 Kilgore et al. CID 1997;24 (April)

Table 1. Laboratory results for patient 2, a patient with Bolivian hemorrhagic fever who was treated with intravenous ribavirin in September
1994.
Date

Laboratory study 12 September 14 September 15 September 17 September 19 September 21 September

WBC count (/mm 3 ) 1,200 2,500 2,700 2,500 3,000 10,500

Hemoglobin level (g/dL) 14 14 12 13 12 12
Hematocrit (g/dL) 45 41 39 40 37 36
Platelet count (X10 3 /mm 3 ) ND ND 41 51 60 65
Blood urea nitrogen level ND 38 28 25 20 50

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(normal range, 20-45 g/dL)
Creatinine level (normal range, ND 1.5 1.3 0.9 0.7 1.9
0.8-1.4 mg/dL)
Aspartate aminotransferase level ND 347 234 113 77 148
(normal range, 5-35 U/L)
Alanine aminotransferase level ND 156 119 111 95 170
(normal range, 8-40 U/L)
Amylase level (normal level, ND ND 171 158 196 140
<120 U/L)
Bilirubin level (normal level, ND ND 1.1/0.6 1.0/0.5 ND 1.7/0.7
<1.0 mg/dL)*
Urinalysis 2+ Protein 4+ Protein 2+ Protein ND Trace protein, 2+ Protein, 3+
3+ Hemoglobin 2+ Hemoglobin 2+ Hemoglobin trace hemoglobin, 12-15
hemoglobin WBCs, >150
RBCs, granular
casts, 3+ bacteria

NOTE. ND = not determined.

* Total level/direct level.

sent the first experience in the use of intravenous ribavirin to
treat suspected BHF in humans. The clinical and laboratory
data obtained during the treatment of these two patients suggest
that intravenous ribavirin may be active against Machupo virus
following natural infection in humans. While the recovery of
patients 2 and 3 coincided with the administration of ribavirin,
we cannot definitively conclude that their recoveries resulted
solely from the administration of the drug.
Patients 2 and 3 shared exposure histories that were consis-
tent with the known epidemiology of BHF [8]. Both patients
were employed by a large ranch to work in open fields con-
taining suitable habitats for C. callosus, the rodent host of

Table 2. Laboratory results for patient 3, a patient with Bolivian hemorrhagic fever who was treated with intravenous ribavirin in October
and November 1994.

Date

Laboratory study* 7 October 10 October 12 October 14 October 17 October 20 October 4 November

WBC count (/mm 3 ) 1,500 2,900 2,000 2,000 4,000 5,200 5,700
Hemoglobin level (g/dL) 15 14 14 14 12 9.6 8.6
Hematocrit (g/dL) 48 43 44 44 40 30 27
Platelet count (X 10 3 /mm 3 ) 170 102 58 65 78 103 296
Aspartate aminotransferase level ND ND ND ND ND 184 ND
(normal range, 5-35 U/L)
Alanine aminotransferase level ND ND ND ND ND 104 ND
(normal range, 8-40 U/L)
Urinalysis ND ND 2+ Protein, 2+ Protein, No protein, ND No protein,
1+ hemoglobin, trace hemoglobin, no hemoglobin, no hemoglobin,
4-6 WBCs, 2-4 WBCs, 3-4 1-2 WBCs 1-2 WBCs
8-9 RBCs RBCs

NOTE. ND = not determined.

* Levels of blood urea nitrogen, creatinine, amylase, and bilirubin were not determined.
CID 1997;24 (April) Ribavirin for Bolivian Hemorrhagic Fever 721
Machupo virus. In addition, these agricultural workers were
provided with room and board in the same dwelling. Although
the exact source(s) of infection in cases 2 and 3 is unknown,
each patient may have become infected with Machupo virus
from direct exposure to C. callosus while working in the fields,
through person-to-person transmission, or by exposure to fomi-
tes (e.g., shared utensils) within the ranch dwelling. An addi-
tional employee (not described in this report), who was identi-
fied during the interview of patient 2, worked and lived with
patients 2 and 3 at the same ranch and developed a febrile
illness with epistaxis and gingival bleeding, consistent with
BHF, in early August 1994. This worker was seen as an outpa-
tient by a local physician in Trinidad and was found to have
a depressed total WBC count but was lost to follow-up in late
August and did not return to work.
Ribavirin is a compound with broad-spectrum activity
against selected RNA- and DNA-containing viruses [9]. In the
rhesus macaque model for BHF, Stephen et al. demonstrated
that ribavirin reduced viremia to nearly undetectable levels
by day 10 of therapy and prevented death during the acute
hemorrhagic phase of the illness; however, the late neurological
signs were not prevented [10]. In another model, mortality
among guinea pigs infected with Junin virus was not affected
by ribavirin therapy, although viral replication was delayed,
and the mean time period until death was increased [11]. Rhe-
sus macaques treated with ribavirin at the time of infection
with Junin virus were protected from clinical disease [12].
In a limited trial, the mortality among patients with Argen-
tine hemorrhagic fever who were treated with ribavirin was
lower than that among controls, and anemia was the only side
effect observed [7]. In a double-blind, placebo-controlled trial
of intravenous ribavirin for the treatment of hemorrhagic fever
with renal syndrome (caused by Hantaan virus in the family
Bunyaviridae), ribavirin reduced the risk of entering the oli-
guric phase as well as the risk of hemorrhage [13]. In that study,
intravenous ribavirin therapy was associated with reversible
anemia without sequelae; this side effect had also been identi-
fied in previous studies [14, 15]. In a more recent study, intrave-
nous ribavirin appeared effective in the treatment of a labora-
tory-acquired infection with Sabia virus, an arenavirus related
to Machupo virus and first isolated in Brazil [16].
To treat our patients, we used the dosing paradigm that has
been used successfully to treat Lassa fever and that was shown
by Enria and Maiztegui to be safe for the treatment of Argentine
hemorrhagic fever [7]. The anemia in patient 3 appeared to
be consistent with both the reversible anemia associated with
ribavirin therapy and the pathophysiology of BHF, which may
involve suppression of hematopoiesis [7, 17].
The early course of therapy for patient 2 was marked by
rapid improvement, followed by a plateau phase in which some
neurological signs (e.g., finger-nose test findings) transiently
worsened. In the final days of the 10-day treatment period,
these neurological sequelae resolved completely. The slower
resolution of neurological signs in comparison with that for
other abnormalities that was observed for patients 2 and 3, as
well as the findings in a study by Enria et al., in which patients
with Argentine hemorrhagic fever who received a passive anti-
body infusion evidenced a late neurological syndrome, suggest
direct viral invasion of the CNS rather than an encephalopathic
process [18].
Our experience with intravenous ribavirin in Bolivia em-
phasizes the challenge of conducting clinical trials for the
treatment of sporadic diseases in developing countries. Be-
cause BHF is no longer an epidemic disease in Bolivia, enroll-
ment of a sufficient number of patients in a randomized trial
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may be impossible, assuming investigators were to complete
such a study in a reasonable period. In addition, ethical con-
cerns about the use of placebo in a randomized study design
may arise, since BHF may be life-threatening, and the results
of both animal and human studies of Argentine hemorrhagic
fever (and animal studies of BHF) suggest that ribavirin is
active against arenaviruses.
In one alternative study design, investigators could compare
drug regimens based on different dosing schedules of intrave-
nous ribavirin to optimize the drug delivery, clinical response,
and side-effect profile. On the basis of observations in the
1960s that patients infected with Machupo virus recovered
following treatment with convalescent-phase immune plasma
from donors, a randomized trial in which treatment with con-
valescent-phase BHF immune plasma is compared to treat-
ment with intravenous ribavirin could be conducted [4]. This
alternative would require a program for screening and storing
plasma that has been frozen after collection from a small
number of patients who have recovered from BHF.
Although hospitals and clinics in the disease-endemic re-
gion of Bolivia have limited resources, available laboratories
may also provide clinical monitoring for both hematologic
and biochemical parameters during ribavirin therapy.
Our experience also highlights the advantages of establish-
ing a diagnostic facility in Bolivia that is capable of detecting
Machupo virus in clinical specimens during the early phase
of BHF. The use of techniques that inactivate Machupo virus
in potentially infectious specimens and enable clinicians to
make more rapid and cost-effective therapeutic decisions
would be required in such a laboratory. Establishment of a
Bolivian laboratory in which real-time testing could be done
would also enhance surveillance for cases of BHF. If clini-
cians seek cases more actively and Machupo virus infection
can be confirmed in a timely fashion, we may learn the true
incidence of BHF and ribavirin can be further evaluated to
ascertain if it provides a physically stable, renewable, and
safe therapy for the disease.
Acknowledgments
This report is dedicated to the memory of Ronald B. MacKenzie,
M.D., M.P.H., who provided invaluable advice and historical in-
sight during preparation of this manuscript. The authors thank
Silvia Pozo, M.D., and Joel N. Kuritsky, M.D., for technical assis-
722 Kilgore et al. CID 1997; 24 (April)
tance and John O'Connor, M.S., for editorial assistance in the 9. Patterson JL, Fernandez-Larsson R. Molecular mechanisms of action of
preparation of this manuscript.
References
1. MacKenzie RB. Epidemiology of Machupo virus infection. I. Patterns of
human infection, San Joaquin, Bolivia, 1962-1964. Am J Trop Med
Hyg 1965; 14:808-13.
2. Webb PA, Justines G, Johnson KM. Infection of wild and laboratory
animals with Machupo and Latino viruses. Bull WHO 1975; 52:493-9.
3. Peters CJ, Kuehne RW, Mercado RR, Le Bow RH, Spertzel RO, Webb
PA. Hemorrhagic fever in Cochabamba, Bolivia, 1971. Am J Epidemiol
1974; 99:425-33.
4. Stinebaugh BJ, Schloeder FX, Johnson KM, Mackenzie RB, Entwisle G,
DeAlba E. Bolivian hemorrhagic fever: a report of four cases. Am J
Med 1966; 40:217 -30.
5. McCormick JB, King IJ, Webb PA, et al. Lassa fever: effective therapy
with ribavirin. N Engl J Med 1986; 314:20-6.
6. Peters CJ, Jahrling PB, Liu CT, Kenyon RH, McKee KT Jr, Barrera-Oro
JG. Experimental studies of arenaviral hemorrhagic fevers. In: Oldstone
MB, ed. Current topics in microbiology and immunology. Vol. 134.
Arenaviruses: epidemiology and immunotherapy, Heidelberg, Germany:
Springer-Verlag, 1987:5-68.
7. Enria DA, Maiztegui JI. Antiviral treatment of Argentine hemorrhagic
fever. Antiviral Res 1994; 23:23-31.
8. MacKenzie RB, Beye HK, Valverde L, Garron H. Epidemic hemorrhagic
fever in Bolivia. I. A preliminary report on the epidemiologic and
clinical findings in a new epidemic area in South America. Am J Trop
Med Hyg 1964; 13:620-5.
ribavirin. Rev Infect Dis 1990; 12:1139-46.
10. Stephen EL, Jones DE, Peters CJ, Eddy GA, Loizeaux PS, Jahrling PB.
Ribavirin treatment of toga-, arena-, and bunyavirus infection in subhu-
man primates and other laboratory animal species. In: Smith RA, Kirk-
patrick W, eds. Ribavirin: a broad spectrum antiviral agent. New York:
Academic Press, 1980:169-83.
11. Kenyon RH, Canonico PG, Green DE, Peters CJ. Effect of ribavirin and
tributylribavirin on argentine hemorrhagic fever (Junin virus) in guinea
pigs. Antimicrob Agents Chemother 1986; 29:521-3.
12. Weissenbacher MC, Calello MA, Colillas OJ, Rondinone SN, Frigerio
MM. Argentine hemorrhagic fever: a primate model. Intervirology
Downloaded from https://academic.oup.com/cid/article-abstract/24/4/718/440018 by guest on 18 August 2019
1979; 11:363-5.
13. Huggins JW, Hsiang CM, Cosgriff TM, et al. Prospective, double-blind,
concurrent, placebo-controlled clinical trial of intravenous ribavirin ther-
apy of hemorrhagic fever with renal syndrome. J Infect Dis 1991; 164:
1119-27.
14. Canonico PG, Kastello MD, Cosgriff TM, et al. Hematological and bone
marrow effects of ribavirin in rhesus monkeys. Toxicol Appl Pharmacol
1984; 74:163-72.
15. Canonico PG. A review of efficacy, toxicity and mechanism of antiviral
activity. In: Hahn FE, ed. Antibiotics. Vol 6. Modes and mechanisms
of microbial growth inhibitors. New York: Springer-Verlag, 1983:
161-86.
16. Barry M, Russi M, Armstrong L, et al. Brief report: treatment of a labora-
tory-acquired Sabia virus infection. N Engl J Med 1995; 333:294-6.
17. Child PL, MacKenzie RB, Valverde LR, Johnson KM. Bolivian hemor-
rhagic fever: a pathologic description. Arch Pathol 1967; 83:434-45.
18. Enria D, Franco SG, Ambrosio A, Vallejos D, Levis S, Maiztegui J.
Current status of the treatment of Argentine homorrhagic fever.
Med Microbiol Immunol 1986; 175:173-6.