Treatment of Hemorrhagic Fever
No specific antiviral therapy has demonstrated benefit for most viral hemorrhagic fevers; treatment is primarily supportive care focused on maintaining hemodynamic stability, correcting coagulopathy, and preventing secondary transmission. 1
Immediate Supportive Management
Supportive care is the cornerstone of treatment for hemorrhagic fever, as no drugs have shown specific benefit to date. 1 Management should be based on symptoms and organ systems involved:
- Provide rest, fluids, and acetaminophen or NSAIDs for fever and myalgias 1
- Avoid aspirin due to hemorrhagic complications risk 1
- Patients with multisystem organ involvement require critical care support with possible mechanical ventilation or hemodialysis 1
- Maintain hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active hemorrhage 2
- Administer high-flow oxygen to all patients with active hemorrhage 2
Infection Control and Isolation
Place patients in negative pressure rooms (airborne infection isolation rooms) to reduce occupational exposure risk, preferably with an anteroom, as aerosolized infectious material may be present in blood, vomitus, stool, and respiratory secretions during end-stage illness. 1
- Healthcare workers must wear face shields or goggles with appropriate respirators when entering rooms of patients with prominent cough, vomiting, diarrhea, or hemorrhage 1
- Protect infected persons from mosquito exposure during the first few days of illness to prevent transmission cycle continuation 1
- Always contact regional reference centers when viral hemorrhagic fever is suspected 1
Specific Antiviral Therapy: Ribavirin
Ribavirin is the only antiviral agent with evidence for specific hemorrhagic fever viruses, particularly Lassa fever and other arenaviruses, though efficacy data remain limited. 1, 3
Ribavirin Administration for Lassa Fever:
- Oral ribavirin should be started immediately after high-risk exposure for post-exposure prophylaxis 1
- The drug should be taken with food 1
- Switch to intravenous ribavirin if the patient develops manifestations of Lassa fever 1
- Ribavirin is also used for Crimean-Congo hemorrhagic fever, Junin, Machupo, Guanarito, Sabia, and Flexal viruses 1, 3
Ribavirin Contraindications and Monitoring:
- Relative contraindications include severe anemia, hemoglobinopathy, pregnancy, breast-feeding, coronary artery disease, renal insufficiency, and decompensated liver disease 1
- Measure baseline hemoglobin and hematocrit before initiation 1
- Recheck complete blood count and bilirubin 5-7 days after starting, adjusting dose if significant anemia develops 1
- Decrease dose in patients with creatinine clearance <50 mL/min 1
Hemodynamic Management
For patients with hemorrhagic shock, establish large-bore IV access immediately and begin aggressive fluid resuscitation with warmed blood products as the primary resuscitation fluid. 2
- Target systolic blood pressure of 80-100 mmHg until bleeding is definitively controlled to avoid worsening coagulopathy 2
- Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 2
- Early infusion of fresh frozen plasma prevents dilutional coagulopathy 2
- Monitor serum lactate and base deficit continuously to track extent of bleeding and shock 2
Critical Pitfalls to Avoid
Never rely on wound dressings or topical agents alone to control active hemorrhage, as this delays definitive treatment. 2
- Avoid excessive crystalloid resuscitation while bleeding is uncontrolled, as this dilutes clotting factors and worsens coagulopathy 2
- Do not delay surgical intervention for extensive imaging in actively hemorrhaging unstable patients 2
- Do not rely on single hematocrit measurements as they are misleading in acute hemorrhage 2
Differential Diagnosis Considerations
Cases with jaundice must be differentiated from viral hepatitis, malaria, leptospirosis, Congo-Crimean hemorrhagic fever, Rift Valley fever, typhoid, Q fever, and typhus. 1