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Published Date: 2019-07-02 23:06:12
Subject: PRO/AH/EDR> Undiagnosed illness - Bolivia (LP) fatal, RFI
Archive Number: 20190702.6549116
UNDIAGNOSED ILLNESS - BOLIVIA (LA PAZ) FATAL, REQUEST FOR INFORMATION
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[1]
Date: Mon 1 Jul 2019
Source: Eje Central Mexico [in Spanish, trans. Mod.MPP, edited]
http://www.ejecentral.com.mx/alertan-por-enfermedad-viral-no-identificada-en-bolivia/


An unknown disease that led to the death of an internal medicine physician and that has another 2 in serious condition has led to the activation of health protocols in Bolivia, requesting assistance from international medical teams in order to identify the etiology of the disease, it was announced on Mon 1 Jul 2019 by the Minister of Health, Gabriela Montano.

Initial diagnostic tests indicated a "viral disease," but through the analysis of the physician who died and the 2 other professionals who are in intensive care, "they have discarded influenza and other viral diseases," such as dengue, according to Montano.

In the last hours, Montano increased the number of infected individuals to 5.

"We have 3 suspected cases in addition to the 1st 2 cases, the doctors; the other 3 are in the same hospital (in La Paz) as the original 2 cases," the Minister of Health said at a press conference.

"Two of the 3 new cases had contact with the 2 doctors who were infected. The 3rd person did not have contact with the professionals, but presented similar symptoms," said Montano.

In order to establish the origin of the disease, an infectious disease specialist from Brasil and another 2 specialists from Atlanta, United States [the Centers for Disease Control and Prevention, CDC], will help the national teams in the investigation.

The health authorities have not declared a state of epidemiologic emergency, while the representative from the Pan American Health Organization [PAHO/OPS] in Bolivia, Alfonso Tenorio, asked to follow protocols in order to "be calm."

"Bolivia has "the equipment and personnel fully trained in order to take the appropriate diagnostic steps, treatment, clinical management, and epidemiologic control," said Tenorio at a press conference.

As part of these protocols, the Ministry of Health ordered the mandatory use of masks and latex gloves in local hospitals.

At the end of last year [2018], Caranavi, the semitropical zone in the northeast of La Paz, where the deceased doctor was infected, reported a dengue outbreak that claimed the lives of 5 people.

--
Communicated by:
ProMED-mail from HealthMap Alerts
<promed@promedmail.org>

******
[2]
Date: Mon 1 Jul 2019
Source: El Tiempo [in Spanish, trans. Mod.MPP, edited]
https://www.lostiempos.com/actualidad/pais/20190701/virus-extrano-afecta-dos-medicos-activan-medidas-bioseguridad


The Ministry of Health activated biosecurity level 4 measures for the health personnel who are caring for the 2 doctors who are in intensive care with a virus as yet not identified, and they are also closely monitoring individuals who had contact with them, such as family members.

According to the information provided, a gastroenterologist and a general practitioner were the physicians who cared for the affected internist, who presumably died (4 Jun 2019) in the Bolivian-Japanese Institute of Gastroenterology.

Following an emergency technical meeting, the Minister of Health, Gabriela Montano, confirmed yesterday [30 Jun 2019] that, until now, the illness affecting the doctors [currently in intensive care] and which led to the death of the 1st case, is unknown; nevertheless, she said that the hypothesis is of a viral disease. She ruled out an epidemiological emergency and announced that 2 experts from the Pan American Health Organization (PAHO) will arrive in the country to strengthen epidemiological diagnostic work.

"We will use the antiviral Rivaninina [Ribavirin?] for all of the healthcare personnel who have cared for these patients. We are going to use all of the mechanisms of biosecurity level IV. That means that they have to use special types of masks, special gloves, and special gowns, and we are currently equipping 100 teams for the Hospital Obrero and the Caja Nacional (where both doctors are hospitalized) so that all healthcare workers have sufficient supplies," said Montano.

She added that other measures that are being taken are related to the treatment of these patients who are being given hyperimmune serum, "and hopefully it will be a favorable treatment," Montano said, and she added that the Ministry of Health will guarantee a supply of Ribavirin, an antiviral that will be used for the healthcare personnel.

Montano said that the laboratories tested the doctors and the 1st fatal case and ruled out influenza, dengue, and chikungunya among other viruses, and sent the specimens to the National Center of Tropical Diseases (Cenetrop) and the National Institute of Health Laboratories (Inlasa), whose initial results should be ready in 48 hours.

Specimens were also sent to the Centers for Disease Control and Prevention in Atlanta [Georgia], Unities States. These results should be finalized in 14 days.

The PAHO representative, Alfanso Tenoria, said that the Ministry of Health has the capacity to care for these types of epidemiologic cases. In addition, the agency is ready to provide collaboration if required.

"The country has the conditions, the equipment, and the trained personnel to perform diagnostic measures, treatment, clinical management, and epidemiologic control measures," the representative of the international agency said. He added that, in the following hours, 2 Brazilian infectious disease specialists would be arriving, both clinical and laboratory experts.

The family members of the gastroenterologist and the general practitioner were in contact with Los Tiempos asking the health authorities to maximize their efforts to identify what the virus is that is causing their illnesses. "My sister-in-law has visited him, but he is not able to speak; his defenses have dropped completely," said a family member of the general practitioner.

He noted that the doctor went to the Caja Petrolera on Wednesday [26 Jun 2019] "with symptoms of a severe cold; they decided to admit him [to the hospital]. We are very worried," said the wife, and her 2 sons were contacted by the Departmental Health Service to go to the laboratories.

Meanwhile, the wife of the gastroenterologist said that her husband was hospitalized in intensive care and continues with established treatment. "That's all I can tell you; they haven't told me anything else," she said.

He [the gastroenterologist] worked in the Bolivian-Japanese Gastroenterology Institute where he cared for the 1st case (the internist who died). She was in the Caranavi hospital with a severe diagnosis related to fever and hemorrhage and died on 4 Jun 2019.

Family members of the internist pointed out that the internist participated in fumigation of mosquito breeding sites in spite of not feeling well on 23 May 2019 while she was still working. She told her family that she had dengue fever.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[It is difficult to tease out what is transpiring from the above media reports, although it sounds as though it is a febrile illness with hemorrhagic phenomena. There also may have been a gastrointestinal component, as a gastroenterologist was treating the primary case as well.

The apparent transmission to healthcare personnel who were treating the primary case suggests that, clinically, the illness is not consistent with what is usually seen with the known arboviruses in the region, such as dengue fever, albeit with the mention of the primary case having worked on reducing a mosquito breeding site, it is tempting to add a disease such as yellow fever to the differential diagnosis.

Another virus that comes to mind as a possible culprit is the Machupo virus, an Arenavirus responsible for Bolivian hemorrhagic fever, 1st described in northeastern Bolivia in an outbreak from 1959 to 1963 (see Patterson M, Grant A, Paessler S. Epidemiology and pathogenesis of Bolivian hemorrhagic fever. Curr Opin Virol. 2014;5:82-90. doi:10.1016/j.coviro.2014.02.007 available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4028408/). Ribavirin has been shown to be effective in management of Bolivian hemorrhagic fever (BHF), and the use of ribavirin by the Bolivian Ministry suggests that BHF is being entertained as a diagnosis.

There is also the possibility that an as yet unknown virus is responsible for this outbreak, as Mother Nature has demonstrated she is omnipresent.

More information on the clinical course of the current known cases and suspected cases as well as epidemiologic investigations would be greatly appreciated.

The HealthMap/ProMED map of Bolivia: http://healthmap.org/promed/p/5
La Paz, Bolivia: http://healthmap.org/promed/p/10123.

A map of Bolivia showing departments: http://www.boliviabella.com/maps.html. Note that La Paz department borders Beni department, where the 1st outbreak of BHF was identified. - Mod.MPP]

[Although no pulmonary signs are indicated in these reports, the possibility of a hantavirus infection should be considered. The previous ProMED posts of a cluster of cases in October 2018 reported 9 affected soldiers in the lowlands of La Paz department (see Hantavirus - Americas (53): Bolivia (LP)20181011.6085684). Hantavirus infections have occurred previously in various parts of Bolivia, including in tropical areas of La Paz department. As noted in previous comments, earlier cases of hantavirus pulmonary syndrome have been reported from tropical, lowland areas of Bolivia. The specific hantaviruses involved in these or previous cases for the last several years in Bolivia are not reported. Depending on the specific areas where the patients had been, Andes hantavirus, located in the Andes ecosystem and related foothills, seems an unlikely etiological agent of these cases. Andes virus is the only hantavirus that can be transmitted directly between people in close contact. If the infected individuals were in the lowland Amazon Basin of Bolivia, the possible hantavirus, its rodent hosts that might be involved in these hantavirus pulmonary syndrome (HPS) cases, with their images, include: - Rio Mamore virus: small eared pygmy rice rat _Oligoryzomys microtis_ https://tinyurl.com/y9kkdgpk (University of Wisconsin Department of Biology); - Laguna Negra virus: small vesper mouse _Calomys laucha_ http://www.faunaparaguay.com/calomyslaucha.html and large vesper mouse _C. callosus_ http://www.faunaparaguay.com/Calomys%20callosus%20www.pybio.org%201.jpg; - Bermejo virus: Chaco rice rat _O. chacoensis_ http://www.faunaparaguay.com/oligorizomyschacoensis.html; - Oran virus: long-tailed pygmy rice rat _O. longicaudatus_ http://calphotos.berkeley.edu/imgs/512x768/0000_0000/0711/1203.jpeg.

Seoul hantavirus/hemorrhagic fever with renal syndrome, with its world-wide distribution is another possibility. See [Jan Clement's comments in ProMED-mail post:] Hantavirus - Americas (61): Bolivia (LP) comment 20181026.6113050. Also see Hantavirus - Americas (59): Bolivia (LP) 20181023.6107497. - Mod.TY]

See Also

Yellow fever - Americas (04): PAHO/WHO, Bolivia, Brazil, Peru 20190307.6355499
2017
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Yellow fever - Americas (53): Bolivia (LP, CB) 20170723.5198910
Yellow fever - Americas (52): Bolivia (LP) 20170720.5193069
Yellow fever - Americas (49): Bolivia (CB), Canada (SK) 20170620.5119332
Yellow fever - Americas (21): Bolivia (LP) comment 20170213.4834655
Yellow fever - Americas (19): Bolivia (LP) 20170211.4832508
2013 
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Bolivian hemorrhagic fever - Bolivia (02): (BE) 20130420.1660132
Bolivian hemorrhagic fever - Bolivia: (BE) 20130317.1590121
Yellow fever - Americas (02): Bolivia (CB) 20130215.1543585
2012 
----
Bolivian hemorrhagic fever - Bolivia (05): (BE) 20120730.1220842
Bolivian hemorrhagic fever - Bolivia (04): (BE) 20120629.1184513
Bolivian hemorrhagic fever - Bolivia (03): (BE) 20120627.1182070
Bolivian hemorrhagic fever - Bolivia (02): (BE) 20120421.1109750
Bolivian hemorrhagic fever - Bolivia: (BE) 20120129.1025260
Yellow fever - South America (07): Bolivia (BE) 20120905.1282586
2011 
----
Bolivian hemorrhagic fever - Bolivia: (BE) 20111202.3514
2007 
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Bolivian hemorrhagic fever - Bolivia (Beni)(02) 20070315.0914
Bolivian hemorrhagic fever - Bolivia (Beni): RFI 20070308.0829
Yellow fever, human, monkey - Brazil, Bolivia: 2007 20071224.4126
Yellow Fever - Bolivia (La Paz) (03) 20070410.1207
Yellow fever - Bolivia: RFI 20070319.0969
Yellow fever - Bolivia (La Paz)(02) 20070319.0969
Yellow fever - Bolivia (La Paz) 20070206.0464
2006
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Yellow fever - Bolivia (Cochabamba): RFI 20060423.1190
Yellow fever - Bolivia (03) 20060326.0931
Yellow fever - Bolivia (02) 20060304.0697
Yellow fever - Bolivia (Cochabamba) 20060218.0531
2004 
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Bolivian hemorrhagic fever - Bolivia (Beni) 20040703.1784
2000 
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Bolivian hemorrhagic fever, background 20000416.0545
Bolivian Haemorrhagic Fever - Bolivia (Beni) (02) 20000413.0529
Bolivian hemorrhagic fever - Bolivia (Beni) 20000331.0475
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