Severe Lassa Fever with Heart Failure and Respiratory distress in a Toddler: Survival Without Ribavirin Through Intensive Supportive Care

Abstract

Lassa fever (LF) remains a significant public health threat in West Africa, with Nigeria experiencing a case fatality rate (CFR) of 25.2% among confirmed cases in 2026. Intravenous ribavirin has been the standard of care for nearly four decades, but its efficacy and safety in children remain poorly substantiated due to critical biases in historical studies and the absence of modern paediatric randomised trials. We report a toddler with severe, virologically-confirmed LF who survived without ribavirin, challenging prevailing emphasis on the drug-centric paradigm and argues for stronger policy focus on intensive supportive care. A previously healthy 20-month-old Nigerian female toddler presented with one-week history of fever, vomiting, severe respiratory distress (SpO2 88% on room air), and clinical signs of heart failure. Admission haemoglobin was 13.3 g/dL), thrombocytopenia (90,000/μL), marked leukocytosis with neutrophils predominant. Lassa fever was suspected only after clinical deterioration and later confirmed by RT-PCR. Ribavirin was not administered because of delayed suspicion, delayed molecular confirmation and supply constraints. She was managed exclusively with intensive supportive care: supplemental oxygen, sequential broad-spectrum IV antibiotics, antiemetics, cautious fluid resuscitation, diuretics and nutritional care. On day 13, her father requested discharge against
medical advice (DAMA) as she appeared fully recovered. A delayed RT-PCR returned positive for Lassa virus three days later. Four-week follow-up confirmed sustained good health. This case adds to emerging evidence that survival of severe pediatric LF is achievable with intensive supportive care alone, addressing clinical and physiological derangement early and intensively. Compared to previously published pediatric LF survivors (all received ribavirin), our patient had comparable disease severity but no drug-related anemia. The 5-day diagnostic delay, while a serious challenge, created a natural experience demonstrating that life-saving supportive care need not await virological confirmation. Diagnostic delay and parental anxiety leading to DAMA are common challenges in resource-limited settings and must be addressed through decentralized rapid diagnostics and structural family counselling.