First reported case of Andes hantavirus cardiopulmonary syndrome treated with a combination of favipiravir, ribavirin, icatibant and baricitinib.

OBJECTIVES

To describe the first documented case of Andes virus (ANDV) hantavirus cardiopulmonary syndrome (HCPS) in Spain and the first worldwide use of a therapeutic regime including two antivirals (favipiravir and ribavirin) and two host-directed drugs (baricitinib and icatibant).

METHODS

A 69-year-old Spanish man, repatriated after a multinational ANDV outbreak aboard a cruise ship, was managed in a high-level isolation unit. Diagnosis was established by RT-PCR and serology while he was still asymptomatic as part of protocol-driven screening. Under compassionate-use authorization and written informed consent, the patient received ribavirin (initially intravenous, then switched to oral on day +4), oral favipiravir, subcutaneous icatibant, and oral baricitinib, with serial clinical, laboratory, and radiological monitoring.

RESULTS

Hypoxaemia, bilateral B-lines, thrombocytopaenia, lymphopaenia, and hyponatraemia developed within 24 hours after diagnosis. The combination regimen was initiated on day 0, and baricitinib was added on day +1, coinciding with the need for high-flow nasal oxygen. Sustained clinical, laboratory, and radiological recovery occurred from day +2 onwards, without progression to invasive ventilation or vasopressors. Mild diarrhoea attributed to ribavirin led to its discontinuation on day +5, shortly after the intravenous-to-oral switch. Severe recurrent diarrhoea on day +8, attributed to favipiravir, prompted its withdrawal before completion of the planned 10-day course; baricitinib was completed on day +10.

CONCLUSIONS

This sentinel case of imported HCPS in nonendemic Europe was managed with, to our knowledge, the first reported combined antiviral and host-directed regimen for this syndrome and the first reported use of favipiravir in a patient with hantavirus infection. The favourable outcome supports prospective evaluation of antiviral combinations and adjunctive immunomodulation within international preparedness protocols.