Clinical Presentation and Management of Severe Ebola Virus Disease

Abstract

Clinicians caring for patients infected with Ebola virus must be familiar not only with screening and infection control measures but also with management of severe disease. By integrating experience from several Ebola epidemics with best practices for managing critical illness, this report focuses on the clinical presentation and management of severely ill infants, children, and adults with Ebola virus disease. Fever, fatigue, vomiting, diarrhea, and anorexia are the most common symptoms of the 2014 West African outbreak. Profound fluid losses from the gastrointestinal tract result in volume depletion, metabolic abnormalities (including hyponatremia, hypokalemia, and hypocalcemia), shock, and organ failure. Overt hemorrhage occurs infrequently. The case fatality rate in West Africa is at least 70%, and individuals with respiratory, neurological, or hemorrhagic symptoms have a higher risk of death. There is no proven antiviral agent to treat Ebola virus disease, although several experimental treatments may be considered. Even in the absence of antiviral therapies, intensive supportive care has the potential to markedly blunt the high case fatality rate reported to date. Optimal treatment requires conscientious correction of fluid and electrolyte losses. Additional management considerations include searching for coinfection or superinfection; treatment of shock (with intravenous fluids and vasoactive agents), acute kidney injury (with renal replacement therapy), and respiratory failure (with invasive mechanical ventilation); provision of nutrition support, pain and anxiety control, and psychosocial support; and the use of strategies to reduce complications of critical illness. Cardiopulmonary resuscitation may be appropriate in certain circumstances, but extracorporeal life support is not advised. Among other ethical issues, patients' medical needs must be carefully weighed against healthcare worker safety and infection control concerns. However, meticulous attention to the use of personal protective equipment and strict adherence to infection control protocols should permit the safe provision of intensive treatment to severely ill patients with Ebola virus disease.

Neurological Complications of Ebola Virus Infection

“…Renal insufficiency and lactic acidosis may also be commonly seen. Coagulation abnormalities such as prolongation of international normalized ratio and partial thromboplastin time may also occur, although these laboratory abnormalities were not as prominent in this outbreak compared with others [18]. In cases of multiorgan failure, all of the above may be seen, often at markedly deranged values [20].…”

“…Altered mental status, from mild confusion to delirium with hallucinations, may also occur, but may be secondary to a host of variables, including electrolyte abnormalities and shock. In severe cases, coma may occur [18]. Meningitis and encephalitis related to EVD have also been reported in the recent outbreak, as well as in prior outbreaks, although the incidence is not well documented [22][23][24].…”

“…Symptoms may begin abruptly and progress over a few days to include abdominal pain, nausea, and highvolume vomiting and diarrhea. Other associated signs and symptoms include conjunctival injection, chest pain, arthralgias, myalgias, asthenia, and hiccoughs [7,18]. Early in the disease course, symptoms may be mistaken for other tropical diseases, such as malaria, dengue, or cholera [19].…”

“…Transaminase testing often reveals abnormalities, usually with a greater elevation in aspartate transaminase than alanine transaminase [18]. With the marked volume loss common in the recent outbreak, electrolyte derangements such as hypo-and hypernatremia, hypocalcemia, hypokalemia, and hypomagnesemia have often been reported [7].…”

Where there is no overlap, there is a gap

“…In West Africa, this symptom collection could indicate a number of differential diagnoses including malaria, typhoid fever, leptospirosis, rickettsiosis, African trypanosomiasis, Lassa fever, cholera, Marburg virus, and Crimean-Congo hemorrhagic fever 5 . Therefore, in the early stages of an outbreak, lack of positive confirmatory serological tests could delay health authorities' responses, depending on the disease severity.…”