Microbio Monday
CASE
42 yo F, previously healthy, presents to ED with 4-5 days of fever, chills, nonproductive cough followed by muscle aches. Symptoms are getting worse and have not responded to OTC treatments. Patient presented today after noticing bleeding from the gums that have not stopped after brushing her teeth this morning, also with some bruising in the arms but does not recall trauma. Upon further questioning, the patient reveals they just returned from Guinea after working in a medical clinic for the last month and came in contact with a few locals with similar symptoms recently, remembers getting coughed in her face while taking care of patient, also reports a few deaths in these same patients, denies needle sticks or handling of corpses. VS show T 101.8, P110, BP 123/70, R 22, O2 98% RA.
The next step for this patient should be?:
- Labs/CXR/IVF
- Immediately place m95 mask over yourself and patient, place patient in isolation room
- Tylenol, reassurance, d/c with PMD f/u
- IVF, cultures, broad spectrum abx, LP, admission
Answer:
B. IMMEDIATELY PLACE M95 MASK OVER YOURSELF AND PATIENT, PLACE PATIENT IN ISOLATION ROOM
**also important to use faceshields, gowns, shoe covers and gloves (double gloving) in addition to the masks for personal protection
The largest concern in this patient, given current events and patient history, is Ebola virus infection, and is classified as high-risk by CDC guidelines listed below. Patient has been to an endemic region, likely encountered patient with symptomatic Ebola, and now is concerning for active Ebola infection. The virus is a filovirus, believed to have reservoirs in bats, transmitted directly to humans or to apes then humans. Current outbreaks include countries of Guinea (~472 cases), Liberia (~391 cases), Sierra Leone (~574 cases). Typical course of the virus includes inoculation either by animal or infected person, transmitted by contact with blood, urine, sweat, semen, and breast milk (also rarely but suspected to be transmissible through aerosolized fluids, especially during medical procedures). Symptoms including fever (generally >101.5F), chills, headache, muscle aches, abdominal pain, nausea, vomiting, diarrhea, bleeding/bruising/rash, jaundice. As the disease progresses, patients may develop stupor, hypotension, shock/multi-organ failure. Incubation is 8-10 days on average (2-21 days range), IS NOT BELEIVED TO BE TRANSMISSIBLE IN ASYMPTOMATIC PATIENTS, rash typically appears on day 5-7. Abnormal labs include elevated AST/ALT ( AST typically >ALT), thrombocytopenia (<150,000), leukopenia with left shift, evidence of DIC [1]. Those who survive typically show sign of improvement by week 2. Mortality associated with current outbreak is 55-60%.
CDC recommends screening for high-risk exposures, defined as the following:
-percutaneous or mucous membrane exposure or direct skin contact with body fluids of a person with a confirmed or suspected case of EVD without appropriate personal protective equipment (PPE),
– laboratory processing of body fluids of suspected or confirmed EVD cases without appropriate PPE or standard biosafety precautions, or
– participation in funeral rites or other direct exposure to human remains in the geographic area where the outbreak is occurring without appropriate PPE.
Persons with no known exposures listed above but who have fever with other symptoms and abnormal bloodwork within 21 days of visiting EVD-affected countries should be considered for testing if no other diagnosis is found (defined as low-risk). Testing may be indicated in the same patients if fever is present with other symptoms and blood work is abnormal or unknown. Consultation with local and state health departments is recommended.
If testing is indicated, the local or state health department should be immediately notified (NY Health Department #1-866-881-2809). Healthcare providers should collect serum, plasma, or whole blood. A minimum sample volume of 4 mL should be shipped refrigerated or frozen on ice pack or dry ice (no glass tubes), in accordance with IATA guidelines as a Category B diagnostic specimen. Please refer to http://www.cdc.gov/ncezid/dhcpp/vspb/specimens.html for detailed instructions and a link to the specimen submission form for CDC laboratory testing. [2]
TREATMENT: no antivirals have been shown to treat or improve mortality in humans, treat these patients as you would most septic/infected patients with aggressive fluid resuscitation and electrolyte balance/repletion, symptomatic control, antibiotics only if there is suspicion of superinfection. Current research efforts to use recombinant adenovirus-based vectors have been identified as potential vaccine candidates, with some affording both pre- and post-exposure protection from the virus in animal models [3]. There has also been research into use of monoclonal antibodies [4] and interferon-beta [5] use in treating active infections with some success in rhesus macaque models, however, up until the most recent cases of Writebol and Brantly (both receiving monoclonal antibodies), had not been tested on humans.
Sources:
1. http://www.uptodate.com; search: ebola
2. http://www.cdc.gov/vhf/ebola/
3. Choi JH, Croyle MA. Emerging targets and novel approaches to Ebola virus prophylaxis and treatment. BioDrugs. 2013 Dec;27(6):565-83.
4. Qiu X, Wong G, Fernando L, Audet J, Bello A, Strong J, Alimonti JB, Kobinger GP. mAbs and Ad-vectored IFN-α therapy rescue Ebola-infected nonhuman primates when administered after the detection of viremia and symptoms. Sci Transl Med. 2013 Oct 16;5(207):207
