Symptomatic Therapy

Treatment of nausea, vomiting, and fever was implemented intravenously immediately after admission, because oral drug intake was not possible. An overview of all the administered drugs with respective timelines and our treatment considerations regarding the administration of experimental therapies is provided in the Supplementary Appendix.

Baseline Fluid and Nutrition Management

Maximal supportive measures were initiated, with a primary goal of restoring and maintaining volume and electrolyte balance. The patient was considered to be at high risk for hypovolemic shock on the basis of a stool output of more than 8000 ml per 24 hours in the first 3 days after the transfer to Hamburg (days 10 to 12) (Table 1). Nausea and vomiting precluded oral rehydration, and high-volume resuscitation of up to 10 liters per day, with a positive net-volume balance of 30 liters during the first week, was necessary to stabilize cardiocirculatory values. Rehydration was guided by clinical examination and by repeated ultrasonographic examinations of the inferior vena cava. Persistently low potassium levels necessitated continuous intravenous substitution of 8 to 10 mmol of potassium chloride per hour. To meet the demands of volume and electrolyte repletion, a central venous catheter was placed on day 15.

Owing to paralytic ileus and high gastric residual volumes with severe hiccups, enteral nutrition was not tolerated. Attempts to stimulate peristalsis with the use of erythromycin and neostigmine were unsuccessful, prompting the initiation of parenteral nutrition on day 11, including the administration of glutamine at a dose of 0.3 g per kilogram of body weight per day as possible support for mucosal integrity.5 After stabilization of the patient's condition, enteral nutrition with a low-fiber standard formula was initiated on day 17.

Clinical Course and Management of Complications

The patient remained clinically stable on days 10 through 12. Emesis ceased on day 13, and high-volume diarrhea (>1000 ml) resolved on day 15. Hemoglobin and creatinine levels returned to the normal range by day 12, and the aminotransferase levels gradually declined (Table 1). However, fever (40.0°C), hypoxemia, tachycardia, shortness of breath, and abdominal pain developed on day 13. Laboratory studies revealed leukocytosis (14.1×103 white cells per cubic millimeter) with a predominance of neutrophils (87%) and an elevated C-reactive protein level (43 mg per liter). These findings were interpreted as suggestive of concomitant secondary peritonitis and sepsis due to the loss of mucosal integrity and bacterial translocation.

Figure 1. Figure 1. Timeline of Plasma Viral RNA Load, Septicemia, and Antimicrobial Therapy in a Patient with Severe Ebola Virus Disease. The decline in viral copies in plasma (red line) and the development and course of leukocytosis (gray line) are shown. The maximum C-reactive protein levels (in milligrams per liter) are shown in blue above the respective day numbers. The time when the blood culture was performed is marked by an arrow at day 12. The duration of antimicrobial therapy is shown by the gray bars. The dashed gray line represents the upper limit of the normal range for white cells. The dashed red line represents the lower limit of detection of viral RNA in plasma on reverse-transcriptase–polymerase-chain-reaction assay.

Antimicrobial therapy with ceftriaxone was initiated on day 13 and was changed to meropenem and vancomycin on the evening of day 14, when the patient's condition deteriorated further, with an increase in the white-cell count (26.9×103 per cubic millimeter). Blood cultures drawn on day 12 and performed within the UTHCI revealed growth of a gram-negative bacterium resistant to ampicillin, ciprofloxacin, and third-generation cephalosporins but sensitive to meropenem. More advanced tools for full identification of the organism and assessment of speciation were not accessible under the conditions of the UTHCI. An overview of the timeline of sepsis is presented in Figure 1, showing that new severe systemic symptoms developed while the EBOV RNA load was already declining.

The patient's treatment course was further complicated by the development of small pleural and pericardial effusions, ascites, and increasing intestinal edema, which were probably due to a combination of EBOV endothelial-cell cytotoxicity6 and decreasing serum protein concentrations as a consequence of rigorous volume management. On day 15, this condition led to a deficit in organ perfusion complicated by hypoglycemia and lactic acidosis, which was treated with increased volume repletion, sodium bicarbonate, and 40% glucose solution.

A combination of pulmonary atelectasis, volume overload, and encephalopathy with altered mental status resulted in acute respiratory failure on day 18. The respiratory status was further compromised by aspiration of blood from epistaxis in the context of thrombocytopenia. In spite of relative contraindications (gastroparesis and altered mental status), noninvasive ventilation was initiated. After 8 days of intermittent noninvasive ventilation, the patient gradually recovered, and his laboratory values started to normalize. However, the patient had persistent tachycardia (heart rate, 120 to 150 beats per minute) and hypertension (blood pressure, >150/80 to 180/100 mg Hg) with normal electrocardiographic and echocardiographic findings. The tachycardia and hypertension were unresponsive to metoprolol and clonidine but resolved gradually without intervention by day 35.

The patient had severe encephalopathy for 6 days (days 14 to 19) until vigilance slowly improved. However, the encephalopathy was followed by transient delirium with hallucinations (days 20 to 25), which were unresponsive to haloperidol but subsided spontaneously before discharge.

EBOV RNA Load and Serologic Findings

Figure 2. Figure 2. Timeline of Viral RNA Load in Plasma, Sweat, and Urine and Antibody Titers in Plasma. The y axis on the left side of the graph shows the viral RNA load (solid lines). Owing to strong fluctuations in single measurements, line plots for urine and sweat are shown as moving averages over a period of 3 days. The y axis on the right side of the graph shows the antibody titers (dashed lines). The horizontal dashed line indicates the lower limit of detection of viral RNA on reverse-transcriptase–polymerase-chain-reaction assay.

Before transfer, the patient had tested positive for EBOV RNA in blood, as measured by means of a real-time RT-PCR assay, on days 6 and 7 at a local treatment center. From the day of arrival in Hamburg (day 10), the EBOV RNA concentration in plasma was measured daily (RealStar Filovirus Screen RT-PCR Kit 1.0, Altona Diagnostics). The presence of EBOV-specific IgG and IgM antibodies was determined by means of an immunofluorescence assay with the use of EBOV-infected Vero E6 cells as an antigen. The EBOV RNA load decreased starting on day 10 and first became negative on day 17. Anti-EBOV antibody titers steadily increased, with peak titers of 1:2560 for IgM antibodies and of more than 1:320,000 for IgG antibodies (Figure 2).

After plasma EBOV RNA became negative on day 17, real-time RT-PCR surveillance of sputum, saliva, conjunctival swabs, stool, urine, and sweat (from the axillary, forehead, and inguinal regions) was performed. Saliva, sputum, conjunctival swabs, and stool were already negative on the first day of testing (day 18). However, urine samples remained positive for EBOV RNA until day 30, and RNA extracts from sweat remained positive throughout the observation period until day 40.

In addition, to test for the infectivity of the specimens in cell culture, Vero E6 cells were inoculated with plasma, sweat, and urine (150 μl of inoculum per 25-cm2 flask). Cell cultures were incubated for 40 days, and cells were monitored for viral growth by means of immunofluorescence assay. EBOV was isolated on cell culture from plasma samples obtained on days 10 to 14, when EBOV RNA was still detectable in the blood. In addition, viable EBOV was still isolated from urine samples obtained on days 18, 19, 20, 24, and 26, which was up to 9 days after the clearance of EBOV RNA from plasma. At the time of writing (day 63), all cell cultures of clinical specimens (plasma, sweat, and urine) obtained after day 26 of illness were negative for viable EBOV.

Discharge from UTHCI and Infectious Disease Ward

On day 28, the patient was transferred from the UTHCI to an infectious disease ward with barrier nursing precautions, which are similar to the precautions used in biosafety level 3 laboratories. In addition to negative results on the RT-PCR assay in plasma, the three criteria for the patient's transfer, based on an agreement between the hospital and local and national health authorities, were clinical recovery, continence for stool and urine, and ability to comply with instructions. Discharge from the hospital was delayed until day 40, owing to the prolonged detection of virus RNA in urine and sweat. On agreement with local health authorities, the patient was discharged after all cultures of PCR-positive samples of body fluids had been free of infectious virus particles for 20 days. The patient ultimately recovered, with all laboratory values, including liver-enzyme levels, within the normal range, and he was able to return to his family in Senegal without assistance.

Infection-Control Measures

Staff members working in the UTHCI were protected by pressurized suits (Astro-Protect, Asatex) that were equipped with ventilators with high-efficiency particulate air filters to provide fresh air supply with a maximum airflow of 160 liters per minute (ProFlow 2 SC, Asatex). All the staff who cared for the patient did so without becoming infected. More details regarding the unit and protective measures are provided in the Supplementary Appendix.