Routine ICU Care May Effectively Treat Even Severe Ebola

Laurie Barclay, MD

October 22, 2014

A patient with severe Ebola virus disease (EVD) complicated by gram-negative septicemia, respiratory failure, and encephalopathy responded to routine intensive care, according to a case report published online October 22 in the New England Journal of Medicine.

"Since December 2013, a Zaire ebolavirus (EBOV) epidemic of unprecedented scale has ravaged West Africa, with a focus on Guinea, Sierra Leone, and Liberia," write Benno Kreuels, MD, from the division of tropical medicine, University Medical Center Hamburg, in Germany, and colleagues. "The current epidemic has led to a public health emergency in the region, exacerbated by high rates of infection among health care personnel."

In Sierra Leone, a 36-year-old man presented with malaise, headache, and muscle and joint pain. The next day he had fever and was treated empirically for malaria and also received ceftazidime from days 2 to 6, when a real-time reverse transcriptase polymerase chain reaction assay was positive for EBOV.

History suggested that the patient contracted EBOV from a coworker with whom he shared an office and restroom facilities, and who had died with symptoms of EBOV 10 days before the patient in this case report developed symptoms.

On day 7, the patient had nausea, vomiting, abdominal pain, and nonbloody diarrhea. On day 10, he was airlifted to an isolation facility in Hamburg, Germany, for intensive supportive treatment with high-volume fluids (approximately 10 L/day for 72 hours), broad-spectrum antibiotics (ceftriaxone and then meropenem and vancomycin), and ventilation. Laboratory testing was consistent with dehydration and sepsis, and abdominal ultrasound showed complete collapse of the inferior vena cava and paralytic ileus.

Complications included gram-negative septicemia, respiratory failure requiring ventilation, and severe encephalopathy, as well as peritonitis, pleural and pericardial effusions, and paralytic ileus. Nonetheless, routine intensive care without experimental therapy allowed complete recovery from Ebola.

The last positive culture in plasma was on day 14, and in urine on day 26. However, the patient remained in the hospital because of polymerase chain reaction detection of viral RNA in urine on day 31 and in sweat on day 40 (at the last evaluation).

"This case shows the challenges in the management of EVD and suggests that even severe EVD can be treated effectively with routine intensive care," the authors conclude.

"Sepsis led to severe illness when the viral load was already decreasing, which suggests that sepsis may contribute substantially to the mortality observed in the current outbreak, specifically with regard to deaths occurring late after disease onset."

The authors have disclosed no relevant financial relationships.

N Engl J Med. Published online October 22, 2014. Full text

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