Ebola virus disease and critical illness

Abstract

As of 20 May 2016 there have been 28,646 cases and 11,323 deaths resulting from the West African Ebola virus disease (EVD) outbreak reported to the World Health Organization. There continue to be sporadic flare-ups of EVD cases in West Africa.EVD presentation is nonspecific and characterized initially by onset of fatigue, myalgias, arthralgias, headache, and fever; this is followed several days later by anorexia, nausea, vomiting, diarrhea, and abdominal pain. Anorexia and gastrointestinal losses lead to dehydration, electrolyte abnormalities, and metabolic acidosis, and, in some patients, acute kidney injury. Hypoxia and ventilation failure occurs most often with severe illness and may be exacerbated by substantial fluid requirements for intravascular volume repletion and some degree of systemic capillary leak. Although minor bleeding manifestations are common, hypovolemic and septic shock complicated by multisystem organ dysfunction appear the most frequent causes of death.Males and females have been equally affected, with children (0–14 years of age) accounting for 19 %, young adults (15–44 years) 58 %, and older adults (≥45 years) 23 % of reported cases. While the current case fatality proportion in West Africa is approximately 40 %, it has varied substantially over time (highest near the outbreak onset) according to available resources (40–90 % mortality in West Africa compared to under 20 % in Western Europe and the USA), by age (near universal among neonates and high among older adults), and by Ebola viral load at admission.While there is no Ebola virus-specific therapy proven to be effective in clinical trials, mortality has been dramatically lower among EVD patients managed with supportive intensive care in highly resourced settings, allowing for the avoidance of hypovolemia, correction of electrolyte and metabolic abnormalities, and the provision of oxygen, ventilation, vasopressors, and dialysis when indicated. This experience emphasizes that, in addition to evaluating specific medical treatments, improving the global capacity to provide supportive critical care to patients with EVD may be the greatest opportunity to improve patient outcomes.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1325-2) contains supplementary material, which is available to authorized users.

Multi-platform ’Omics Analysis of Human Ebola Virus Disease Pathogenesis

“…While some evidence suggests that REG1A is a biomarker of sepsis (Llewelyn et al, 2013) and/or intestinal damage mediated by inflammation (Vives-Pi et al, 2013), increased circulating levels of pancreatic trypsins and lipase are associated with acute pancreatitis (Malfertheiner and Kemmer, 1991), which can be caused by viral infection. Symptoms of acute pancreatitis include severe abdominal pain, and complications may include acute respiratory distress, disseminated intravascular coagulopathy and kidney failure (Agarwal and Pitchumoni, 1993), all of which have been observed in patients with severe EVD (Leligdowicz et al, 2016). These observations suggest a potential role for EBOV-induced pancreatic tissue damage and the consequential effects of systemic release of pancreatic enzymes in EVD pathogenesis.…”

Heterogeneities in the case fatality ratio in the West African Ebola outbreak 2013–2016

“…This could be either because they were fairly homogeneous between TCs, or because the levels of clinical care available in the resource-poor West African setting were simply not sufficient to make much of a difference. This is also plausible in the context of little differences between TC types, but would be in contrast with the experience with cases among western healthcare workers who were med-evacuated and cared for in state-of-the-art high dependency units that resulted in considerably lower mortality [34,35]. However, the few outliers identified would be good candidates for further selective investigation, to identify the characteristics that set these apart, based on complementary datasets, e.g.…”

Intensive Care Unit Preparedness During Pandemics and Other Biological Threats

“…A vastly smaller number of patients with EVD received treatment outside of Africa, including 11 in the United States and 16 in Europe. 16 Of these 27 patients, the majority were infected in West Africa, but 2 patients were nurses who were secondarily infected following exposure to a man with EVD who had traveled recently to Liberia. These cases of imported EVD increased awareness of the risk of viral hemorrhagic fevers in a globalized world, but, more practically, it also demonstrated to clinicians in industrialized countries the intensity of resources, staffing, and training required to safely care for patients with EVD.…”