Answer to Q1

The patient meets the case definition of a suspected Ebola Virus Disease case namely:

1. Visited a country with a present EVD outbreak in the last 21 days
2. AND had direct contact with suspected or confirmed EVD cases
3. OR had multisystem illness with negative malaria testing

he patient was isolated in a side room with standard, contact and droplet precautions.

Question 2: What investigations should be requested?

Answer to Q2

The following investigations should be requested

1. Full blood count, urea, creatinine and electrolytes, liver function test, PT and PTT, malaria smear and blood cultures.
2. EVD testing should only be commenced after the results of the above tests are available and results have been discussed with the NICD Hotline - +27-82-883-9920.

In consultation with the relevant authorities a chest radiograph was ordered. Blood specimens were obtained for blood culture (negative); malaria (negative); urea, electrolytes, creatinine (normal); liver function tests (normal); CRP (63.3 mg/L); FBC (Hb 11.8g/dL, platelets 133 x 10₉/L, clotting profile (normal) and Rickettsia (negative). Specimens were sent to the NICD for Chikungunya, Sindbis, West Nile Rift Valley, arboviruses and Ebola virus determination.

Question 3: Which countries in West Africa still pose a risk of EVD to travellers?

Answer to Q3

Guinea and Sierra Leone. Nigeria had isolated outbreaks during 2014 but is not presently considered a risk country, and Liberia has been declared Ebola-free by the WHO

Question 4: For how long, following travel to an EVD afflicted country, should one consider EVD?

Answer to Q4

Any patient who has left a country affected by EVD should be considered at risk for 21 days (3 weeks).

Question 5: Which persons are at higher risk for contacting EVD?

Answer to Q5

Increased risk of acquiring ebola in:

1. Persons with recent travel to the countries in West Africa as discussed in question 1.
2. Healthcare and laboratory workers attending directly to or handling specimens of confirmed or suspected EVD patients.
3. Exposure to bats, animals (or their tissues).
4. Non-occupational contact with suspected cases of EVD.
5. Handling or being bitten by ticks or insects, especially mosquitoes.

Outcome to the Case

The patient was discharged from the Emergency Department when all viral haemorrhagic fever blood tests returned negative from the NICD. Follow up was arranged for repeat malaria tests and full blood count. Malaria remained negative.

In the week following admission the result for Parvovirus B19 PCR returned positive. This test had subsequently been added to the battery of tests after an expert from the NICD obtained a full medical history of contacts since return from Sierra Leone.

Parvovirus B19

Parvovirus B19 is a DNA virus known to invade immature reticulocytes. Parvovirus B9 results in infections year-round and has been known to cause outbreaks during winter and summer.

The exact route of transmission of the virus is unknown but may be through respiratory and direct contact. Mother-to-foetus transmission may occur. The virus may be spread by blood and blood products.

Parvovirus B19 presents with viraemia 6 days after inoculation and patients experience viraemic symptoms for one week. After a further 7-10 days, a drop in haemoglobin, lymphocytes, neutrophils and platelets may be noted. Within 17-18 days after inoculation rash, arthralgia or arthritis may present.

Parvovirus B19 may be asymptomatic in some; however a multitude of distinct presentations exist namely:

• Erythema infectiosum.
• Arthropathy.
• Sudden transient aplastic crisis.
• Chronic anaemia in the immunosuppressed patient.
• Foetal and congenital infection.

(A full description of the presentations of Parvovirus B19 is available in the literature and the reader is referred to the References.)

Diagnosis is confirmed by the presence of IgM antibodies in the blood together with clinical symptoms and signs suggestive of acute Parvovirus B19 infection. PCR testing can be done in the immune-suppressed population.

Generally speaking, no specific treatment is recommended. Arthropathy and arthritis can be managed symptomatically. Aplastic crisis may require a transfusion of packed red blood cells. The immunosuppressed patient may require immunoglobulins as they may fail to clear the viraemia.

The presence of IgG antibodies indicates previous infection and immunity. The presence of IgG antibodies for Parvovirus B19 in a population increases with age. Between 3 and 16% of adults over the age of 19 years have IgG for Parvovirus B19.

Resolution
The patient made a slow recovery over the following days. During this time she suffered from headache and arthralgia. She subsequently noted a rash, which developed on her feet, legs and arms. The rash faded and resolved together with the arthralgia.

Lessons learned:

• Returning travellers who present with fever require thorough investigation to exclude life-threatening conditions.
• A detailed history is paramount – not only whilst the traveller is away, but on return. Contact with persons in the household should be included in a good patient history.
• Not every patient with fever who returns from West Africa has EVD – although this needs to be actively excluded.

Reference

1. Blacklow NR. Parvovirus. In Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, editors. Harrison’s Principles of Internal Medicine. 16th ed. New York. McGraw-Hill; 2005.
2. Blum FC, Biros MH. Fever in the Adult Patient. In Marx JA editor. Rosen’s emergency Medicine – Concepts and Clinical Practice. 8th ed. Philidelphia. Elsevier Saunders; 2014.
3. South Africa. National Department of Health. Ebola Virus Disease Risk Assessment for Use in Healthcare Facilities. Pretoria; NATHOC; 2014.
4. South Africa. National Department of Health. Interim Guidelines for the Clinical Recognition, Diagnosis and Management of Ebola Virus Disease (EVD) in South Africa. Pretoria: NATHOC; 2014.