S Kotzé, SASTM
A 33-year old woman presented to the Emergency Department (ED) 21 days after return from Sierra Leone. She was part of a response team to the Ebola-stricken country testing blood samples for the presence of Ebola virus.
Her symptoms included acute onset arthralgia, fever (38.5°C at home), myalgia and backache. She had a background medical history of repeated urinary tract infections and pyelonephritis.
She took Malanil® (atovaquone-proguanil) malaria chemoprophylaxis – she was compliant. She had previously been vaccinated against rabies, hepatitis A and hepatitis B.
During her time in Sierra Leone, she drank bottled water, ate canned food and hotel/restaurant food. Her meals consisted mainly of a combination of eggs, bread, burgers and chips. She denied eating uncooked meat, unpeeled fruit or unprepared vegetables.
She recalled being stung by a flying ant on the neck one week prior to return to South Africa self-medicating with oral antihistamines and the area remained bothersome for three days.
On examination she had no skin changes. She had a resting tachycardia of 112 bpm with a blood pressure of 121/83 mmHg. On respiratory examination she had a minimally productive cough, SaO2 of 96%, respiratory rate of 19 bpm. Abdominal examination revealed left renal angle tenderness with paraspinal low back muscle spasm. She had thick nasal secretions and signs suggestive of sinusitis.
Urine dipstix showed blood ++, protein ++ and bilirubin +. Note was made that she was menstruating at the time of consultation.
Question 1: Does the patient meet the criteria for the case definition of Ebola Virus Disease (EVD) and isolation of the patient?
Answer to Q1
The patient meets the case definition of a suspected Ebola Virus Disease case namely:
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
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:
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 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:
(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.
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.
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