This is the transcript of an interview with Tim Uyeki, MD, MPH, the Centers for Disease Control and Prevention (CDC) clinical team lead (Ebola response) and chief medical officer for the influenza division at the CDC’s National Center for Immunization and Respiratory Diseases.
JMH: Thank you for taking the time for this interview. With all the excitement and anxiety, it is important to send a clear and precise message about this disease. Recognizing how busy you are, let me get quickly to our questions. My first question is, from a clinical perspective, what would you recommend for initial evaluation and diagnosis?
TU: Thank you Jon Mark. I appreciate this opportunity to help inform the ACEP membership about Ebola. The key, from a clinical perspective, is a good history. Essentially, there are two groups of people who are most at risk. The first is individuals recently returned from West Africa, and specifically the most affected countries of Liberia, Guinea, and Sierra Leone who have had direct contact with the blood or bodily fluids of a person who was sick with or died of Ebola virus disease (household, community, or health care setting). The second group would be individuals with direct contact with the blood or bodily fluids of a patient with Ebola virus disease in the United States (close contacts, including health care personnel). To date, in the United States, there have only been two imported cases and two secondary cases (nosocomial transmission to two nurses), other than a handful of individuals who had been medically evacuated for further medical care from West Africa. The key pieces of information to obtain are recent travel history, recent contact history, and timeline of illness signs and symptoms.
JMH: That’s excellent information. So, really, the risk of transmission in the United States is extremely low. How long after exposure do symptoms typically appear? Let’s say that someone presents with possible exposure—what are the signs and symptoms of the disease?
TU: In general, the average incubation period after exposure to fever and symptom onset is eight to 12 days, though symptoms may appear anywhere from two to 21 days after exposure. Initial signs and symptoms are nonspecific and may include low-grade temperature elevation, fatigue, chills, weakness, anorexia, and malaise. Within four to five days, profuse watery diarrhea, nausea, vomiting, and abdominal pain can start along with a high fever (>38.6º C). Substantial gastrointestinal fluid losses can lead to intravascular volume depletion, hyponatremia, hypokalemia, hypomagnesemia, and hypocalcemia. Conjunctival injection or subconjunctival hemorrhage may be present. Most patients develop a significant transaminitis with aspartate transaminase (AST) markedly elevated compared to alanine transaminase (ALT). Some patients may also develop a diffuse erythematous maculopapular rash on the face and torso by days four to six. Although hemostasis is impaired, frank hemorrhage is not common and is usually manifested by gastrointestinal tract bleeding and sometimes with oozing from mucous membranes and intravenous catheter sites in persons with severe disease later in the clinical course. Central nervous system involvement can be manifested by delirium, agitation, seizures, and coma. Patients with fatal disease usually develop more severe clinical signs early during the clinical course and die typically between days six and 16 of complications including multiorgan failure and septic shock.