Case Presentations & Case Conclusions
Case Presentations & Case Conclusions
A 4-year-old girl presents to the ED with a 4-day history of tactile fever, headache, malaise, joint pain, difficulty breathing, large-volume diarrhea, and nonbloody, nonbilious emesis. She lives at home with her parents and 8-year-old sister. She emigrated from Liberia 2 weeks ago. On examination, she is pale, ill-appearing, and lethargic. Her vital signs are: temperature, 40.4ºC (104.7ºF); respiratory rate, 40 breaths/min; heart rate, 185 beats/ min; blood pressure, 72/43 mm Hg; and oxygen saturation, 86% on room air. Dried blood is noted in her right nare. Her lung sounds are normal, but tachypnea with moderate retractions are present. She is tachycardic with a normal rhythm and a capillary refill of 4 seconds. Her abdomen is soft and mildly tender diffusely, but no distention or rebound is present. Her extremities are cool to the touch and mottled, but no rash is noted. She moans in response to the examination.
A 10-year-old girl presents with a 2-day history of cough, runny nose, fever to 38.6ºC (101.5ºF), body aches, abdominal pain, headache, and nonbloody, nonbilious emesis. She has not had diarrhea. Three other family members are ill with similar symptoms. Her aunt, who is staying with her, recently traveled to West Africa and returned 20 days ago. The girl’s vital signs are: temperature 38.6ºC (101.5ºF); respiratory rate, 34 breaths/min; heart rate, 127 beats/min; blood pressure, 98/69 mm Hg; and oxygen saturation, 93% on room air. She is moderately ill-appearing but alert and answering questions appropriately. Her mucous membranes are dry. She is tachycardic with normal rhythm. Her abdomen is soft and mildly tender diffusely, but no distention or rebound is present. Her lungs have bibasilar crackles, greater on the right than the left. Tachypnea is noted with mild intercostal retractions. Her capillary refill and skin examination are normal.
What is the first step in the prescreening of these patients? What precautions should healthcare workers take? What are the initial steps in assessment and resuscitation? What signs and symptoms point to multisystem involvement? What historical and physical examination clues would point to a diagnosis of Ebola virus disease? What other diagnoses should the clinician consider? What diagnostic testing should be undertaken? Which patient(s) requires quarantine? What management techniques should be initiated in the care of these patients?
Given the presentation and the recent emigration from Liberia, the 4-year-old girl was considered to be at high risk for EVD. She was placed on isolation and precautions. Healthcare workers trained in donning and doffing PPE used it to cover all skin surfaces and mucous membranes.
Airborne precautions were also placed in case there were any unexpected aerosol-generating procedures. The patient was aggressively resuscitated with intravenous fluids, blood products, broad-spectrum antibiotics, and oxygen therapy. Acetaminophen and antiemetics were also administered. Laboratory personnel were notified of possible EVD and precautions were taken with all laboratory specimens. Thick and thin smears were negative for malaria. Laboratory analysis was performed, revealing substantial dehydration with significant microcytic anemia and thrombocytopenia. The patient was admitted to the ICU and required intubation and mechanical ventilation. She developed worsening coagulation and disseminated intravascular coagulation. The results from the Ebola RT-PCR assay were positive. Despite aggressive and maximal supportive measures, she progressed to multiorgan failure and expired on hospital day 6.
On further questioning, the 10-year-old girl's aunt had no known exposure to anyone with Ebola and was otherwise without symptoms. The patient’s 3 siblings were also ill with upper respiratory tract symptoms. Since the patient was tachypneic with signs of dehydration, IV fluids were started. Antiemetics and acetaminophen were given. The girl responded very well to fluids and looked much improved on reassessment. Her vital signs improved in the ED. Given her presentation, rapid influenza testing was sent and the results were positive for influenza A. A chest radiograph was ordered, which showed patchy infiltrates in the right lower base and some bibasilar atelectasis. Oseltamivir was initiated. The patient was observed in the short-stay unit for a few hours. Repeat vital signs normalized. The girl was eating and talkative in the unit. Since she was at low risk for Ebola and had another etiology for her symptoms, the decision was made to discharge her home with close follow-up.
Marlie Dulaurier, MD;Katherine Moyer, DO;Rebecca Wallihan, MD
July 2, 2016
August 2, 2019
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 0.5 Pharmacology CME credits