Structure

Item

Instruction

Example

Title （Chinese and English）

1

Including symptoms, diagnosis, test or intervention of the case.

A case of meningoencephalitis caused by late Ebola virus recrudescence.

Abstract

(Chinese and English)

2a

Introduction: what is significance of the case?

Relapse of the virus leading to life-threatening condition and potentially transmissible diseases has not been reported.

2b

Characteristics: symptoms, clinical findings, diagnosis, intervention and outcome.

Symptoms: symptoms of acute meningitis;

Clinical findings: the level of Ebola virus RNA in cerebrospinal fluid (circulation threshold 23.7) was higher than that in plasma (31.3); infectious viruses were recovered only from cerebrospinal fluid;

Diagnosis: meningoencephalitis caused by Ebola virus reoccurrence;

Interventions: GS-5734 + high-dose cortico-steroids during treatment;

Outcome: CSF Ebola virus RNA decreased slowly and could not be detected.

2c

Conclusion: what is the lesson learned from the case?

These findings fundamentally change the understanding of the natural history of Ebola virus. For recurrent infectious diseases, we should be alert to relapse for thousands of Ebola survivors.

Key Words

(Chinese and English)

3

Summarize the case with 2~5 keywords.

Introduction

4

Relevant literature review and a brief summary.

However, the possibility of serious clinical relapse and infectiousness were not expected for the late stage of Ebola.

Patients

5a

General information (such as age, gender, race, occupation, etc.)

A 39-year-old female nurse from Scotland.

5b

Chief complaint.

Rapid onset of severe headache with neck pain, photophobia, fever and vomiting.

5c

History, family history and psychosocial factors, including diet, lifestyle, genetic information (those deemed as necessary by patients and doctors), relevant comorbidities (including previous interventions and outcomes)

Medical history;

First hospitalization (December 2014 to January 2015);

First rehabilitation (January October 2015).

Clinical Manifestation

6

Describing the findings of physical examination.

Headache aggravated, photophobia, neck stiffness, fever up to 38.5° C, complete rigidity (Glasgow Coma Scale 15/15), normal for comprehensive neurological examination, no ocular symptoms.

Timeline

7

Describing the important clinical timeline in this case. It is recommended to show in tables or figures.

Diagnostics

8a

Diagnostic methods (such as physical examination, laboratory test, imaging and scale form).

Glasgow Coma Scale;

Complete neurological examination;

Admission blood test;

HIV detection;

Lumbar puncture;

RT-PCR.

8b

Factors affecting diagnosis (such as financial challenge, language difficulty or cultural differences).

Due to the risk of infection among laboratory staff, only limited analysis of cerebrospinal fluid (CSF) was performed.

8c

Diagnostic basis, including differential diagnosis.

The high level of Ebola virus RNA in CSF (circulation threshold 23.7) and much lower level in plasma (31.3) were detected by RT-PCR.

8d

Factors affecting prognosis (such as tumor pathological stage).

Treating & Intervention

9

Type of intervention (such as medicine, surgical treatment, prevention, self-care);

Implementation (such as dose, intensity and duration);

Change of intervention (the reason and rationale shall be explained).

Early support and symptomatic treatment;

Specific antiviral treatment.

Follow-Up & Outcome

10

Outcome assessed by doctors and by patients;

Follow-up results (positive or negative);

Compliance and tolerance of intervention evaluated by a specific method;

Adverse reactions and accidents.

On the 5th to 10th day of illness, the patient was getting pain in head, chest and waist. Ebola virus was not detected on the 24th day. The patient was discharged on the 52nd day, with residual weakness in her left leg and deafness in her left side.

Discussion

11a

Lessons learned in the treatment and limitations

We firstly treated this Ebola relapse with monoclonal antibody therapy. Our patient was the first who had received the treatment twice and developed a life-threatening allergic reaction. Since the number of survivors treated with monoclonal antibodies increased in late outbreaks in west Africa, it is important to be aware of the possibility of allergic reactions, although we do not know whether re-stimulated immune allergy is common or not.

11b

Literature review of the similar or relevant cases.

In 2015, it was reported that Ebola virus were transmitted through the sperm of survivors 179 days after the onset of the disease.

11c

Reasonable explanation of the conclusion (including the evaluation of etiology and curative effect)

It seems reasonable that patients with very high Ebola viral load are most likely to have immune privileged infection sites (e.g., CNS) and therefore have the greatest risk of relapse. Most of these patients will die from the initial disease in West Africa.

11d

Key lessons learned from this case report

It is essential that all health care professionals remain vigilant against recurrent Ebola virus infection among survivors, as we do not yet understand the various clinical diseases that may lead to. The role of antiviral therapy in the persistence of the virus or in the survivors who have great risk of relapse may need to be reconsidered. Our case illustrates why good medical care, surveillance and research for survivors should be an important part of the global response to the devastating Ebola epidemic in west Africa.

References

12

Mainly in recent years, no less than 10 literatures.