Case history #1
A 27-year-old man presents to a hospital in Europe with a 2-day history of high fevers, malaise, myalgias, and severe headache which developed 3 days after a 2-week trip to Uganda. While there, the man tracked chimpanzees and gorillas, and visited the Marangambo Forest python cave. Fruit bats were flying in and out of the cave, but he was not touched, bitten, or scratched by the bats. Later, he ate goat stew containing intestine at a local hotel and swam in a local lake. No one fell ill during the trip. The man developed fever 12 days after visiting the python cave, 11 days after eating goat stew, and 10 days after lake swimming. Prior to travel, he was vaccinated against hepatitis A, polio, typhoid, and yellow fever. He took doxycycline as malaria prophylaxis, but admits to missing "a couple of doses". At presentation, physical examination is normal except for a temperature of 40.1°C (104.2°F) and relative bradycardia (79 beats per minute). Based on his exposure history and the pulse-temperature dissociation, typhoid fever is diagnosed and ceftriaxone begun. Blood examination demonstrates mild leukopenia (2.9 x 10⁹ cells/L), moderate thrombocytopenia (66 x 10⁹ cells/L) and mildly elevated alanine aminotransferase (146 U/L) and aspartate aminotransferase (137 U/L). Rapid diagnostic testing for malaria is negative. The differential diagnosis includes leptospirosis, viral hepatitis, and dengue fever. On hospital day 2, the man develops profuse watery diarrhoea, nausea, and vomiting, and viral gastroenteritides are considered. Repeat lab testing demonstrates acute liver failure with liver enzymes >400 U/L. Creatinine is elevated at 2.1 mg/dL. The patient develops severe abdominal pain and a maculopapular rash, which generalises over 2 days. The differential diagnosis is broadened to include hepatitis E and viral haemorrhagic fevers, and on illness day 5 the patient is isolated. Reverse transcriptase polymerase chain reaction (RT-PCR) returns positive for Marburg virus. On illness day 7, the patient develops anuria and hypotension with ongoing ‘wet’ symptoms. On day 10, hypotension worsens to frank circulatory shock requiring vasopressor support. He becomes progressively confused and develops a petechial rash. Liver enzymes are >10,000 U/L, D-dimer is markedly elevated, and leukocytosis of 21.4 x 10⁹ cells/L (81% neutrophil predominant) develops. On day 11, circulatory shock worsens and nursing staff note prolonged oozing of blood at venipuncture sites. Overnight from day 11 into day 12 of illness, vascular collapse occurs despite maximal pressors and the patient dies.
Case history #2
A 29-year-old miner in Angola presents to a local hospital with 3 days of fever, anorexia, chills, headache, and arthralgia. Three days after admission, he continues to be febrile and begins vomiting. The next day, he develops confusion, seizures, haematemesis, and epistaxis. On day 5 of illness he dies. His 26-year-old wife attends his burial, where she kisses and touches the face of the deceased. Eight days later, the wife also presents to the local hospital with fever, myalgia, and severe headache. She develops profound watery diarrhoea and nausea on illness day 4 and dies from dehydration, circulatory shock, and presumed disseminated intravascular coagulation on illness day 9.
Atypical presentations of Marburg virus disease can include haemoptysis or haematemesis on presentation. Children including neonates and infants may also be infected, particularly if exposed to breastmilk or other intimate contact with a person with Marburg virus disease. Presentation in pregnant women is likely to be similar to non-pregnant reproductive-aged women, though signs and symptoms could be confused with normal labour and delivery or pregnancy-related infections or bleeding.
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