History and exam

Key diagnostic factors

common

exposure to Marburg virus in previous 21 days

Human-to-human transmission occurs via contact with body fluids (e.g., sweat, blood, faeces, vomit, saliva, genital secretions [including semen], and breast milk) from infected patients. Virus levels in these fluids are particularly high in more severe or advanced infection. The incubation period after infection is typically 5 to 10 days.[1][9][10]

Body fluids remain infectious even after death. As a consequence, transmission of infection may occur at traditional funeral services in Africa where mourners touch the bodies of the deceased or through washing of clothes or linens soiled with body fluids from an infected individual.[2][9]

Marburg virus can still be detected in semen up to 7 weeks after recovery from infection, possibly due to testicular tissue being an immunologically protected site.[2] Presence of filovirus in semen means that sexual transmission may be possible even after the infection has resolved.

People living or working in endemic areas (e.g., Central or East Africa) are at potentially high risk of infection, especially if exposed to caves or mines inhabited by African fruit bats. Recent arrival from endemic areas is also a significant risk factor, in particular if there is a history of visiting caves, mines, or burials. Most patients with suspected infection in developed countries will be returning travellers or healthcare workers who have cared for patients during outbreaks.

fever

Presenting symptom in most patients, its presence is enough to raise concern for infection in the appropriate epidemiological context. Wide variations in body temperature can be observed during the course of illness with normothermia or hypothermia occurring in the later stages of fatal infection. High fever (>40°C [104°F]) is common.[9][10]

myalgia

Common feature of infection.

May be associated with arthralgia and persist through convalescence.

malaise

Feeling generally unwell is a common feature of infection and may persist through convalescence.

Other diagnostic factors

common

fatigue

Severe tiredness and lethargy is a common feature of infection.

diarrhoea

Common feature of infection. May be bloody.

Cholera beds may be used for cases of profuse diarrhoea in undeveloped countries.[9][Figure caption and citation for the preceding image starts]: Cholera beds with central hole in mattress to manage patients with profuse diarrhoea at an Ebola treatment centre in West Africa, 2014From the personal collection of Catherine F. Houlihan, MSc, MB ChB, MRCP, DTMH; used with permission [Citation ends].com.bmj.content.model.Caption@4dd27237

nausea/vomiting

Common feature of infection. May contain blood.[9]

severe headache

Non-specific feature of early infection. Meningismus has rarely been observed and other neurological symptoms including confusion indicate late infection.[9]

abdominal pain

Non-specific feature of infection at any phase of illness.[9]

sore throat

Pharyngitis is a non-specific feature, it may cause dysphagia.

prostration

Profound prostration is a typical finding in late disease.

maculopapular rash

In the 1967 outbreak a non-itchy rash occurred in most patients between day 2 and day 7.[2][9]

conjunctivitis

Common in the generalisation phase of illness, days 2 to 7.[9]

hiccups

Common during a previous outbreak in the Democratic Republic of Congo.[31]

difficulty breathing

Common during a previous outbreak in the Democratic Republic of Congo.[31]

anorexia

Non-specific feature of the illness at any phase.[9]

uncommon

bleeding

Presence suggests late-stage disease and presence of disseminated intravascular coagulation.

Bleeding manifestations include epistaxis, bleeding gums, haemoptysis, easy bruising, conjunctival bleeding, haematuria, vaginal bleeding, oozing from injection or venipuncture sites.

Massive bleeding is usually only observed in fatal cases and typically occurs in the gastrointestinal tract (e.g., melaena, bloody diarrhoea).[10]

Internal bleeding may be missed if there are no external signs.

tachycardia

May be seen in the later stages of infection.[10]

hypotension

Hypotension is a feature of dehydration and shock and usually occurs in late-stage disease. It is under-documented in field studies owing to a lack of measuring equipment in endemic areas.[10] However, septic shock with vascular leakage and microcirculatory failure does not appear to be a dominant feature, although many features are similar to sepsis.

neurological signs

Confusion, delirium, and encephalitis are associated with late infection and are predictors of death.[9]

Often coexist with bleeding and hypotension making fluid resuscitation hazardous.

Encephalopathy is possibly related to electrolyte disturbances, uraemia, and cerebral hypoperfuson in terminal infection.

petechiae

Presence suggests late-stage disease and presence of disseminated intravascular coagulation.[9]

Risk factors

strong

living or working in, or arrival from, endemic area in previous 21 days

People living or working in endemic areas (e.g., Central and East Africa) are at potentially high risk of infection, especially if exposed to caves or mines inhabited by African fruit bats. Recent arrival from endemic areas is also a significant risk factor, in particular if there is a history of visiting caves, mines, or burials. Most patients with suspected infection in developed countries will be returning travellers or healthcare workers who have cared for patients during outbreaks.

contact with infected body fluids

Human-to-human transmission occurs via contact with body fluids (e.g., sweat, blood, faeces, vomit, saliva, genital secretions [including semen], and breast milk) from infected patients. Virus levels in these fluids are particularly high in more severe or advanced infection. The incubation period after infection is typically 5 to 10 days.[1][9][10]

Body fluids remain infectious even after death. As a consequence, transmission of infection may occur at traditional funeral services in Africa where mourners touch the bodies of the deceased or through washing clothes or linens soiled with body fluids of the deceased.[2][9]

Marburg virus can still be detected in semen up to 7 weeks after recovery from infection, possibly due to testicular tissue being an immunologically protected site.[2] Presence of filovirus in semen means that sexual transmission may be possible even after the infection has resolved.

occupational exposure

Healthcare workers in contact with infected patients are at high risk.

Needlestick injuries from an infected donor are a very high-risk exposure depending on the inoculum and nature of the injury, and may be associated with more severe disease. The incubation periods in such cases may be considerably shorter compared with human-to-human transmission.[2]

Other high-risk occupations include mining in endemic areas and laboratory or field work with primates or bats from endemic areas, or with high-risk clinical samples.

weak

bioterrorism

Marburg virus has long been considered a potential bioterrorism weapon due to its high case fatality rate and the ease of human-to-human transmission. However, despite its potential, there is no evidence that the Marburg virus has been used as a weapon.

Use of this content is subject to our disclaimer