Investigations

1st investigations to order

reverse transcriptase-polymerase chain reaction (RT-PCR)

Test
Result
Test

Should be ordered in all patients with suspected Ebola infection while the patient is in isolation. [94]

Returns result 24 to 48 hours before ELISA testing.

Several different commercial PCR kits are available with varying sensitivity, specificity, and limits of detection. [95]

In Western settings, the test may only be available in regional or national laboratories that have category 4 facilities. [10] In epidemic settings and some countries, category 4 laboratories are set up locally and results are available 4 hours after the sample has arrived.

Viral RNA can be detected in the patient’s blood by RT-PCR from day 3 up to days 6 to 17 of symptom onset. A positive PCR result implies that the patient is potentially infective, particularly if he or she has active diarrhea, vomiting, or bleeding.

If negative, the test should be repeated within 48 hours since viral load is low and can be undetectable early in the course of the illness. Negative tests should be repeated to rule out a diagnosis if it is strongly suspected (or confirm resolution of infection). [94]

Higher viral load correlates with adverse outcome and increased mortality. [20] [21] [22] [65] [79] [94] [96]

Result

positive for Ebola virus RNA

malaria investigations

Test
Result
Test

Giemsa-stained thick and thin blood smears and rapid diagnostic tests are the tests of choice for malaria screening.

A negative result makes Ebola virus infection more likely in the appropriate epidemiological context; however, coinfection with malaria was seen in up to 5% of patients in West Africa during the 2014 outbreak, so the possibility of dual infection should be considered in all patients. [79]

Result

negative (may be positive if dual infection)

Investigations to consider

serum electrolyte levels

Test
Result
Test

Important test to order (if available) in areas where other investigations are limited.

May indicate acute kidney injury. [98]

Especially useful in patients with diarrhea and vomiting.

Hypokalemia or hyperkalemia, due to vomiting and diarrhea or acute kidney injury, was seen in approximately 33% of cases in the 2014 outbreak. [79]

Hypocalcemia has been associated with fatal infection. [16]

Useful to guide correction of electrolytes and fluid replacement.

Result

may be abnormal

BUN/serum creatinine

Test
Result
Test

Important test to order (if available) in areas where other investigations are limited.

May indicate acute kidney injury, which was common in the 2014 outbreak, [22] [98] and was associated with death. [79]

Especially useful in patients with diarrhea and vomiting.

Result

may be elevated

blood lactate

Test
Result
Test

Important test to order (if available) in areas where other investigations are limited.

Elevated lactate is a marker of tissue hypoperfusion and is an indicator of shock. It is useful in acutely ill patients with signs of sepsis to identify the degree of systemic hypoperfusion and to guide fluid resuscitation. [99]

Elevated lactate was one indicator of gram-negative sepsis at day 15 in a patient treated in Germany. [41]

Result

variable

ABG

Test
Result
Test

Arterial or venous blood pH and bicarbonate are useful in acutely ill patients with signs of sepsis to identify the degree of systemic hypoperfusion and guide fluid resuscitation. [99]

Result

variable

CBC

Test
Result
Test

Decrease in platelet count and marked lymphopenia can be seen in the initial stages of infection; however, this is not diagnostic. Often followed by neutrophil leukocytosis in the later stages of patients who eventually recover, along with normalization of thrombocytopenia. Leukocytosis may persist and show immature forms. [16]

Patients with severe disease may show a progressive decline in platelet count as a manifestation of disseminated intravascular coagulation (DIC).

Decreased hemoglobin levels were reported in 24% of patients in the 2014 outbreak, [79] and have been associated with bleeding in previous outbreaks. [16]

Result

thrombocytopenia, marked lymphopenia; decreased hemoglobin (if bleeding manifestations)

coagulation studies

Test
Result
Test

Prolonged prothrombin time (PT) or activated partial thromboplastin time (aPTT) is associated with more severe infection and bleeding manifestations such as DIC.

Patients with fatal infection have been found to have D-dimer levels four-fold higher on days 6 to 8 of infection compared with patients who survive. [100]

Result

prolonged PT or aPTT, elevated D-dimer level (if bleeding manifestations)

urinalysis

Test
Result
Test

Hematuria or proteinuria may be seen in severe disease. [16]

Oliguria that does not respond to fluid resuscitation is a poor prognostic sign.

Result

may show hematuria or proteinuria

LFTs

Test
Result
Test

Both ALT and AST are usually elevated; however, most studies show that AST rises out of proportion to ALT, and this is more suggestive of systemic tissue damage rather than hepatocellular injury. [79]

AST:ALT ratio peaked at 15:1 on days 6 to 8 of infection in fatal cases when compared with nonfatal cases, which had a peak of 5:1. [8] [16] [100]

Bilirubin, GGT, and ALP are often slightly elevated. Highly elevated ALT and severe jaundice suggests an alternative diagnosis (e.g., viral hepatitis).

Result

high AST:ALT ratio; bilirubin, GGT, and ALP may be slightly elevated

serum amylase level

Test
Result
Test

Elevated levels have been reported in several studies and indicates the presence of pancreatitis, an indicator of severe infection. [16]

Result

may be elevated

serum blood glucose

Test
Result
Test

Hypoglycemia may be present in adults, but it is not commonly reported. [22] However, it is common in children and may be severe. It is a potentially reversible cause of confusion. [87] [88]

Result

may be low

blood cultures

Test
Result
Test

Negative blood cultures are helpful as they rule out other nonviral infectious causes (e.g., sepsis, enteric fever).

Gram-negative bacteremia, presumably from gut translocation, has been identified as a complication of the disease course in two patients. [101] [41] However, a study in Sierra Leone where blood cultures were taken from patients on admission to an Ebola treatment center found that only one of the 22 cultures was positive with a presumed contaminant. [102]

Therefore, blood should be collected for culture at baseline and/or at the time of the onset of gastrointestinal symptoms or other clinical deterioration.

Result

negative

antigen-capture enzyme-linked immunosorbent assay (ELISA)

Test
Result
Test

Useful diagnostic test with high specificity; however, it is not universally available. Can be used to confirm the diagnosis along with a positive RT-PCR result.

Most likely to give a positive result from day 3 until day 6 of infection, and can give widely variable results from days 7 to 16. [46]

Result

positive for Ebola virus antibodies

IgM and IgG antibodies

Test
Result
Test

Useful in later stages of the infection.

IgM antibodies can appear in serum as early as day 2 post infection, but can give variable results up to day 9. They become negative between 30 and 168 days after symptom onset. IgG response develops between day 6 and 18 and can persist for several years. [46]

A positive IgM or a rising IgG titer is strong evidence for recent Ebola virus infection.

Result

positive

CXR

Test
Result
Test

Useful in patients with respiratory symptoms.

Pulmonary infiltrates are not typical of infection and suggest an alternative (or comorbid) diagnosis.

May be difficult to arrange in an isolation unit and should only be ordered judiciously to avoid contamination. [103]

Result

negative

Emerging tests

rapid bedside tests

Test
Result
Test

Rapid PCR testing for Ebola virus infection remains a major hurdle for effective, targeted isolation of affected patients. Current tests take an average of 4 hours to perform with a fully equipped laboratory close at hand, but results may take several days to arrive in remote areas. This means that, until they are confirmed negative, patients with febrile illnesses other than Ebola virus infection are confined to isolation and often unwittingly exposed to the virus.

Rapid bedside tests can therefore make a very significant contribution to infection control in treatment centers.

Several different technologies are being evaluated by WHO for use in field conditions. These include numerous RT-PCR-based assays that have been made simpler to use with a shorter turnaround time of <1 hour. The WHO has listed ReEBOV™ Antigen Rapid Test Kit for potential use; however, it currently only recommends its use in special situations. World Health Organization (WHO): interim guidance on the use of rapid Ebola antigen detection tests

The alternatives are ELISA-based antigen-detection assays that could be quicker and simpler with the possible advantage of only needing a drop of blood. Their major disadvantage is a reduced sensitivity, particularly in the initial stages of illness. [104]

Nanopore technology may allow rapid detection and sequencing in the presence of very low levels of virus, and can potentially be deployed using a pocket-sized detection kit. [106] [107] [108]

A GeneXpert® diagnostic tool (Xpert® Ebola) has been trialled in the field, and is an automated cartridge-based system that requires minimal laboratory skill. An inactivated sample is placed into a single-use cartridge, which is then entered into the enclosed machine. Sample preparation, nucleic acid amplification and detection, and production of a result are automated processes minimizing staff training requirements, risk of infection, and cross contamination. [109] This test was used in the field during the 2018 outbreak in the Democratic Republic of the Congo.

The Food and Drug Administration has approved a rapid, single-use test for the detection of Zaire ebolavirus . It is the second rapid antigen fingerstick test available under an emergency use authorization, but is the first that uses a portable battery-operated reader which can provide results outside of laboratories. [111]

This is a rapidly evolving field and different kits are approved according to the country and settings in which they are to be deployed. Food and Drug Administration (FDA) and WHO recommendations are available: Food and Drug Administration (FDA): 2014 Ebola virus emergency use authorizations World Health Organization (WHO): Ebola vaccines, therapies, and diagnostics

Result

positive for Ebola virus

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