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Billioux BJ, Nath A, Stavale EJ, et al. Cerebrospinal Fluid Examination in Survivors of Ebola Virus Disease. JAMA Neurol. 2017;74(9):1141–1143. doi:10.1001/jamaneurol.2017.1460
With the extent of the recent Ebola virus disease (EVD) epidemic in West Africa (including >28 000 cases and ≤17 000 survivors), many aspects of Ebola virus have become clearer, including acute manifestations, sequelae, and the possibility of relapse and persistence.1 Neurologic complications are becoming more commonly recognized in EVD during the acute phase, with long-term sequelae.2-4 More remarkable, however, is the potential for persistence and relapse of EVD in the central nervous system (CNS), as in the case of a nurse who developed meningoencephalitis with seizures, cranial nerve involvement, and radiculitis 9 months after EVD recovery.5 Ebola virus was recovered from the cerebrospinal fluid (CSF) at higher levels than from the blood, indicating viral replication in the CNS.5 This case reveals the need to determine the role of the CNS as a potential reservoir for Ebola virus after initial clinical recovery.
To investigate potential Ebola virus persistence in the CNS, we undertook a systematic study of CSF samples from patients who survived EVD (hereinafter referred to as EVD survivors). Through partnership between the National Institutes of Health and Liberia’s Ministry of Health, the Partnership for Research on Ebola Virus in Liberia (PREVAIL) III Ebola natural history study is ongoing at John F. Kennedy Medical Center in Monrovia, Liberia. This study was approved by the institutional review boards of the National Institute of Allergy and Infectious Diseases and the Liberian National Research Ethics Board. All patients included in the analysis provided written informed consent.
A subset of EVD survivors (n = 165) underwent evaluation by neurologists as part of this study. Survivors who reported coma, delirium, or meningitis during acute EVD, who reported new neurologic symptoms since recovery, and who had neurologic abnormalities on examination were selected as candidates for lumbar puncture (LP). These survivors (n = 22) were informed about LP using illustrated flip charts; those who decided to proceed were screened for eligibility (n = 18). Eligibility criteria included age 18 to 60 years, positive for Ebola virus antibody, no new neurologic findings at time of LP, negative for human immunodeficiency virus antibody, no recent seizure or head trauma, no use of nonsteroidal anti-inflammatory drugs, no papilledema, and normal results of coagulation studies.
For patients who met criteria and signed informed consent (n = 8), LPs were performed in standard fashion by operators in full personal protective equipment (B.J.B., J.D., and B.R.S.). Samples were collected from December 15 to 18, 2015. Each LP sample collected included 15 to 20 mL of CSF. Fluid was analyzed for Ebola viral RNA by reverse transcriptase–polymerase chain reaction (RT-PCR) at the Liberian Institute for Biomedical Research laboratory. The RT-PCR systems used to detect nucleoprotein and glycoprotein gene targets included ABI 7500 (Applied Biosystems) and GeneXpert IV (Cepheid); the level of detection for the GeneXpert assay is 232 copies/mL.6 The CSF cell count was assessed using a hemocytometer. Glucose and protein levels were measured using a semiautomated clinical chemistry analyzer (Excel; Stanbio Laboratory).
We collected CSF samples from 7 participants (5 men and 2 women; mean [SD] age, 34.9 [12.0] years). Median time from discharge from the Ebola treatment unit was 414 days (range, 364-459 days). No Ebola viral RNA was detected in the 7 CSF samples by either RT-PCR assay. Furthermore, all samples had protein and glucose levels and white blood cell counts within reference range, although 1 patient had borderline elevation of protein levels. Another patient had red blood cells in the CSF due to a traumatic LP (Table).
Few reports exist of CSF studies during or after Ebola virus infection.2,3,5 This study represents the first systematic evaluation of CSF in EVD survivors. The CSF from all 7 patients undergoing analysis was negative for Ebola viral RNA and showed no signs of inflammation; however, this finding could be related to the relatively long period from resolution of acute EVD to performance of LP. Alternately, if Ebola virus is dormant in the CNS of EVD survivors and is cell associated, it may not be released into CSF. Any release of virus from reservoirs into the CSF would be expected to cause acute meningoencephalitis. Thus, EVD survivors should be monitored for neurologic symptoms suggestive of EVD relapse in the CNS because of the potential for Ebola virus transmission during relapse.
Corresponding Author: Avindra Nath, MD, Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, National Institutes of Health, 10 Center Dr, Bldg 10, Room 7C-103, Bethesda, MD 20892 (firstname.lastname@example.org).
Accepted for Publication: May 12, 2017.
Published Online: July 17, 2017. doi:10.1001/jamaneurol.2017.1460
Author Contributions: Drs Billioux and Smith had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Billioux, Nath, Sneller, Smith.
Acquisition, analysis, or interpretation of data: Billioux, Nath, Dorbor, Stavale, Smith.
Drafting of the manuscript: Billioux, Nath, Smith.
Critical revision of the manuscript for important intellectual content: Billioux, Nath, Stavale, Dorbor, Sneller, Smith.
Obtained funding: Nath, Sneller.
Administrative, technical, or material support: Billioux, Nath, Stavale, Smith.
Study supervision: Nath, Sneller, Smith.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by the intramural programs of the National Institute of Allergy and Infectious Diseases (NIAID) and the National Institute of Neurological Disorders and Stroke, National Institutes of Health (NIH).
Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Group Information: Members of the Partnership for Research on Ebola Virus in Liberia (PREVAIL) III Study Group include the following: Deborah Wentworth, MPH, of the University of Minnesota, Minneapolis, aided with acquisition and analysis of the data; Helen Tarfeh-Burnette, PA, of John F. Kennedy (JFK) Medical Center, Monrovia, Liberia, contributed to acquisition and analysis of data; Lisa Hensley, PhD, of the Integrated Research Facility, NIAID, NIH, Ft Detrick, Maryland, contributed to acquisition and analysis of data; and Elizabeth Higgs, MD, of the NIAID, NIH, Bethesda, Maryland, contributed to the conception and design of the study.
Additional Contributions: Wissedi Njoh, MSN, Sara Albert, MPH, Patricia Boison, MS, Jestina Doe Anderson, PhD, Joseph Meyer, BFA, and Nikki Gettinger, MPH, Leidos Biomedical Research, Frederick National Laboratory for Cancer Research, Frederick, Maryland; Victor Doolakeh Taryor, MPA, PREVAIL Site Manager, JFK Medical Center, Monrovia, Liberia; Mary Smolskis, RN, MA, Division of Clinical Research, NIAID, NIH, Rockville, Maryland; and Marie Hoover, PhD, Advanced Biomedical Laboratories, Riverton, New Jersey, helped with the logistical details for this study. James Pettitt, MS, and Gene Olinger, PhD, Integrated Research Facility, NIAID, NIH, Ft Detrick, Maryland, helped to implement the assays used in the Liberian Institute for Biomedical Research laboratory. These individuals were compensated for their work on the project through their employers. We thank the patients in the PREVAIL Neurology cohort, particularly those patients in this study, and the many contributors of the PREVAIL III study.