SAN DIEGO – Add neurologic issues to the growing list of medical problems faced by survivors of Ebola virus.
Among 153 Liberian patients about a year out from their acute illness, “there were only a handful who didn’t have” some lingering neurologic problem. “The most commonly reported ongoing symptoms were headache and memory loss. A couple of people had seizures possibly related to Ebola.” Depression, anxiety, and posttraumatic stress disorder were common, said neurologist Jeanne Billioux, MD, a clinical fellow at the National Institute of Neurological Disorders and Stroke, Bethesda, Md.
Almost two-thirds of the patients had abnormal neurologic exams. The most common findings were tremors, pathological reflexes, mild dysmetria, and abnormalities of eye pursuits and saccades, plus nystagmus. The findings were statistically significant, compared with 81 close contacts, generally household members, who served as controls in the ongoing natural history study, which was presented at the annual meeting of the American Neurological Association.
Dr. Jeanne Billioux
“It was really surprising to me that” so many “people had abnormal neurologic exams.” For the most part, “they weren’t overtly abnormal compared to the controls, but you could tell the difference. They mentated more slowly, had issues with cranial nerves, and things like that. They couldn’t function the way they did before. We did not realize Ebola affected the CNS as much as it does,” Dr. Billioux said.
What’s become clear in the wake of the recent outbreak in West Africa, by far the worst to date with over 28,000 cases and more than 11,000 deaths, is that there is a post-Ebola syndrome that includes ophthalmologic, cardiac, and rheumatologic problems. It now appears that “neurologic sequelae are a part of it,” as well, she said.
The natural history study – dubbed the Partnership for Research on Ebola Virus in Liberia (PREVAIL III) – is a collaboration between the National Institutes of Health and the Ministry of Health of Liberia, one of the hardest-hit countries; the neurology investigation is just one component of the study, which includes about 1,500 patients overall.
Serology testing confirmed that cases truly did have Ebola, and the controls did not. After the first evaluation a year or so after the acute illness, patients have been followed up every 6 months, with some out to about 3 years.
Although patients aren’t back to normal, the good news is that their symptoms and exams are improving. “We started with only 6 who had no symptoms; now we have 15. Headaches are getting better; memory is getting better. It’s wonderful,” Dr. Billioux said.
The patients were asked to recall their acute symptoms during their first study visit. Many reported headaches, weakness, altered mental status, and cranial nerve symptoms. About 2% described convulsions or strokelike symptoms, and about 25% described symptoms consistent with meningitis.
It’s unclear how the virus affected the CNS, which isn’t considered to be a target organ. Perhaps fluid loss from severe diarrhea led to cerebral hypoperfusion. The cytokine storm during the acute phase might also have played a role. The virus has, however, been isolated from cerebral spinal fluid and, although uncommon, there are the reports of meningitis symptoms, so perhaps it does have direct CNS effects. Much remains to be learned.
Both cases and controls were a mean of about 35 years old, and evenly split between the sexes; 108 patients (70.6%) spent more than 2 weeks in an Ebola treatment unit.
The work was funded by the National Institutes of Health. Dr. Billioux had no disclosures.