On October 2, the day of Patient 2's death, contact tracing revealed that an ICU nurse (Patient 3) who cared for Patient 1 was admitted to a private hospital west of Johannesburg, close to her family home. Patient 3 was a 34 year old black female who became ill on September 25 (ID-1), nine days after caring for Patient 1 (a previous publication on this outbreak erroneously cites this patient's first day of illness as September 23). She was primarily involved in turning and cleaning Patient 1, including washing the corpse and removing the dialysis catheter after her death. Infection control precautions in the care of Patient 1 included providing care in an isolation room and wearing of surgical gowns, latex gloves, surgical masks, and plastic visors. No needle stick injuries or splashes of blood or bodily fluids were reported.
Patient 3's illness began with headache and myalgia followed by sore throat, high fever, and rigors on ID-5. Oral amoxicillin and antipyretics were started by her general practitioner. Worsening headache and fever prompted hospitalization and isolation on ID-6, where nausea, abdominal cramps, non-bloody vomiting, and dysphagia were reported and a fine, macular rash noted on her trunk. (NB: Although Paweska et al. reported that no rash was seen in the black patients with LHF, subsequent review of the treating physician's notes confirmed that a rash was indeed seen in this patient.) Clinical laboratory testing on admission was limited but demonstrated thrombocytopenia (78,000/microL) and normal transaminases (AST 18 IU/L, ALT 24 IU/L). Renal function was normal. Initial therapy consisted of IV fluids and ceftriaxone, fluconazole, and omeprazole.
The patient's condition worsened on ID-7 with non-bloody diarrhea, worsening rash, and peri-orbital and facial swelling. Sub-conjunctival hemorrhage was noted. Clinical laboratory analysis showed leukocytosis (13,000/microL), worsening thrombocytopenia (38.000/microL), and drastic elevations of liver enzymes (AST 2,182 IU/L; ALT 748 IU/L; LDH 3,421 IU/L). The quantitative D-Dimer was markedly elevated(>10.0 ug/l). Oral ribavirin (1,800 mg loading dose followed by 800 mg q8 hours) and IV gancyclovir (5 mg/kg q12 hr) were begun, the latter to cover the possibility of disseminated herpes virus infection. Nevertheless, the patient's condition worsened on ID-9, with continued diarrhea and facial edema, progressive mental obtundation, thrombocytopenia (47,000/microL) and persistently elevated transaminases (AST 2,486 IU/L; ALT 804 IU/L). A decision not to institute intensive care was taken collectively by the Provincial outbreak investigators given the circumstances at the time and the facilities available at the hospital. The patient became comatose and died on ID-10.