Pediatric and Developmental Pathology 18, 84, 2015 DOI: 10.2350/14-11-1569-LET.1 ª 2015 Society for Pediatric Pathology
LETTER TO THE EDITOR
Ebolavirus Hemorrhagic Fever and the Obstetric Patient To the Editor, Ebola virus (EBOV) and Marburg virus (MARV) constitute the family Filoviridae that are enveloped, nonsegmented, negative-stranded RNA viruses of varying morphology. They are markedly contagious and fatal in close to 90% of cases in Africa. Although all of the past outbreaks of EBOV have been in West Africa, affecting Guinea, Liberia, Sierra Leone, and Nigeria, and most outbreaks of MARV have been in Africa as well, due to ease of travel of individuals over long distances and other factors, in the United States and Western Europe we have started to see cases of Ebola hemorrhagic fever (EHF) and have experienced mortality. Pathology traditionally has had a critical role in the discovery and advancement of our knowledge of emerging infectious diseases [1]. Autopsies can determine the pathologic features of the disease, help identify the causative pathogen, and provide new insights into the pathogenesis of these infections [1]. The number of human tissue studies in EHF have been very limited due biosafety concerns, occurrence of the disease in remote areas with very limited facilities, sporadic and unpredictable nature of the outbreaks, and poor EBOV surveillance. The use and significance of tissue studies, such as routine histological techniques, immunohistochemical staining, and ultrastructural studies, are explained and illustrated in a recent publication by the Centers for Disease Control (CDC) [1]. The mortality rates of females are much higher than for the males in the EHF outbreaks including the current one [2]. The virus also is thought to cause miscarriages, stillbirths, and neonatal demise shortly after birth [2,3]. Nevertheless, to date, CDC recommendations have been silent about the procedures for handling pregnant women with suspected or proven EHF [4]. Procedures for the pathologic examination of the placentas, stillborns, and tissues from products of conception have not been addressed. Although EBOV and MARV are highly virulent and are classified as Biosafety Level (BSL) 4 pathogens, standard precautions for infection control, as outlined by the CDC should be sufficient to enable safe handling during a postmortem examination performed in a stillborn, an examination of placental tissue or tissue obtained from a miscarriage [5]. One of the main factors that make these
procedures less hazardous is the virus’ complete inactivation when exposed to 10% formalin. A recent review describing how to care for the obstetric patient with proven or suspected EBOV also has omitted this topic and does not mention the autopsy and histopathologic examination of obstetric tissues [3]. Since in the absence of a sufficient blood sample, the only other way to diagnose an EHF definitively is to use immunohistochemical staining in the diseased tissues using antiEBOV antibodies, the pathologists should speak up about this very pertinent omission and, as they have traditionally done in the past, fulfill their responsibility and process these tissues, and use every tool in their possession to make a definitive diagnosis of this fatal viral infection. HALIT PINAR* Division of Perinatal and Pediatric Pathology, Women and Infants Hospital, Alpert School of Medicine at Brown University, Providence, Rhode Island, USA ROBERT L. GOLDENBERG Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, New York, USA *Corresponding author, e-mail: [email protected] REFERENCES 1. Martines RB, Ng DL, Greer PW, Rollin PE, Zaki SR. Tissue and cellular tropism, pathology and pathogenesis of Ebola and Marburg Viruses. J Pathol 2015;235:153–174. 2. Finnegan LP, Sheffield J, Sanghvi H, Anker M. Infectious diseases and maternal morbidity and mortality [conference summary]. Emerg Infect Dis 2004;10:e17. 3. Jamieson DJ, Uyeki TM, Callaghan WM, Meaney-Delman D, Rasmussen SA. What obstetrician-gynecologists should know about ebola: a perspective from the centers for disease control and prevention. Obstet Gynecol. 2014;124:1005–1010. 4. Centers for Disease Control and Prevention. Guidance for Safe Handling of Human Remains of Ebola Patients in US Hospitals and Mortuaries. Available at: http://www.cdc.gov/vhf/ebola/hcp/ guidance-safe-handling-human-remains-ebola-patients-us-hospitalsmortuaries.html. Accessed October 26, 2014. 5. Centers for Disease Control and Prevention. Interim Guidance for Specimen Collection, Transport, Testing, and Submission for Persons under Investigation for Ebola Virus Disease in the United States. Available at: http://www.cdc.gov/vhf/ebola/hcp/interim-guidancespecimen-collection-submission-patients-suspected-infection-ebola. html. Accessed October 26, 2014. Published online December 1, 2014.
LETTER TO THE EDITOR
Ebolavirus Hemorrhagic Fever and the Obstetric Patient To the Editor, Ebola virus (EBOV) and Marburg virus (MARV) constitute the family Filoviridae that are enveloped, nonsegmented, negative-stranded RNA viruses of varying morphology. They are markedly contagious and fatal in close to 90% of cases in Africa. Although all of the past outbreaks of EBOV have been in West Africa, affecting Guinea, Liberia, Sierra Leone, and Nigeria, and most outbreaks of MARV have been in Africa as well, due to ease of travel of individuals over long distances and other factors, in the United States and Western Europe we have started to see cases of Ebola hemorrhagic fever (EHF) and have experienced mortality. Pathology traditionally has had a critical role in the discovery and advancement of our knowledge of emerging infectious diseases [1]. Autopsies can determine the pathologic features of the disease, help identify the causative pathogen, and provide new insights into the pathogenesis of these infections [1]. The number of human tissue studies in EHF have been very limited due biosafety concerns, occurrence of the disease in remote areas with very limited facilities, sporadic and unpredictable nature of the outbreaks, and poor EBOV surveillance. The use and significance of tissue studies, such as routine histological techniques, immunohistochemical staining, and ultrastructural studies, are explained and illustrated in a recent publication by the Centers for Disease Control (CDC) [1]. The mortality rates of females are much higher than for the males in the EHF outbreaks including the current one [2]. The virus also is thought to cause miscarriages, stillbirths, and neonatal demise shortly after birth [2,3]. Nevertheless, to date, CDC recommendations have been silent about the procedures for handling pregnant women with suspected or proven EHF [4]. Procedures for the pathologic examination of the placentas, stillborns, and tissues from products of conception have not been addressed. Although EBOV and MARV are highly virulent and are classified as Biosafety Level (BSL) 4 pathogens, standard precautions for infection control, as outlined by the CDC should be sufficient to enable safe handling during a postmortem examination performed in a stillborn, an examination of placental tissue or tissue obtained from a miscarriage [5]. One of the main factors that make these
procedures less hazardous is the virus’ complete inactivation when exposed to 10% formalin. A recent review describing how to care for the obstetric patient with proven or suspected EBOV also has omitted this topic and does not mention the autopsy and histopathologic examination of obstetric tissues [3]. Since in the absence of a sufficient blood sample, the only other way to diagnose an EHF definitively is to use immunohistochemical staining in the diseased tissues using antiEBOV antibodies, the pathologists should speak up about this very pertinent omission and, as they have traditionally done in the past, fulfill their responsibility and process these tissues, and use every tool in their possession to make a definitive diagnosis of this fatal viral infection. HALIT PINAR* Division of Perinatal and Pediatric Pathology, Women and Infants Hospital, Alpert School of Medicine at Brown University, Providence, Rhode Island, USA ROBERT L. GOLDENBERG Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, New York, USA *Corresponding author, e-mail: [email protected] REFERENCES 1. Martines RB, Ng DL, Greer PW, Rollin PE, Zaki SR. Tissue and cellular tropism, pathology and pathogenesis of Ebola and Marburg Viruses. J Pathol 2015;235:153–174. 2. Finnegan LP, Sheffield J, Sanghvi H, Anker M. Infectious diseases and maternal morbidity and mortality [conference summary]. Emerg Infect Dis 2004;10:e17. 3. Jamieson DJ, Uyeki TM, Callaghan WM, Meaney-Delman D, Rasmussen SA. What obstetrician-gynecologists should know about ebola: a perspective from the centers for disease control and prevention. Obstet Gynecol. 2014;124:1005–1010. 4. Centers for Disease Control and Prevention. Guidance for Safe Handling of Human Remains of Ebola Patients in US Hospitals and Mortuaries. Available at: http://www.cdc.gov/vhf/ebola/hcp/ guidance-safe-handling-human-remains-ebola-patients-us-hospitalsmortuaries.html. Accessed October 26, 2014. 5. Centers for Disease Control and Prevention. Interim Guidance for Specimen Collection, Transport, Testing, and Submission for Persons under Investigation for Ebola Virus Disease in the United States. Available at: http://www.cdc.gov/vhf/ebola/hcp/interim-guidancespecimen-collection-submission-patients-suspected-infection-ebola. html. Accessed October 26, 2014. Published online December 1, 2014.
