Abstract
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 anti-EBOV 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.