What are the symptoms and treatment options for a patient suspected of having Nipah virus infection?

Nipah Virus: Symptoms and Treatment

Clinical Presentation

Nipah virus infection presents with fever (80% of cases), myalgia, headache, and shortness of breath, rapidly progressing to altered mental status and acute respiratory distress syndrome, with a mortality rate of 73.9%. 1

Common Symptoms

• Fever is the most frequent presenting symptom, occurring in 80% of cases 1
• Myalgia and headache each occur in approximately 47% of patients 1
• Respiratory manifestations including shortness of breath and acute respiratory distress syndrome affect 44.1% of patients 1
• Neurological symptoms including altered sensorium (44.1%), seizures (39.2%), and encephalitis are hallmark features 1
• Gastrointestinal symptoms such as vomiting occur in 42.6% of cases 1

Neurological Complications

• Myoclonic jerks with characteristic 1:1 relationship to EEG periodic complexes indicate severe CNS involvement 2
• Dystonia, areflexia, and hypotonia are additional poor prognostic neurological signs 2
• Long-term sequelae including relapsing encephalitis may occur in survivors 3

Treatment Approach

The cornerstone of Nipah virus management is intensive supportive care, as there are no FDA-approved antiviral therapies, though ribavirin can be considered as investigational therapy based on Infectious Diseases Society of America guidelines. 3

Primary Treatment Strategy

• Intensive supportive care focusing on maintaining vital organ function and managing complications is the mainstay of treatment 3, 4, 5
• Ribavirin can be considered as investigational therapy (C-III recommendation) for Nipah virus encephalitis, though evidence for efficacy remains limited 3, 2
• No licensed treatments exist for human use against Nipah virus, making prevention and supportive care critical 4, 5

Respiratory Management Protocol

Early intubation with invasive mechanical ventilation is recommended for severe hypoxemia rather than prolonged trials of non-invasive ventilation, as delays worsen outcomes and increase risk to healthcare workers. 2

Stepwise Approach:

1. Initial oxygen therapy: Start with standard oxygen via nasal cannula or mask, titrating to maintain SpO2 >90-96% 3
2. Escalation if needed: Consider high-flow nasal oxygen (HFNO) or non-invasive ventilation (NIV) with close monitoring if respiratory distress persists 3
3. Early intubation: Proceed to endotracheal intubation and invasive mechanical ventilation within 1-2 hours if no improvement occurs 3, 2
4. Lung-protective ventilation: Use tidal volumes of 4-6 mL/kg predicted body weight and plateau pressures <30 cmH2O if ARDS develops 3

Critical Pitfall to Avoid:

• Do not delay intubation by attempting prolonged trials of non-invasive ventilation—this increases mortality and puts staff at risk during emergency intubation 2
• If NIV or HFNO is attempted, it must be done in an ICU setting with strict airborne precautions, proper interface fitting, and a low threshold for proceeding to intubation 2

Neurological Management

• Aggressive anticonvulsant therapy is required for myoclonic seizures and status epilepticus 2
• Continuous EEG monitoring to detect subclinical seizure activity 2
• Manage increased intracranial pressure with standard critical care protocols 3

Critical Care Monitoring

Continuous monitoring with preparedness for urgent intubation is essential, as treatment failure rates with non-invasive ventilation are high in severe viral infections. 2

Essential Parameters:

• Vital signs: Continuously monitor heart rate, respiratory rate, blood pressure, and pulse oximetry 3, 2
• Neurological status: Assess frequently for declining consciousness, seizures, or focal neurological deficits 3, 2
• Organ function: Monitor water-electrolyte balance, acid-base balance, and organ function continuously 2
• Complications: Watch for ARDS, septic shock, stress ulcers, and deep vein thrombosis 2

Nutritional and Psychological Support

• Nutritional support: Provide high-protein, high-vitamin diets for patients who can tolerate oral intake 2
• Enteral nutrition: Initiate as soon as possible in critically ill patients; if not feasible, start parenteral nutrition promptly 2
• Psychological care: Provide mindfulness-based stress reduction and positive encouragement to relieve anxiety and panic 2

Infection Control Measures

• Airborne precautions: Healthcare workers must use N-95 respirators, gowns, aprons, and face shields when caring for suspected or confirmed cases 2
• Person-to-person transmission occurs in approximately 50% of cases, making strict infection control critical 2, 6

Diagnostic Approach

• RT-PCR is the most commonly used diagnostic test (45.5% of cases) 1
• Herpes simplex PCR should be performed on all CSF specimens to rule out treatable causes of encephalitis 2
• Contact CDC Special Pathogens Branch for guidance on case management and diagnostic testing 3

Prognosis

• Mortality rate is 73.9%, with case fatality rates ranging from 40% to 75% in documented outbreaks 1, 5
• Survivors may have long-term neurological sequelae or relapsing encephalitis 3
• Do not discharge patients without comprehensive follow-up plans, as neurological sequelae may emerge later 2