Maternal and fetal survival following Ebola, HIV and Malaria co-infection in the first trimester of gestation in resource-limited setting in Democratic Republic of Congo.

Background: Ebola-HIV and malaria co-infection is one of the rare clinical situations that remains complex to manage even in the context of unlimited resources. In pregnancy, each of these infections can compromise maternal and fetal outcomes. The synergy of their effects on maternal immunity are often fatal, and survival is an exception, especially in a context of limited resources, such as in Ebola Treatment Units (ETUs).

Case Presentation: Our 22-year-old patient, weighing 56 kg and nine weeks pregnant was admitted to the ETU during the 10th outbreak in DRC. She had HIV and had abandoned antiretroviral treatment (ART) seven months before. One month before her admission, her HIV viral load was high with a low CD4 T cell count. She was vaccinated against EVD with rVSV-ZEBOV four days before her symptoms. She appeared generally in ill-health but her vital signs were within normal range. Without ultrasound, the fetal vitality could not be assessed. Laboratory tests confirmed malaria, pregnancy, HIV, and Ebola infection through RT-PCR. She received supportive treatment and a neutralizing monoclonal antibody (mAb114). On the 2nd day, we observed a significant decrease in Ebola viral load. Her clinical evolution improved with no disturbance in many biological parameters. She was negative for Ebola infection on 13th day and was discharged from the ETU after three weeks of admission. After referral to a health facility an ultrasound revealed 12 weeks of gestation and lab results showed a decrease of 47% in HIV viral load with 44% CD4 T cell count increase. She began ART treatment and at 38 weeks gestation, the HIV viral load was undetectable and gave birth by caesarian section to a healthy male newborn. The mother and newborn' s blood, buccal swab and adnexal samples tested negative for Ebola virus and both were discharged 10 days after the delivery.

Conclusion: In case of Ebola, HIV and malaria co-infection, maternal and fetal survival remains possible even in the context of resources limited-setting. This case raises questions about the effects of the interactions of these co-infections and/or their antibodies, treatment during immune adaptation of the gravid organism.