SUAKOKO, Liberia — Soon after he lost his parents to Ebola, Junior Samuel, 8, slumped in a plastic chair inside a treatment center here, listless, feverish and racked with aches. Within a day, he began bleeding from his gums, a particularly ominous sign.
“The kid’s very sick,” Elvis Ogweno, the ambulance supervisor, told a triage nurse when he brought the child in. “There’s no one to take care of him.”
Ten days later, 9-year-old Rancy Willie, who had just lost his mother, inched out of a pickup truck in the driveway. Weak, hot with fever and barely able to swallow after lying outdoors for more than a day while awaiting help, he, too, would soon begin bleeding.
The boys became roommates at the treatment center, run by the American charity International Medical Corps. They received essentially the same care. But one boy died hours before the other one went home, having recovered. And the fate of a third boy, 5-year-old Williams Beyan, remained unclear.
Over and over, doctors here have been confounded by the divergent paths of patients whose cases appeared similar at first. “No matter how long we were there, we didn’t know how to predict it,” said Dr. Steve Whiteley, a California emergency physician who volunteered.
They say they have been especially baffled by what Dr. Whiteley called the “light bulb” phenomenon — a patient who appeared to get better, then suddenly died. Wondering why the boys had different outcomes, the physicians asked: Were the children battling different levels of the virus early on? Did one start out healthier? Could their genes or immune systems have helped determine their fate? And what could health workers do to improve children’s chances?
The answers are hard to come by. In the absence of much lab testing and research, the disease seems heartbreakingly random.
A study published last month in the journal Emerging Infectious Diseases showed that children who survived a previous outbreak tended to have higher blood levels of an immune system activator, and those who died tended to have higher levels of substances that indicated dysfunction of the cells lining blood vessels, which can lead to organ failure. Among adults, the amounts of those proteins were not associated with either survival or death.
“Kids are not adults,” said Dr. Anita McElroy, an assistant professor at Emory University School of Medicine and one of the authors of the study. “They really are different in how they respond to this virus.”
The researchers speculated that children might benefit from certain treatments — perhaps including statin drugs, which act on those cells lining blood vessels — but those possible remedies had not been studied in humans with Ebola and there was a chance that they could worsen outcomes.
As in previous, smaller outbreaks, children are underrepresented among Ebola patients in the current epidemic. According to the World Health Organization, those under 15 made up 13 percent of cases in the epidemic’s first nine months, though they accounted for about 43 percent of the population. They may be less exposed to major risk factors, such as caring for sick relatives or preparing bodies for burial.
At the center here, half of the children under 15 have survived, a rate slightly, but not significantly, higher than that of patients over all. Sixteen children in that age group have been discharged or have died since the center opened in mid-September, after being built by the charity Save the Children. Seven are now being treated, as a recent surge in patients has filled the 26-bed confirmed ward to capacity.
Junior, who weighed 44 pounds, seemed very ill at admission. He had no relatives to take care of him, and staff members, sweltering in their protective suits, could not always stay long enough to provide comfort. Like the two boys with whom he would share the ward, his viral load was fairly high, a bad sign. He was given an intravenous line and oral liquids with electrolytes to combat dehydration.
Over days, his trajectory was noted. Oct. 3: admitted with fever, vomiting, diarrhea, loss of appetite, difficulty swallowing, and pain in his abdomen, chest and head. Oct. 4: bleeding from gums. The only other child in the ward was “scared to death to be in the room with him,” Audrey Rangel, an American nurse, said during rounds.
Oct. 5: diarrhea and vomiting. Oct. 7: stable and “jumping around like crazy pants.” Oct. 10: fever of 102.
Rancy Willie arrived three days later. That evening, Ms. Rangel helped lift Rancy off the bed to weigh him. With her goggles fogged, she had a hard time reading the number on the scale — only 37 pounds, it appeared — which was needed to calculate the right doses of medications.
Ms. Rangel tied a glove around one limp arm, then the other, apologizing as she searched for a vein to start an IV. Other workers looked, too, and Rancy whimpered as they did, but it was difficult to see well at night in the unit, and the small boy was severely dehydrated. As the nurses held each forearm aloft, Rancy’s hand drooped like a flag.
“You’re so brave,” Ms. Rangel said. A colleague inserted the needle but missed his vein. The team decided to wait for morning, when a nurse experienced in pediatrics would be on duty.
After wrapping the boy in a fuzzy orange and yellow blanket for the night, Ms. Rangel helped him sit up to drink a rehydration solution. His sips were so small, though, that he barely swallowed anything. Moments later, the nurse heard him moan. He vomited on the bed and over the rail.
“O.K., better?” Ms. Rangel asked. Then another wave overtook him.
Everyone called Rancy by his last name, “Willie,” because there was no relative to correct them. The little boy’s voice was weak and hard to hear, muffled by the medical workers’ headgear.