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Eurosurveillance, Volume 7, Issue 13, 27 March 2003
Articles

Citation style for this article: Clinical descriptions of Severe Acute Respiratory Syndrome (SARS). Euro Surveill. 2003;7(13):pii=2194. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=2194

Clinical descriptions of Severe Acute Respiratory Syndrome (SARS)

Reproduced from references 1 and 2 by Editorial team (eurowkly@phls.org.uk), Eurosurveillance editorial office.

WHO coordinated virtual conference (http://www.who.int/csr/sars/cliniciansconference/en/)

On 26 March 80 clinicians from 13 countries participated in an electronic "grand round" on clinical features and treatment for patients with Severe Acute Respiratory Syndrome (SARS) (1). Their discussion, organised by the World Health Organization (WHO) network of clinicians focused on features of the disease at presentation, treatment and progression of the disease, prognostic indicators and discharge criteria. No therapy demonstrated any particular effectiveness. Clinicians agreed that a subset of SARS patients, perhaps 10%, decline and need mechanical assistance to breathe. These patients often have other illnesses which complicates their care, and in this group, mortality is high.

Disease presentation:
All of the clinicians described presentations of SARS patients and a general consensus is agreed that presentation is relatively consistent across all nations. Presentation is of a prodromal illness with a sudden onset of high fever. In a great number of cases this sudden, high fever is associated myalgia, chills, rigors, and nonproductive cough. At presentation (which is often three to four days after onset of symptoms), a large proportion of patients have characteristic changes on chest radiographs.

Disease progression:
Following presentation, chest radiographs continue to worsen and most patients demonstrate bilateral changes with interstitial infiltrations. These infiltrations produce radiographs with a characteristic cloudy appearance. Patients then fall into one of two groups. Most patients (80-90%) show improvement in signs and symptoms at day six or seven. A second smaller group, progress to a more severe form of SARS, many of whom develop acute respiratory distress syndrome and require mechanical ventilatory support. Mortality associated with the more severe group is high, however, a number of patients have remained on ventilator support for prolonged periods of time. Mortality in the severe group appears to be linked to a patient's other illnesses (comorbid factors).

Prognostic indicators:
Generally, patients over 40 with other illnesses are more likely to progress to the severe form of the disease.

Therapy:
Numerous antibiotic therapies have been tried to date with little clear effect. Ribavirin with or without use of steroids has been used in an increasing number of patients. But in the absence of clinical indicators, its effectiveness has not been proven. Currently the most appropriate management measures are general supportive therapy, insuring the person is hydrated and treated for subsequent infections.

What next:
Planning these grand rounds regularly. The clinicians involved in establishing management guidelines (treatment, management of patients and contacts, discharge).
The participants agreed to "meet" regularly using electronic communications and to rapidly develop international guidelines for the care of SARS patients.

MMWR Dispatch (http://www.cdc.gov/mmwr/preview/mmwrhtml/m2d321.htm)

As of 21 March 2003, most patients identified as having SARS have been adults aged 25-70 years who were previously healthy. Few suspected cases of SARS have been reported among children aged <15 years.

The incubation period for SARS is typically 2-7 days; although, isolated reports have suggested an incubation period as long as 10 days. The illness begins generally with a prodrome of fever (>100.4°F (>38.0°C)), which is often high, and sometimes associated with chills and rigors. It may be accompanied by other symptoms, including headache, malaise, and myalgia. At the onset of illness, some persons have mild respiratory symptoms. Typically, rash and neurological or gastrointestinal findings are absent; but some patients have reported diarrhoea during the febrile prodrome.

After 3-7 days, a lower respiratory phase begins with the onset of a dry, nonproductive cough or dyspnea, which might be accompanied by or progress to hypoxaemia. In 10-20% of cases, the respiratory illness is severe enough to require intubation and mechanical ventilation. The case fatality rate among persons with illness meeting the current WHO case definition of SARS is approximately 3%.

Chest radiographs may be normal during the febrile prodrome and throughout the course of illness. However, in a substantial proportion of patients the respiratory phase is characterised by early focal interstitial infiltrates progressing to more generalised, patchy, interstitial infiltrates. Some chest radiographs from patients in the late stages of SARS have shown areas of consolidation.

Early in the course of disease, the absolute lymphocyte count is often decreased. Overall, white blood cell counts have generally been normal or decreased. At the peak of the respiratory illness, approximately 50% of patients have leukopenia and thrombocytopenia or low to normal platelet counts (50 000-150 000/µL). Early in the respiratory phase, elevated creatine phosphokinase concentrations (as high as 3000 IU/L) and hepatic transaminases (two to six times the upper limits of normal) have been noted. In most patients, renal function has remained normal.

The severity of illness might be highly variable, ranging from mild illness to death. Although a few close contacts of patients with SARS have developed a similar illness, most have remained well. Some close contacts have reported a mild, febrile illness without respiratory signs or symptoms, suggesting the illness may not always progress to the respiratory phase.

Treatment regimens have included several antibiotics for presumptive treatment of known bacterial agents of atypical pneumonia. In several locations, treatment has also included antiviral agents such as oseltamivir or ribavirin. Steroids have also been administered orally or intravenously to patients, in combination with ribavirin and other antimicrobials. At present, the most efficacious treatment regimen, if any, is unknown.

Clinicians who suspect cases of SARS are requested to report such cases to their local public health authorities. Updates on the developing situation are also available from WHO, on ProMED, and at the websites of various national public health organisations, including CDC, Health Canada, and the Public Health Laboratory Service in the UK.

Eurosurveillance Weekly reproduces these reports here in the interests of disseminating the information more widely.

References:
  1. WHO. Severe Acute Respiratory Syndrome (SARS). Clinicians hold virtual conference on management of SARS patients. 26 March 2003 (http://www.who.int/csr/sars/cliniciansconference/en/).
  2. MMWR. Preliminary Clinical Description of Severe Acute Respiratory Syndrome. MMWR 2003; 52 (Dispatch); 1-2. (http://www.cdc.gov/mmwr/preview/mmwrhtml/m2d321.htm).

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