Archive Number 20030326.0748
Published Date 26-MAR-2003
Subject PRO/EDR> SARS - worldwide (09): clinical features
SARS - WORLDWIDE (09): CLINICAL FEATURES
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[1]
Date: 26 Mar 2003
From: ProMED-mail <
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Source: WHO SARS website
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http://www.who.int/csr/sars/cliniciansconference/en/>>
Clinicians hold virtual conference on management of SARS patients 26 Mar 2003
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Today, 80 clinicians from 13 countries participated in an electronic "grand
rounds" on clinical features and treatment for patients with Severe Acute
Respiratory Syndrome, known as SARS. Their discussion, organized by the WHO
network of clinicians focused on the disease's features at presentation,
treatment, progression, prognostic indicators, and discharge criteria. No
therapy demonstrated any particular effectiveness. Clinicians agreed that a
subset of SARS patients, perhaps 10 percent, decline and need mechanical
assistance to breathe. These people often have other illnesses that
complicate their care. In this group, mortality is high.
Based on their experiences with patients, SARS clinicians are drawing the
following conclusions:
Disease presentation:
All of the clinicians described presentations of SARS patients and the
general consensus is 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
with myalgia, chills, rigors, and non-productive cough. At presentation
(which is often 3 to 4 days after onset of symptoms), a large proportion of
patients have characteristic changes on chest x-rays.
Disease progression:
Following presentation, chest x-rays continue to worsen and most patients
demonstrate bilateral changes with interstitial infiltrations (fluid
build-up between cells in the lungs). These infiltrations produce x-rays
with a characteristic cloudy appearance. Patients then fall into one of 2
groups. The majority, 80 to 90 percent of patients at day 6 or 7, show
improvement in signs and symptoms. 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. Though mortality
associated with the more severe group is high, 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
(co-morbid 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.
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[2]
Date: 26 Mar 2003
From: ProMED-mail <
promed@promedmail.org <mailto
romed@promedmail.org>>
Source: CDC MMWR 21 Mar 2003 52 (Dispatch);1-2
< <
http://www.cdc.gov/mmwr/preview/mmwrhtml/m2d321.htm>>
Preliminary Clinical Description of Severe Acute Respiratory Syndrome
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Severe acute respiratory syndrome (SARS) is a condition of unknown etiology
that has been described in patients in Asia, North America, and Europe.
This report summarizes the clinical description of patients with SARS based
on information collected since mid-February 2003 by the World Health
Organization (WHO), Health Canada, and CDC in collaboration with health
authorities and clinicians in Hong Kong, Taiwan, Bangkok, Singapore, the
United Kingdom, Slovenia, Canada, and the United States. This information
is preliminary and limited by the broad and necessarily nonspecific case
definition.
As of 21 Mar 2003, the majority of 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; however, isolated
reports have suggested an incubation period as long as 10 days. The illness
begins generally with a prodrome of fever (greater than 100.4 F [greater
than 38.0 C]). Fever often is high, sometimes is associated with chills and
rigors, and might be accompanied by other symptoms, including headache,
malaise, and myalgia. At the onset of illness, some persons have mild
respiratory symptoms. Typically, rash and neurologic or gastrointestinal
findings are absent; however, some patients have reported diarrhea 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 hypoxemia. In 10--20 percent 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 percent [based on today's data with the additional
information from China, 49 deaths reported and 1323 cases the observed case
fatality rate is now 3.7 percent - Mod.MPP].
Chest radiographs might be normal during the febrile prodrome and
throughout the course of illness. However, in a substantial proportion of
patients, the respiratory phase is characterized by early focal
interstitial infiltrates progressing to more generalized, patchy,
interstitial infiltrates. Some chest radiographs from patients in the late
stages of SARS also 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 percent
of patients have leukopenia and thrombocytopenia or low-normal platelet
counts (50 000 - 150 000 / microL). Early in the respiratory phase,
elevated creatine phosphokinase levels (as high as 3000 IU/L) and hepatic
transaminases (2 to 6 times the upper limits of normal) have been noted. In
the majority of 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, the majority have remained well. Some close
contacts have reported a mild, febrile illness without respiratory signs or
symptoms, suggesting the illness might not always progress to the
respiratory phase.
Treatment regimens have included several antibiotics to presumptively treat
known bacterial agents of atypical pneumonia. In several locations, therapy
also has 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.
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