ABSTRACT & COMMENTARY
Clinical Experience in Critically Ill Patients with MERS-CoV
By Dean L. Winslow, MD, FACP, FIDSA
Clinical Professor of Medicine and Pediatrics Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Associate Editor of Infectious Disease Alert
Dr. Winslow is a consultant for Siemens Diagnostic
SYNOPSIS: 12 patients with severe Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV) were admitted to 3 ICU's in 2 tertiary care medical centers in Saudi Arabia. All of these patients had severe hypoxemic respiratory failure and most had organ dysfunction involving other organ systems. All patients had pre-existing co-morbid conditions. 5 patients survived hospitalization.
SOURCE: Arabi YM, et al. Clinical Course and Outcomes of Critically Ill Patients With Middle East Respiratory Syndrome Coronavirus Infection. Ann Int Med 2014; epub Jan 28.
Between December 2012 and August 2013 114 patients admitted to two hospitals with suspected MERS-CoV infection were shown to be infected with this agent by RT-PCR. 12 patients (including one health care worker who was part of a health care-associated case cluster of 3 HCW's with MERS-CoV infection) required admission to the ICU. All 12 patients had underlying comorbid conditions and presented with acute severe hypoxemic respiratory failure. Median age of patients was 59. The comorbid conditions present in at least 25% of patients included diabetes, hypertension, chronic kidney disease, coronary artery disease, obesity and previous stroke. Patients usually presented to the hospital acutely ill in one day or less following onset of symptoms, which generally consisted of dyspnea, cough and fever. Imaging studies showed findings of lobar/multilobar infiltrates to diffuse airspace disease consistent with ARDS. Most patients (92%) had extrapulmonary manifestations, including shock, acute kidney injury, and thrombocytopenia. All 12 patients required endotracheal intubation and mechanical ventilation, 11 received vasopressors, and 7 required renal replacement therapy. Five (42%) survived the ICU and were alive at day 90. Of the 520 exposed HCWs, only 4 (1%) were positive by RT-PCR for infection with MERS-CoV.
This case series provides a very useful report on the clinical characteristics of patients with severe infection due to MERS-CoV. In contrast to patients with Hantavirus Pulmonary Syndrome and SARS-CoV where severe infection was seen in some previously-healthy individuals, severe disease due to MERS-CoV requiring admission to the ICU was in this series seen only in patients with one or more underlying co-morbid conditions. Despite state-of-the-art critical care management of these 12 patients in the three ICU's in Saudi Arabia, only 5 of 12 patients survived to hospital discharge. In their discussion the authors state that all patients received empiric broad-spectrum antibiotics and many received oseltamivir and various doses of corticosteroids. However, there was no evidence that any of these therapies were helpful. The numbers of secondary cases of MERS-CoV encountered in exposed HCW's was very low with only 4 of 520 exposed HCW's testing positive for the virus by RT-PCR. Of these, 2 were asymptomatic, one had mild disease and was treated symptomatically at home, and one patient (included in the case series) required ICU admission. The relative lack of secondary cases is likely related to the relatively short duration of viral shedding. Only 4 patients had MERS-CoV detected by RT-PCR beyond the first day of admission to the ICU, although one patient shed virus out to day 22.