LATEST SARS UPDATE - DETAILED MEDICAL INFORMATION

ProMed ^ | 03-17-03 | WOlfgang Preiser

[Mother Abigail]

Wolfgang Preiser

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We report on a patient admitted the day before yesterday (Sat 15 Mar 2003) to our Isolation Unit with atypical pneumonia, together with his travel companions. The patient is a medical doctor from Singapore who treated one of the earliest cases of SARS there between 3 and 9 Mar 2003. On 9 Mar 2003 he himself developed fever (39.4°C), myalgia and bone pain but did not have cough, dyspnoea or sore throat. Despite this, he flew to New York City to attend a medical meeting, accompanied by his wife who is also a doctor and by his mother-in-law. In New York he experienced a disseminated, transient rash. Because of persistent fever he sought medical attention in New York. A chest X-ray revealed a pneumonic infiltrate of the lingula (left lobe), and antibiotic treatment using levofloxacin was initiated.

Because he continued to feel unwell, he decided to return to Singapore via Frankfurt on 14 Mar 2003. During the first leg of this flight he developed fever again with deterioration of his general condition. In addition, his mother-in-law had developed a sore throat the day before and became febrile on the day of departure (14 Mar 2003). In accordance with the global alert about cases of atypical pneumonia recently issued by WHO \, an international health alert was declared after consultation between the Ministry of Health of Singapore and the German Health Authorities and the plane was met at Frankfurt airport by health officials. The index patient, his mother-in-law and his pregnant wife - who felt well and had no signs or symptoms - were admitted to the Isolation Unit at Frankfurt University Hospital under full biosafety precautions.

At admission, the index patient was still febrile up to 39.6°C, with elevated CRP [C-reactive protein - used to assess an acute phase reaction in inflammatory and infective processes with an elevated value interpreted as an indication of an acute phase response or active disease - Mod.MPP], leukopenia and mild elevation of transaminases and LDH. His chest X-ray still showed an infiltrate of the lingula. Antibiotic treatment was broadened by adding imipenem, vancomycin, doxycyclin and oseltamivir to levofloxacin. Nevertheless, he has now developed a cough and difficulty breathing and today transiently requires oxygen through a mask at 4 l/min. CRP and white blood cell count increase, other laboratory markers have not changed significantly since admission. The pulmonary infiltrates now extend to the left and right upper lobes.

His mother-in-law is currently afebrile, but she also developed a cough; since admission, her CRP has increased from 6.8 mg/dl to 9.9 mg/dl (normal range, <0.5 mg/dl), and her white blood cell count decreased slightly from 10.2/nl to 8.8/nl. Her chest X-ray shows no abnormalities. Coagulation parameters and renal function are normal in both patients. She is on imipenem, and levofloxacin, doxycyclin and tamiflu. Emergency microbiological tests undertaken in Frankfurt have yielded no evidence of Legionella infection; electron microscopy of respiratory swab samples was negative for virus particles, and testing for influenza antigen was negative. The results of viral cultures are pending. Further tests for influenza viruses are being performed by the Institute for Virology in Marburg and the Robert Koch Institute in Berlin; so far, the results of electron microscopy and PCR are negative.

Further testing (serology, PCR etc.) is under way. Up to Sunday [16 Mar 2003], the patient's wife has remained well without any symptoms; she is quarantined in a side room apart from her relatives. Over the past hours, however, she, too, has developed a fever (38.2 C at 8 PM local time, later 37.6 C spontaneously). Therefore we started treatment of the pregnant wife with erythromycin. After thorough cleaning and disinfection, the aircraft has in the meantime flown back to Singapore, albeit without passengers, due to demands by the Singaporean authorities. 83 fellow passengers resident in Germany are currently under "domestic quarantine"; they have been told to stay at home during the incubation period of 2 to 7 days and are being looked after by their local health authorities. -- PD Dr. med. H.-R. Brodt Dr. M. Eichel Infectious Diseases Dept., Medical Clinic III Dr. W. Preiser Institute for Medical Virology J. W. Goethe University Hospital Frankfurt am Main Germany

[Mother Abigail]

Suspected SARS - Germany ex Singapore via New York:

Paramyxovirus-like particles identified by electron microscopy

Numerous tests have been performed on the 3 patients admitted on
Saturday 15 March to the Isolation Unit at Frankfurt am Main with suspected severe acute respiratory syndrome (SARS). Tests from respiratory specimens for influenza A and B virus, respiratory syncytial virus, enteroviruses, _Mycoplasma pneumoniae_ and _Chlamydia_ spp. by antigen enzyme linked immunosorbent assay (ELISA) and/or polymerase chain reaction (PCR) were all negative; antibody tests for dengue, influenza A and B, measles, hantaviruses, _Mycoplasma pneumoniae_ and _Chlamydia_ spp. were likewise negative or unremarkable so far; further test results are pending.

Particles morphologically resembling paramyxoviruses were seen in respiratory specimens (throat swab and sputum) obtained from the index patient, a doctor from Singapore, by the teams in Marburg and in Frankfurt am Main.

It remains to be seen whether this finding can be confirmed -- tests including low-stringency paramyxovirus PCR and tissue culture are currently under way in Hamburg, in Marburg and in Frankfurt am Main. It needs to be emphasised that at this time these preliminary results only indicate a suspicion. Furthermore, even if the presence of a paramyxovirus was confirmed, it is not clear at this stage whether this might represent the causal agent of SARS or rather a coincidental finding.

[Mother Abigail]

Preiser's caution on the interpretation of these results is paramount here: "It needs to be emphasised that at this point of time these preliminary results only indicate a suspicion. Furthermore, even if the presence of a paramyxovirus was confirmed, it is not clear at this stage whether this might represent the causal agent of SARS or rather a coincidental finding."

Confirmation of these findings will be important as well as identification of a similar agent from additional cases of SARS will be necessary before it can be concluded that this agent is the etiology of SARS. - Mod.MPP]

[Paramyxoviruses are viruses associated predominantly with respiratory infections (the parainfluenza viruses, and respiratory syncytial virus (RSV)) and common childhood illnesses (mumps and measles).

Some of these viruses are ubiquitous (in particular human RSV) and it would not be exceptional to detect one of these viruses fortuitously by electron microscopy in any virus screening exercise. In general, paramyxoviruses only infect vertebrates and no arthropod vectors are known.


Unexpectedly, in recent years several new paramyxoviruses have been discovered. Predominant among these are _Hendra virus_ and _Nipah virus_, 2 related viruses isolated from bats in Australia and South East Asia, which have been responsible for outbreaks of severe disease in the human population. These two viruses differ significantly from other paramyxoviruses in molecular terms and might not be detected by PCR without the use of specific primers.

Other novel paramyxoviruses of unknown pathogenic potential are _Salem virus_, isolated from a horse in North America, _Tupaia paramyxovirus_, isolated from a tree shrew (_Tupaia_ sp.) in Thailand, and a heterogeneous collection of paramyxoviruses isolated from snakes, lizards, and turtles. Perhaps the most surprising discovery was the recent characterization of a novel pneumovirus (that is, a member of the sub-family _Pneumovirinae_ of the family _Paramyxoviridae)), designated _Human metapneumovirus_, which is associated with respiratory illness in infancy worldwide. Consequently a novel paramyxovirus must rank high among candidates for the etiologic agent of SARS. - Mod.CP]

[Endeavor]

I think you're right, it isn't Hanta. but I also think you're right in comparing the clinical syndrome of SARS to Hanta.

[Mamzelle]

If people expect their fellow passengers to be be germless, they'd better set up clinics at the airport checkpoints. Add another thousand or so to the ticket price. Hose those biohazards down. This is a ridiculous expectation to cultivate. An airplane is a nasty place to be, which is why I avoid them, period. I've always had a splitting headache when I get off due to the funny air.

There's no place worth going that is worth the beastly experience of getting there.

If the rich, restless, and self-indulgent must get their bragging rights, they'll bring home pathogens. And a lot more travel amateurs than medical conference attendees do this. Go pick on *them*. But your notions of what can be screened at an airport are naive.

[Mother Abigail]

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A CHRONOLOGICAL COMPILATION OF THE "SARS" OUTBREAK AS REPORTED ON FREE REPUBLIC

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1. Precognition

2. Hong Kong Health Secretary calls for calm as SARS cases double, (83 up from 42 on Sunday)

3. LATEST SARS UPDATE - DETAILED MEDICAL INFORMATION

4. BREAKING BIG: POSSIBLE PATHOGEN DETECTED IN SARS CASE

5. Killer Virus (SARS) Identified

6. Seven victims of mystery pneumonia stayed on same floor of Hong Kong hotel

7. Guangdong doctor linked to SARS outbreak

[Freedom'sWorthIt]

I have been told the "bug" has been identified, effective treatment is available, and the panic is over. Is that what the truth is - in a nutshell?

[Mother Abigail]

The pathogen is still unknown, we suspect it to be from a family of common viruses, but it may be a unknown strain, testing continues

There is no known treatment - some antivirals have shown promise

I do not know if there is panic in Hong Kong - mixed reports

[Freedom'sWorthIt]

Thanks - so the "panic" could still be there. We just may not be hearing about it. Thanks again.