Lancet Study: Clinical Features & Viral Diag. of 2 Cases #Coronavirus

[editing in red is mine]
Published Online May 29, 2013

Clinical features and viral diagnosis of two cases of infection with Middle East Respiratory Syndrome coronavirus:  a report of nosocomial transmission

Benoit Guery, Julien Poissy, Loubna el Mansouf, Caroline Séjourné, Nicolas Ettahar, Xavier Lemaire, Fanny Vuotto, Anne Goffard, Sylvie Behillil,

Vincent Enouf, Valérie Caro, Alexandra Mailles, Didier Che, Jean-Claude Manuguerra, Daniel Mathieu, Arnaud Fontanet, Sylvie van der Werf, and

the MERS-CoV study group*

Summary

Background

Human infection with a novel coronavirus named Middle East Respiratory Syndrome coronavirus

(MERS-CoV) was first identified in Saudi Arabia and the Middle East in September, 2012, with 44 laboratory-confirmed cases as of May 23, 2013. We report detailed clinical and virological data for two related cases of MERS-CoV disease, after nosocomial transmission of the virus from one patient to another in a French hospital

Methods

Patient 1 visited Dubai in April, 2013; patient 2 lives in France and did not travel abroad. Both patients had underlying immunosuppressive disorders. We tested specimens from the upper (nasopharyngeal swabs) or the lower (bronchoalveolar lavage, sputum) respiratory tract and whole blood, plasma, and serum specimens for MERS-CoV by real-time RT-PCR targeting the upE and Orf1A genes of MERS-CoV.

Findings

Initial clinical presentation included fever, chills, and myalgia in both patients, and for patient 1, diarrhoea.  Respiratory symptoms rapidly became predominant with acute respiratory failure leading to mechanical ventilation and extracorporeal membrane oxygenation (ECMO). Both patients developed acute renal failure. MERS-CoV was detected in lower respiratory tract specimens with high viral load (eg, cycle threshold [Ct] values of 22·9 for upE and 24 for Orf1a for a bronchoalveolar lavage sample from patient 1; Ct values of 22·5 for upE and 23·9 for Orf1a for an induced sputum sample from patient 2), whereas nasopharyngeal specimens were weakly positive or inconclusive.  The two patients shared the same room for 3 days. The incubation period was estimated at 9–12 days for the second case. No secondary transmission was documented in hospital staff despite the absence of specific protective measures before the diagnosis of MERS-CoV was suspected. Patient 1 died on May 28, due to refractory multiple organ failure.

Interpretation

Patients with respiratory symptoms returning from the Middle East or exposed to a confirmed case should be isolated and investigated for MERS-CoV with lower respiratory tract sample analysis and an assumed incubation period of 12 days. Immunosuppression should also be taken into account as a risk factor

Funding

French Institute for Public Health Surveillance, ANR grant Labex Integrative Biology of Emerging Infectious Diseases, and the European Community’s Seventh Framework Programme projects EMPERIE and PREDEMICS

Introduction

Excerpt:

Whereas an as yet unidentified animal reservoir might

have caused the initial outbreaks by introducing the virus

into the human population, the occurrence of clusters,

whether in the community or in hospitals, is a worrying

development, because it might result from adaptation of

the virus to inter-human transmission. This process of

adaptation might have been pivotal in the switch from

aborted outbreaks to the international pandemic of

SARS-CoV in 2003–04.

14

We report detailed clinical and virological information for two related cases of MERS-CoV

disease, after nosocomial transmission of the virus from one patient to another in a French hospital in April, 2013

-snip-

Results

Excerpt:

Patient 1 was transferred to the Douai hospital

intensive-care unit (ICU) on April 29, where non-invasive

mechanical ventilation was started, and antimicrobial

therapy was modified to piperacilline plus tazobactam

and linezolid. He had rapid respiratory deterioration, and

was intubated on April 30 (figure 1B). Respiratory failure

was followed by shock and renal failure, leading to

noradrenaline administration and continuous veno

- venous haemofiltration.

On May 1, on the basis of the clinical presentation and

the history of recent travel to Dubai, the hypothesis of an

infection with MRES-CoV was raised, prompting the

transfer of nasopharyngeal and stored bronchoalveolar

lavage samples to the National Reference Center in Paris.

Further worsening of the respiratory status with a

partial pressure of oxygen (PaO

2

)

to fraction of inspired

oxygen (FiO

2

) ratio of 1 despite low tidal volume and high-

positive end expiratory pressure (PEEP) ventilation,

inhaled nitric oxide, prone positioning, sedation, and

neuromuscular blockade, prompted the implementation

of extracorporeal membrane oxygenation (ECMO).

Persisting haemodynamic support with norepinephrine

at 0·5 mg/h was necessary. The patient was transferred to

the ECMO referral centre ICU of Lille University

Teaching Hospital on May 8 (figure 1C). As of May 27, the

patient remained under ECMO therapy because of

persisting severe acute respiratory distress syndrome

(figure 1D). At 100% FiO

2

on both ECMO and ventilator

settings . . .

Chart on pg. 6/8

Link to full article:  http://download.thelancet.com/flatcontentassets/pdfs/S0140673613609824.pdf