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Letter
Early Defervescence and SARS
Recovery
Jann-Tay Wang,* Jiun-Ling Wang,* Chi-Tai Fang,* and Shan-Chwen Chang*
*National Taiwan University Hospital, Taipei, Taiwan
Suggested citation
for this article: Wang
J-T, Wang J-L, Fang C-T, Chang S-C. Early defervescence and SARS recovery.
Emerg Infect Dis [serial online] 2004 Mar [date cited]. Available
from: URL: http://www.cdc.gov/ncidod/EID/vol10no3/03-0500.htm
To the Editor: Severe acute respiratory syndrome (SARS) is an
emerging disease first recognized November 2002 (1).
Previous studies show patients with probable SARS on ribavirin and steroid
therapy may experience a biphasic course, with clinical symptoms and changes
shown on chest x-rays increasing in the second week of disease (2).
We report a patient with probable SARS who had temporary defervescence
for 7 days before rapidly progressing to respiratory failure.
The patient was a 54-year-old female nursing aide for a patient with
fever and pneumonia who was diagnosed with probable SARS on the basis
of the criteria proposed by World Health Organization (WHO) (3).
Our patient did not have underlying disease, but fever of 38.6°C developed
on May 10, 2003, a total of 3 days after her last contact with the patient
she was caring for. Mild myalgia was noted. She was admitted that day
with suspected SARS. Initial chest x-ray results were normal. Hemogram
showed a normal leukocyte count with mild lymphopenia (absolute lymphocyte
count 0.84 x 109/L) and a normal platelet count (253 x 109/L).
Initial serum aspartate aminotransferase (AST) and alanine aminotransferase
(ALT) levels were 38 U/L and 20 U/L, respectively (normal <35 U/L).
Serum creatinine kinase (CK) level was 84 U/L (normal <190 U/L). Serum
C-reactive protein (CRP) level was elevated (3.49 mg/dL; normal <0.8
mg/dL). Serum sodium level was normal.
After admission, she received oral ribavirin, 1,000 mg/day. No other
antimicrobial agent was administered. Her fever persisted for 2 days,
and she became afebrile spontaneously on May 13, 2003. The result of reverse
transcription¡Vpolymerase chain reaction (RT-PCR) for SARS-associated
coronavirus (SARS-CoV) on a throat swab specimen performed on May 10 was
negative. All other testing, including blood culture; virus isolation;
and serologic tests for SARS-CoV, chlamydiae, mycoplasmas, rickettsiae,
influenza virus, parainfluenza virus, adenovirus, respiratory syncytial
virus (RSV), and coxsackie virus were also negative. She did not take
any nonsteroid antiinflammatory drugs (NSAIDs) or steroids during this
period. Her chest x-ray results on May 13 remained normal. Other laboratory
testing on May 13 showed resolution of lymphopenia, a lower serum CRP
level (2.48 mg/dL), but an elevated lactate dehydrogenase (LDH) level
(627 U/L; normal <460 U/L).
During the next 4 days, she remained afebrile. Results of a repeated
chest x-ray on May 16 were still normal. The serum CRP level decreased
to 2.29 mg/dL. However, borderline leukopenia (4.45 x 109/L),
borderline thrombocytopenia (167 x 109/L), an elevated serum
CK level (238 U/L), hyponatremia (128.2 mmol/L), and a progressively elevated
serum LDH level (1,138 U/L) were noted. Because she had been afebrile
for 5 days, she was discharged on May 17. After discharge, she continued
to take ribavirin and be quarantined at home. Unfortunately, fever and
rapidly progressive dyspnea developed on May 20. On the same day, chest
x-ray showed diffusely increased infiltration over all lung zones. Hemogram
showed leukocytosis (leukocyte count 14.03 x 109/L). Serum
CRP level was elevated to 12.7 mg/dL. Serum sodium level was 129.5 mmol/L.
Serum AST level was 135 U/L, serum CK level was 71 U/L, and serum LDH
level was 1,719 U/L. All blood cultures and sputum culture for bacteria
yielded nothing.
She was intubated on May 21 for respiratory failure. Under the assumption
of probable SARS, she was given high-dose methylprednisolone (120 mg/day),
and her clinical condition stabilized soon after. The results of RT-PCR
for SARS-CoV on a throat swab specimen performed on May 21 were positive.
The results of immunofluorescent assays testing for immunoglobulin (Ig)
M and IgG against SARS-CoV (performed in the research laboratory at National
Taiwan University Hospital on May 21 and 27) were all positive (both IgM
titers >1:10; both IgG titers >1:1,000). Sputum culture and Gram
stain were both negative. Urine tests were also negative for pneumococcal
and Legionella antigens. Other serologic tests, including those
for chlamydiae, mycoplasmas, rickettsiae, influenza virus, parainfluenza
virus, adenovirus, RSV, and coxsackie virus were still negative. The ventilator
was removed on June 9.
A previous report pointed out the great variety in the clinical course
of SARS (4). We emphasize that even a patient with suspected
SARS who became afebrile in the first week and remained so for 7 days
without steroid or NSAID treatment still risks deterioration in the second
week, as long as some laboratory values remain abnormal. Therefore, defervescence,
even up to 7 days, may not be the single indicator for discharging SARS
patients. Obtaining normal results for previously abnormal laboratory
parameters, including hemogram, CRP, CK, AST, ALT, and LDH levels should
be considered when deciding whether a patient can be safely discharged
(5).
References
- SARS epidemiology to date [monograph on the Internet].
World Health Organization: 2003 [cited 2003 Apr 11]. Available from:
http://www.who.int/csr/sars/epi2003_04_11/en/
- Peiris JSM, Chu CM, Cheng VCC, Chan KS, Hung IF, Poon LLM, et al.
Clinical
progression and viral load in a community outbreak of coronavirus-associated
SARS pneumonia: a prospective study. Lancet 2003;361:1767–72.
- World Health Organization. Global
surveillance for severe acute respiratory syndrome. Wkly Epidemiol
Rec 2003;78:100–9.
- Fisher DA, Lim TK, Lim YT, Singh KS, Tambyah PA. Atypical
presentation of SARS. Lancet 2003;361:1740.
- WHO hospital discharge and follow-up policy for patients who have
been diagnosed with severe acute respiratory syndrome (SARS) [monograph
on the Internet]. World Health Organization: 2003 [cited 2003 Mar 28].
Available from: http://www.who.int/csr/sars/discharge/en/
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