Two Cases of Severe Acute Respiratory Syndrome: An Expert Interview

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http://www.medscape.com/viewarticle/451047

Two Cases of Severe Acute Respiratory Syndrome: An Expert Interview With Robert

A. Fowler, MD, MS

Medscape Medical News 2003. © 2003 Medscape

 

 

 

 

Alfred J. Saint Jacques, MBA

 

March 21, 2003 — Editor's note: As scientists race to find answers to the

mysterious worldwide pneumonia outbreak known as severe acute respiratory

syndrome (SARS), physicians in Canada are working quickly to diagnose and treat

suspected victims of the disease. To provide a clinical perspective on what has

been found in patients with SARS, Medscape's Alfred Saint Jacques spoke with

Robert A. Fowler, MD, MS, assistant professor at the University of Toronto and

associate scientist at the Department of Critical Care Medicine and General

Internal Medicine at Sunnybrook and Women's College Health Science Centre in

Toronto, Ontario, about two patients with SARS who were admitted to his

institution.

Medscape: Could you describe the two cases of SARS and how they came to be at

your institution?

Dr. Fowler: On Thursday, March 13, we had our first index case who fulfilled our

case definition. The case definition that Toronto Public Health and Health

Canada have agreed upon is the presence of symptoms (including fever greater

than 38 degrees C, headache, sore throat, dry cough, shortness of breath) and a

compatible travel history (Hong Kong, Guangdong Province, China; Hanoi, Vietnam;

or Singapore) within seven days of symptom onset or close contact with a known

case of SARS. Probable cases would be a patient with progressive respiratory

illness and suspicion of acute respiratory distress syndrome with an abnormal

chest x-ray and/or hypoxemia (Figure). Those are the case definitions that we

are working with.

 

The first patient was a young male who presented to our hospital upon transfer

from an outside institution on Thursday, March 13, and he fulfilled the case

definition. In particular, he had known contacts and, in addition, a recent

history of travel to Asia. He was also febrile, had cough, shortness of breath,

and was hypoxic with an abnormal chest x-ray at presentation. He deteriorated

over the course of a day in the hospital and was admitted to the intensive care

unit the following day. He received supportive and specific treatment.

 

The supportive treatment that we have agreed upon on a local level consists of

supportive care in a monitored environment, including negative-pressure

isolation, support for oxygenation, ventilation, and hemodynamics as required.

The specific antimicrobial and antiviral therapy that we have instituted

consists of meropenem 1 g every 8 hours or 500 mg intravenously every 6 hours,

doxycycline 100 mg orally twice daily or azithromycin 500 mg intravenously or

orally daily, gatifloxacin 400 mg orally daily or ciprofloxacin 750 mg orally

twice daily, oseltamivir 75 mg orally twice daily, and finally ribavirin 2 g

intravenously once then 1 g intravenously every 6 hours for 4 days, and then to

reassess.

 

This patient received the above therapy and this has been the regimen that we

have been going with. After a couple of days in the intensive care unit, he

improved to the point that he was able to be discharged to a negative-pressure

isolation room within the hospital. He is currently doing well and is stable.

Medscape: Do you have an idea how long that person will have to remain in the

hospital?

Dr. Fowler: That is still under discussion.

Medscape: Please describe the second case.

Dr. Fowler: The second case that we dealt with here involves a middle-aged

person who satisfied our case definition and was admitted to hospital over the

weekend of March 15 and 16. Again, this person was hypoxic at presentation with

an abnormal chest x-ray and was admitted directly to a negative-pressure

isolation room and subsequently deteriorated. He was transferred to the

intensive care unit and was treated from the onset with the specific antibiotics

and antivirals that were outlined previously. Currently, he is in the intensive

care unit, intubated and mechanically ventilated. He is in stable but critical

condition.

Medscape: Are you in contact with medical authorities in Canada about these

cases?

Dr. Fowler: Yes. There has been a multiorganizational effort to investigate the

outbreak at the hospital, local university, regional, provincial, and national

level. There have been multiple conference calls and interactions on a

many-times-daily basis with all folks involved.

Medscape: Who are some of the agencies involved?

Dr. Fowler: Health Canada, Toronto Public Health, Ontario Provincial Ministry of

Health and Long-Term Care, University of Toronto and Affiliated Hospitals, and

Infection Control Service at Sunnybrook and Women's College Health Science

Centre. There has also been collaboration with the World Health Organization

(WHO) and the Centers for Disease Control and Prevention (CDC).

Medscape: Currently, how many SARS cases have been found in the Toronto area?

Dr. Fowler: This is a moving target, but as reported in Canada earlier this week

there have been eight cases, including two deaths. A majority of those cases

have been in the greater Toronto area.

Medscape: Recent reports have identified the viral infection as from the

Paramyxoviridae family. Could you comment on that?

Dr. Fowler: The preliminary reports that we have heard as well over the last 24

hours have indicated that the paramyxoviruses have been identified in some of

the cases that have presented over the last month. Currently, we are not able to

corroborate this with our own investigation, and we cannot be certain that this

will be the final diagnosis. We are encouraged that something has been found.

These sorts of viruses are not uncommon, but the paramyxovirus isolated appears

to be a different entity from what we have previously seen.

Medscape: Do you have advice for colleagues who may suspect that one of their

patients has SARS?

Dr. Fowler: They need to have a coordinated approach with the local and national

authorities and an agreed-upon case definition. They need a formulated plan

about how to deal with the public health issues, including media contact, public

education about what has happened, what steps are being taken, and the signs and

symptoms that people should be concerned about. They need to provide a locale

where people can present for triage. There should be a coordinated local effort

to triage and then manage patients that have the suspicion for illness. I can

tell you what we are doing and that includes designating an isolated area within

the acute care facility where patients can present directly for screening and

triage. This is managed by nurses and physicians who will determine whether

individuals fulfill the case definition as probable or suspected. From that

point, patients are admitted, if necessary, directly to a negative-pressure

isolation room.

 

Also, healthcare workers should be taking precautions, including use of

high-efficiency respirators such as N95 masks or equivalent, in addition to

complete glove and gown use with careful hand washing. It is critically

important that patients be managed in strict isolation and patients who are

suspected should be triaged into an airborne isolation area in the emergency

department, ie, negative-pressure room with doors closed.

 

The important thing is to work in a collaborative sense with people who will be

establishing case definitions, working with local media to provide information

to the public, and triaging these patients to minimize risk of spread to

healthcare workers, patients within the hospital, and the public. [Clinicians]

should be encouraged to promptly report suspected cases to the authorities. So

far, with the patients that we have been able to get to and treat with either

supportive or specific care, we have had no deaths in the couple of cases that

we have seen so far. We have screened many other people but so far we have just

two cases at our hospital. There are others who have been admitted to hospitals

in the Toronto area.

Medscape: You said that there were two fatalities out of the total number of

cases identified in the Toronto area. What factors contributed to those

patients' deaths?

Dr. Fowler: One of those two patients was not identified early on and died after

minimal medical care. The second presented very late in the illness, at the very

beginning of our outbreak, before there was a wider appreciation of the illness.

Despite the best efforts of the treating medical team, this patient

unfortunately did not survive.

 

Reviewed by Gary D. Vogin, MD

 

Alfred J. Saint Jacques, MBA, is site editor of Medscape Pulmonary Medicine.

 

 

 

 

 

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