The Use of Corticosteroids in SARS

doi:10.1056/NEJM200305153482017

Volume 348:2034-2035		May 15, 2003		Number 20

The Use of Corticosteroids in SARS

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by Lee, N.

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To the Editor: The use of systemic corticosteroids in patientswith the severe acute respiratory syndrome (SARS) is of seriousconcern. Lee and colleagues report anecdotal success in theirarticle on SARS elsewhere in this issue.¹ And in the recentWeb broadcast on SARS by the CDC, Dr. Sung, one of the coauthors,states, "High-dose steroid should be given early to stop theprogression of the disease."² The pathogenesis of SARS is diffusealveolar damage with the acute respiratory distress syndrome(ARDS), not bronchiolitis obliterans with organizing pneumonia.And SARS is most likely due to coronavirus pneumonitis. Earlytreatment with corticosteroids in patients with ARDS is highlycontroversial and is not a standard of care, at least in NorthAmerica. Although ribavirin has activity against coronavirusesand human metapneumoviruses in vitro, there are no antimicrobialagents with proven effectiveness for the treatment of SARS atthis point. And the use of corticosteroids with possibly ineffectiveantiviral agents in patients with viral-induced pneumonitisor ARDS can be hazardous. I believe systemic corticosteroidsshould not be used at least until the etiologic agent of SARShas been confirmed and effective antiviral agents have beenestablished.

Yuji Oba, M.D.
University of Missouri—Kansas City
Kansas City, MO 64108

References

Lee N, Hui D, Wu A, et al. A major outbreak of severe acute respiratory syndrome in Hong Kong. N Engl J Med 2003;348:1986-1994. [Free Full Text]
Preventing the spread of severe acute respiratory syndrome (SARS). Atlanta: Centers for Disease Control and Prevention, 2003 (broadcast).(Accessed April 25, 2003, at http://www.cdc.gov/ncidod/sars/webcast/broadcast040403.htm.)

The authors reply: We agree with Dr. Oba that the efficicacyof antiviral agents is not certain and that the use of corticosteroidsin patients with infectious disease is potentially hazardous.But SARS is a serious disease with a rapid downhill course.In the Canadian report, 5 of 10 patients required mechanicalventilation, and 3 died.¹ Of the three patients who receivedboard-spectrum antibiotics, 2 died and 1 remained in the intensivecare unit. According to another report on SARS elsewhere inthis issue, antibiotics alone did not have any clinical benefitin patients.²

The combination of ribavirin and corticosteroid is an empiricaltherapy but not without basis. Ribavirin is a antiviral agentpreviously shown to be effective for respiratory syncytial virusinfection, influenza virus A and B infections, measles, parainfluenza,and Lassa fever. It was chosen in this case because of its board-spectrumcoverage. It is also known that in acute viral respiratory infections,early-response cytokines such as interferon-tumor nocrosis factor,interleukin-1 and interleukin-6 mediate lung injury. We usedcorticosteroid treatment to suppress the cytokine storm, hopingthat would stop the progression of pulmonary disease. And, infact, in many cases, it did. Lung shadows started to resolve,and oxygenation improved after corticosteroid treatment. Wemust emphasize that corticosteroids were not used to treat ARDS.We are in the process of analyzing the clinical responses tothese treatments and will make that information available assoon as possible.

Nelson Lee, M.B.,B.S.
Joseph Sung, M.D.
Chinese University of Hong Kong
Hong Kong, China

References

Poutanen SM, Low DE, Henry B, et al. Identification of severe acute respiratory syndrome in Canada. N Engl J Med 2003;348:1995-2005. [Free Full Text]
Tsang KW, Ho PL, Ooi GC, et al. A cluster of cases of severe acute respiratory syndrome in Hong Kong. N Engl J Med 2003;348:1977-1985. [Free Full Text]


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