To the Editor: With regard to the article by Wenzel and Edmond(May 15 issue),1 the management of suspected cases of severeacute respiratory syndrome (SARS) is not harmless. Recently,we admitted a man who had returned from Saigon and had pneumoniadiagnosed at the airport. His symptoms included fever, cough,interstitial lung infiltrates, lymphopenia, and elevated lactatedehydrogenase levels. No microbiologic analysis of sputum wasperformed because of infection-prevention measures.2 Five daysafter empirical antibiotic therapy began, respiratory failuredeveloped, necessitating admission to the intensive care unit.Prevention measures were then discontinued, since the patienthad not been exposed to anyone with a known case of SARS, therehad been no cases reported in Saigon, and polymerase-chain-reactionassays of a throat swab were negative for coronavirus.3 Finally,Burkholderia pseudomallei was found in the sputum.
One must remember that persons returning from Asia with pneumoniamay not have SARS and that other possible diagnoses must bechecked, such as melioidosis, which is the most frequent causeof pneumonia in some areas of Asia.4,5 A chance for a correct,early diagnosis was missed because of the limitations on examinationof this patient's sputum. Infection-prevention measures areessential, but they need to be assessed daily and discontinuedas soon as possible. A rapid diagnostic test would be very helpfulin ruling out SARS and providing care for patients in the usualway.
Wenzel RP, Edmond MB. Managing SARS amidst uncertainty. N Engl J Med 2003;348:1947-1948. [Free Full Text]
Updated interim domestic infection control guidance in the health-care and community setting for patients with suspected SARS. Atlanta: Centers for Disease Control and Prevention, 2003. (Accessed July 10, 2003, at http://www.cdc.gov/ncidod/sars/infectioncontrol.htm.)
Drosten C, Günther S, Preiser W, et al. Identification of a novel coronavirus in patients with severe acute respiratory syndrome. N Engl J Med 2003;348:1967-1976. [Free Full Text]
Currie BJ, Fisher DA, Howard DM, et al. Endemic melioidosis in tropical northern Australia: a 10-year prospective study and review of the literature. Clin Infect Dis 2000;31:981-986. [CrossRef][ISI][Medline]
To the Editor: Without diminishing the problem of SARS, I wonderwhether this situation involves more misinformation and perceiveddanger than actual threat. I am not advocating that we let downour guard and ignore this disease. SARS has affected thousandsof people, but I have to ask whether we really have things inperspective. The Centers for Disease Control and Preventionreports that in the United States, influenza leads to an averageof 36,000 deaths and 114,000 hospitalizations each year.1 TheWorld Health Organization (WHO) essentially shut down Toronto,a city of almost 2.5 million people2 where there were about20 deaths. Not to belittle this situation, but the Toronto Starreported 59 murders in Toronto in 2001, and the Toronto PoliceService has reported 20 murders in 2003. We should be steadfastin our determination to minimize the harm from this disease,but we must also be careful not to let hype create panic, whichwould lead to more harm and fear in an already tenuous worldpsyche.
Christian Donohue, M.D. Summit Medical Group Summit, NJ 07901
2001 Census of Canada. Ottawa, Ont., Canada: Statistics Canada, 2002.
The authors reply: Lila and colleagues make the clinical pointthat not all cases of community-acquired pneumonia from a regionaffected by the SARS epidemic are caused by the SARS coronavirus.We agree that a detailed history, a physical examination, anda series of diagnostic tests are appropriate.
Donohue warns that the medical profession should be carefulnot to panic in the midst of an epidemic, especially if thenumber of cases pales in comparison with the number of patientswith apparently less threatening endemic infections. We agreethat emerging infections should be managed in a data-drivenway, and communications should be balanced and truthful. However,we would not necessarily find fault with the WHO, because ithad to make decisions empirically in the face of limited data.Just as a physician may initially prescribe a broad spectrumof antibiotics for a patient with life-threatening sepsis ofunknown cause and later narrow the antibiotic choices when theantibiogram comes back, we think that it is appropriate to takebroad precautions initially when the public health is involved.Once the epidemiologic details become clear, more focused approachesmay be applied. Initially, the WHO did not know where we stoodon the epidemic curve, what various modes of transmission werepossible, how many new cases resulted from each case (the casereproduction rate), whether the virus was carried for extendedperiods, or whether asymptomatic cases existed. In hindsight,some of the approaches that were taken may seem excessive, butin the context of uncertainty and risk to health, we think thatthey were reasonable.
Richard P. Wenzel, M.D. Michael B. Edmond, M.D., M.P.H. Virginia Commonwealth University Richmond, VA 23219 rwenzel{at}mail2.vcu.edu
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