To the Editor: We evaluated a possible case of severe acuterespiratory syndrome (SARS) that involved issues of hospitaladmission, an inconsistent travel history, and possible enforcedisolation. Some of the problems were similar to those describedin a recent account in New York.1
On May 12, 2003, a 36-year-old white man (accompanied by hisAsian wife) was evaluated in our emergency room for fever andcough. He stated that they had arrived in the United Statesfive days earlier from Taiwan, where he worked as an Englishteacher for physicians. His symptoms began two days after theirarrival in the United States. Emergency room personnel placedmasks on the couple and isolated them from other patients. Thisevent coincided with the start of the Top Officials 2 (TOPOFF2) bioterrorism-response exercise at our hospital. When consultedat 1 a.m., we initially questioned whether this patient mightbe part of the drill. The drill scenario involved an outbreakof pneumonic plague but was also to include some surprises.The patient had no respiratory distress, and a chest radiographand the oxygen saturation were normal, but the couple had nolocal residence. Therefore, the patient was admitted to a negative-pressureisolation room and placed under contact and respiratory-isolationprecautions in accordance with the recommendations of the Centersfor Disease Control and Prevention.2
The following day, the patient's diagnosis was reassessed, becausehe had no fever and he repeatedly requested narcotics for chestpain. That evening, he threatened to leave the hospital. Althoughthey were suspicious of his story and motives, members of thehospital administration, hospital attorneys, and the publichealth department had to consider the potential legal optionsavailable for enforcing the isolation of a patient posing apotential threat to the public health.3 When we were finallyable to interview the patient's wife separately, she confirmedthat they had come from Taiwan but had arrived one month, notfive days, previously. She also confirmed that her husband hadlost his job nine months earlier because of a drug problem.
This case was frustrating, not only because of the amount oftime and resources it demanded, but also because it occurredin association with the TOPOFF 2 exercise. Given the experiencewith hospital-based outbreaks of SARS in Asia, as reported byTsang et al. (May 15 issue),4 and in Toronto, as reported byPoutanen et al. (May 15 issue),5 possible cases of SARS mustbe taken seriously, and appropriate infection-control measuresmust be implemented immediately. Perhaps some of the lessonslearned from the TOPOFF 2 exercise can be translated into aheightened awareness and a readiness to handle a more immediateand real threat to the public health — namely, SARS.
Stuart Johnson, M.D. Meenal Patel, M.D. Kathleen Mullane, D.O., Pharm.D. Loyola University Medical Center Maywood, IL 60153 sjohnson{at}lumc.edu
References
Pérez-Peña R. SARS scare at J.F.K. brings fast response from doctors. New York Times. May 16, 2003:B1.
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 24, 2003, at http://www.cdc.gov/ncidod/sars/infectioncontrol.htm.)
Bush GW. Executive order 13295: revised list of quarantinable communicable diseases. Washington, D.C.: White House, April 4, 2003.
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]
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]
Drs. Tsang and Ho reply: In response to the letter by Johnsonet al. about their case of "pseudo-SARS," in Hong Kong, we seenumerous patients with respiratory symptoms and fever, manyof whom have radiologically confirmed pneumonia. Although mostpatients with SARS have fever, lymphopenia, increased levelsof alanine aminotransferase and lactate dehydrogenase, and radiographicevidence of ground-glass consolidation, these findings are byno means diagnostic. A small proportion of patients with SARSpresent with a normal chest radiograph, but in most of thesepatients, ground-glass opacification or frank consolidationis visible on repeated radiography or on high-resolution computedtomography. More specific tests, such as the demonstration ofSARS-associated coronavirus RNA on reverse-transcriptase polymerase-chain-reactionanalysis, are still unreliable, and anti-SARS IgG is more than90 percent sensitive, but only 21 to 30 days after the onsetof symptoms.1 The case described by Johnson et al. stronglyreemphasizes the difficulties for front-line clinicians, especiallythose in Asia, who deal with patients with possible SARS, sincethere is still no effective, rapid diagnostic test, despitethe original optimism about its development.
Kenneth W. Tsang, M.D. Pak L. Ho, M.D. University of Hong Kong Hong Kong, China kwttsang{at}hku.hk
References
Peiris JSM, Chu CM, Cheng VCC, et al. Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. London: Lancet Publishing, May 2003. (Accessed July 24, 2003, at http://image.thelancet.com/extras/03art4432web.pdf.)
Dr. Low replies: Although SARS has been brought under controlin affected areas worldwide, there is ongoing concern that itcould reappear and once again spread widely unless we maintainheightened awareness. Control entails the identification ofpatients and the quick institution of effective isolation precautions.But the case reported by Johnson and colleagues raises an importantquestion: How many patients will we be willing to put in isolationin order to avoid missing one case of SARS? As with SARS, themost important part of tuberculosis-infection control is theisolation of the patient.1 In regions where tuberculosis isan uncommon diagnosis, a ratio of isolation of 15 patients withoutdisease to 1 patient with disease appears to be acceptable.2However, this ratio is likely to be much higher for SARS, aslong as we are using the current case definition, which consistsof clinical and epidemiologic criteria. The clinical criteriahave low predictive ability.3 The epidemiologic criteria includetravel within 10 days before the onset of symptoms to an areawith current or previously documented or suspected communitytransmission of SARS. With the number of affected areas in theworld rapidly dwindling, the challenge will be to maintain ourvigilance as the memory of the outbreaks fades.
Donald E. Low, M.D. University of Toronto Toronto, ON M5G1X5, Canada
References
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Rainer TH, Cameron PA, Smit D, et al. Evaluation of WHO criteria for identifying patients with severe acute respiratory syndrome out of hospital: prospective observational study. BMJ 2003;326:1354-1358. [Free Full Text]
Zhong, N., Zhang, S., Zou, P., Chen, J., Kang, X., Li, Z., Liang, C., Jin, C., Xia, B.
(2008). Without Its N-Finger, the Main Protease of Severe Acute Respiratory Syndrome Coronavirus Can Form a Novel Dimer through Its C-Terminal Domain. J. Virol.
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Hsu, W.-C., Chang, H.-C., Chou, C.-Y., Tsai, P.-J., Lin, P.-I., Chang, G.-G.
(2005). Critical Assessment of Important Regions in the Subunit Association and Catalytic Action of the Severe Acute Respiratory Syndrome Coronavirus Main Protease. J. Biol. Chem.
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