Clinical features and short-term outcomes of 144 patients with SARS in the greater Toronto area.
BACKGROUND
Severe acute respiratory syndrome (SARS) is an emerging infectious disease that first manifested in humans in China in November 2002 and has subsequently spread worldwide.


OBJECTIVE
To describe the clinical characteristics and short-term outcomes of SARS in the first large group of patients in North America; to describe how these patients were treated and the variables associated with poor outcome.


METHODS
Retrospective case series involving 144 adult patients admitted to 10 academic and community hospitals in the greater Toronto, Ontario, area between March 7 and April 10, 2003, with a diagnosis of suspected or probable SARS. Patients were included if they had fever, a known exposure to SARS, and respiratory symptoms or infiltrates observed on chest radiograph. Patients were excluded if an alternative diagnosis was determined.


METHODS
Location of exposure to SARS; features of the history, physical examination, and laboratory tests at admission to the hospital; and 21-day outcomes such as death or intensive care unit (ICU) admission with or without mechanical ventilation.


RESULTS
Of the 144 patients, 111 (77%) were exposed to SARS in the hospital setting. Features of the clinical examination most commonly found in these patients at admission were self-reported fever (99%), documented elevated temperature (85%), nonproductive cough (69%), myalgia (49%), and dyspnea (42%). Common laboratory features included elevated lactate dehydrogenase (87%), hypocalcemia (60%), and lymphopenia (54%). Only 2% of patients had rhinorrhea. A total of 126 patients (88%) were treated with ribavirin, although its use was associated with significant toxicity, including hemolysis (in 76%) and decrease in hemoglobin of 2 g/dL (in 49%). Twenty-nine patients (20%) were admitted to the ICU with or without mechanical ventilation, and 8 patients died (21-day mortality, 6.5%; 95% confidence interval [CI], 1.9%-11.8%). Multivariable analysis showed that the presence of diabetes (relative risk [RR], 3.1; 95% CI, 1.4-7.2; P =.01) or other comorbid conditions (RR, 2.5; 95% CI, 1.1-5.8; P =.03) were independently associated with poor outcome (death, ICU admission, or mechanical ventilation).


CONCLUSIONS
The majority of cases in the SARS outbreak in the greater Toronto area were related to hospital exposure. In the event that contact history becomes unreliable, several features of the clinical presentation will be useful in raising the suspicion of SARS. Although SARS is associated with significant morbidity and mortality, especially in patients with diabetes or other comorbid conditions, the vast majority (93.5%) of patients in our cohort survived.
University of Toronto, Mount Sinai Hospital, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada.
Christopher M
CM
Booth
Larissa M
LM
Matukas
George A
GA
Tomlinson
Anita R
AR
Rachlis
David B
DB
Rose
Hy A
HA
Dwosh
Sharon L
SL
Walmsley
Tony
T
Mazzulli
Monica
M
Avendano
Peter
P
Derkach
Issa E
IE
Ephtimios
Ian
I
Kitai
Barbara D
BD
Mederski
Steven B
SB
Shadowitz
Wayne L
WL
Gold
Laura A
LA
Hawryluck
Elizabeth
E
Rea
Jordan S
JS
Chenkin
David W
DW
Cescon
Susan M
SM
Poutanen
Allan S
AS
Detsky
D000328:Adult; D000368:Aged; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use; D000998:Antiviral Agents / Q000009:adverse effects / Q000627:therapeutic use; D015415:Biomarkers / Q000097:blood; D021821:Communicable Diseases, Emerging / Q000097:blood / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy; D015897:Comorbidity; D003371:Cough / Q000209:etiology; D003710:Demography; D004196:Disease Outbreaks; D018450:Disease Progression; D004417:Dyspnea / Q000209:etiology; D005260:Female; D005334:Fever / Q000209:etiology; D006760:Hospitalization; D006801:Humans; D006854:Hydrocortisone / Q000627:therapeutic use; D017053:Infection Control; D007362:Intensive Care Units; D008168:Lung / Q000000981:diagnostic imaging; D008297:Male; D008875:Middle Aged; D009864:Ontario / Q000453:epidemiology; D016016:Proportional Hazards Models; D011859:Radiography; D012121:Respiration, Artificial; D012189:Retrospective Studies; D012254:Ribavirin / Q000009:adverse effects / Q000627:therapeutic use; D045473:Severe acute respiratory syndrome-related coronavirus / Q000302:isolation & purification; D045169:Severe Acute Respiratory Syndrome / Q000097:blood / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy; D018709:Statistics, Nonparametric; D016019:Survival Analysis
D000893:Anti-Inflammatory Agents; D000998:Antiviral Agents; D015415:Biomarkers; D012254:Ribavirin; D006854:Hydrocortisone