Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study.
BACKGROUND
We investigated the temporal progression of the clinical, radiological, and virological changes in a community outbreak of severe acute respiratory syndrome (SARS).


METHODS
We followed up 75 patients for 3 weeks managed with a standard treatment protocol of ribavirin and corticosteroids, and assessed the pattern of clinical disease, viral load, risk factors for poor clinical outcome, and the usefulness of virological diagnostic methods.


RESULTS
Fever and pneumonia initially improved but 64 (85%) patients developed recurrent fever after a mean of 8.9 (SD 3.1) days, 55 (73%) had watery diarrhoea after 7.5 (2.3) days, 60 (80%) had radiological worsening after 7.4 (2.2) days, and respiratory symptoms worsened in 34 (45%) after 8.6 (3.0) days. In 34 (45%) patients, improvement of initial pulmonary lesions was associated with appearance of new radiological lesions at other sites. Nine (12%) patients developed spontaneous pneumomediastinum and 15 (20%) developed acute respiratory distress syndrome (ARDS) in week 3. Quantitative reverse-transcriptase (RT) PCR of nasopharyngeal aspirates in 14 patients (four with ARDS) showed peak viral load at day 10, and at day 15 a load lower than at admission. Age and chronic hepatitis B virus infection treated with lamivudine were independent significant risk factors for progression to ARDS (p=0.001). SARS-associated coronavirus in faeces was seen on RT-PCR in 65 (97%) of 67 patients at day 14. The mean time to seroconversion was 20 days.


CONCLUSIONS
The consistent clinical progression, shifting radiological infiltrates, and an inverted V viral-load profile suggest that worsening in week 2 is unrelated to uncontrolled viral replication but may be related to immunopathological damage.
Peiris
J S M
JS
Department of Microbiology, Queen Mary Hospital, University of Hong Kong, Hong Kong, Special Administrative Region, China.
Chu
C M
CM
Cheng
V C C
VC
Chan
K S
KS
Hung
I F N
IF
Poon
L L M
LL
Law
K I
KI
Tang
B S F
BS
Hon
T Y W
TY
Chan
C S
CS
Chan
K H
KH
Ng
J S C
JS
Zheng
B J
BJ
Ng
W L
WL
Lai
R W M
RW
Guan
Y
Y
Yuen
K Y
KY
D000284:Administration, Oral; D000328:Adult; D000368:Aged; D019980:Amoxicillin-Potassium Clavulanate Combination / Q000008:administration & dosage; D004196:Disease Outbreaks / Q000706:statistics & numerical data*; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007262:Infusions, Intravenous; D007902:Length of Stay; D008168:Lung / Q000000981:diagnostic imaging; D008297:Male; D008875:Middle Aged; D015242:Ofloxacin; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000175:diagnosis / Q000628:therapy; D020551:Pulse Therapy, Drug; D011859:Radiography; D045473:Severe acute respiratory syndrome-related coronavirus / Q000302:isolation & purification*; D045169:Severe Acute Respiratory Syndrome / Q000175:diagnosis* / Q000188:drug therapy / Q000453:epidemiology* / Q000821:virology; D015996:Survival Rate; D019562:Viral Load / Q000706:statistics & numerical data*
D019980:Amoxicillin-Potassium Clavulanate Combination; D015242:Ofloxacin