title: Role of laboratory variables in differentiating SARS-coronavirus from other causes of community-acquired pneumonia within the first 72 h of hospitalization.
abstract: The Centers for Disease Control and Prevention (CDC) recommend that SARS-coronavirus (SARS-CoV) testing be considered in epidemiologically high-risk patients hospitalized with community-acquired pneumonia (CAP) if no alternative diagnosis is identified after 72 h. The aim of this study was to identify routine laboratory variables that might indicate the need for SARS-CoV testing. Routine hematological/biochemical variables in patients with laboratory-confirmed SARS (2003) were compared with those in consecutive patients hospitalized June-December 2004 with radiologically confirmed CAP. Stepwise logistic regression analyses were performed to identify discriminating variables at baseline and by day 3 of hospitalization. Nasopharyngeal aspiration and antigen detection for influenza virus and respiratory syncytial virus using an immunofluorescence assay (IFA) were routinely performed in patients with CAP. Altogether, 181 patients with CAP (who remained undiagnosed by IFA) and 303 patients with SARS were studied. The mean intervals from symptom onset to admission were 3.1 and 2.8 days, respectively (p > 0.05). The etiological agent of CAP was identified retrospectively in only 39% of cases, the majority being bacterial pathogens. At baseline, age and absolute neutrophil count (ANC) were the only independent discriminating variables (p < 0.0001). Using a value of <4.4 x 10(9)/l as the cutoff for ANC, the sensitivity and specificity of ANC for discriminating SARS were 64 and 95%, respectively (AUC 0.90). By day 3 of hospitalization, age (p < 0.0001), change in ANC (p = 0.0003), and change in bilirubin (p = 0.0065) were discriminating variables. A model combining age <65 years, a change in ANC of >-3 x 10(9)/l, and a change in bilirubin of > or =0 mmol/l had a sensitivity of 43% and a specificity of 95% for SARS (AUC 0.90). There are only a few laboratory features (including lymphopenia) that clearly discriminate SARS from other causes of CAP. Nevertheless, when evaluating epidemiologically high-risk patients with CAP and no immediate alternative diagnosis, a low ANC on presentation along with poor clinical and laboratory responses after 72 h of antibiotic treatment may raise the index of suspicion for SARS and indicate a need to perform SARS-CoV testing.
authors.affiliation: Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong.
authors.forename: N
authors.initials: N
authors.lastname: Lee
authors.forename: T H
authors.initials: TH
authors.lastname: Rainer
authors.forename: M
authors.initials: M
authors.lastname: Ip
authors.forename: B
authors.initials: B
authors.lastname: Zee
authors.forename: M H
authors.initials: MH
authors.lastname: Ng
authors.forename: G E
authors.initials: GE
authors.lastname: Antonio
authors.forename: E
authors.initials: E
authors.lastname: Chan
authors.forename: G
authors.initials: G
authors.lastname: Lui
authors.forename: C S
authors.initials: CS
authors.lastname: Cockram
authors.forename: J J
authors.initials: JJ
authors.lastname: Sung
authors.forename: D S
authors.initials: DS
authors.lastname: Hui
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001663:Bilirubin / Q000097:blood*; D017714:Community-Acquired Infections / Q000175:diagnosis* / Q000382:microbiology; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D007958:Leukocyte Count; D008297:Male; D008875:Middle Aged; D009504:Neutrophils / Q000166:cytology*; D011024:Pneumonia, Viral / Q000097:blood / Q000175:diagnosis*; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D012307:Risk Factors; D045473:Severe acute respiratory syndrome-related coronavirus / Q000472:pathogenicity*; D045169:Severe Acute Respiratory Syndrome / Q000097:blood / Q000175:diagnosis*
chemical_list: D001663:Bilirubin