title: Clinical features and viral diagnosis of two cases of infection with Middle East Respiratory Syndrome coronavirus: a report of nosocomial transmission.
abstract: BACKGROUND
  Human infection with a novel coronavirus named Middle East Respiratory Syndrome coronavirus (MERS-CoV) was first identified in Saudi Arabia and the Middle East in September, 2012, with 44 laboratory-confirmed cases as of May 23, 2013. We report detailed clinical and virological data for two related cases of MERS-CoV disease, after nosocomial transmission of the virus from one patient to another in a French hospital.
  
  
  METHODS
  Patient 1 visited Dubai in April, 2013; patient 2 lives in France and did not travel abroad. Both patients had underlying immunosuppressive disorders. We tested specimens from the upper (nasopharyngeal swabs) or the lower (bronchoalveolar lavage, sputum) respiratory tract and whole blood, plasma, and serum specimens for MERS-CoV by real-time RT-PCR targeting the upE and Orf1A genes of MERS-CoV.
  
  
  RESULTS
  Initial clinical presentation included fever, chills, and myalgia in both patients, and for patient 1, diarrhoea. Respiratory symptoms rapidly became predominant with acute respiratory failure leading to mechanical ventilation and extracorporeal membrane oxygenation (ECMO). Both patients developed acute renal failure. MERS-CoV was detected in lower respiratory tract specimens with high viral load (eg, cycle threshold [Ct] values of 22·9 for upE and 24 for Orf1a for a bronchoalveolar lavage sample from patient 1; Ct values of 22·5 for upE and 23·9 for Orf1a for an induced sputum sample from patient 2), whereas nasopharyngeal specimens were weakly positive or inconclusive. The two patients shared the same room for 3 days. The incubation period was estimated at 9-12 days for the second case. No secondary transmission was documented in hospital staff despite the absence of specific protective measures before the diagnosis of MERS-CoV was suspected. Patient 1 died on May 28, due to refractory multiple organ failure.
  
  
  CONCLUSIONS
  Patients with respiratory symptoms returning from the Middle East or exposed to a confirmed case should be isolated and investigated for MERS-CoV with lower respiratory tract sample analysis and an assumed incubation period of 12 days. Immunosuppression should also be taken into account as a risk factor.
  
  
  BACKGROUND
  French Institute for Public Health Surveillance, ANR grant Labex Integrative Biology of Emerging Infectious Diseases, and the European Community's Seventh Framework Programme projects EMPERIE and PREDEMICS.
authors.affiliation: Service de Gestion du Risque Infectieux, Vigilances et Infectiologie, Hopital Huriez, Pavillon Fourrier, Centre Hospitalier Régional et Universitaire de Lille, Université de Lille 2, Lille Cedex, France. bguery@invivo.edu
authors.forename: Benoit
authors.initials: B
authors.lastname: Guery
authors.forename: Julien
authors.initials: J
authors.lastname: Poissy
authors.forename: Loubna
authors.initials: L
authors.lastname: el Mansouf
authors.forename: Caroline
authors.initials: C
authors.lastname: Séjourné
authors.forename: Nicolas
authors.initials: N
authors.lastname: Ettahar
authors.forename: Xavier
authors.initials: X
authors.lastname: Lemaire
authors.forename: Fanny
authors.initials: F
authors.lastname: Vuotto
authors.forename: Anne
authors.initials: A
authors.lastname: Goffard
authors.forename: Sylvie
authors.initials: S
authors.lastname: Behillil
authors.forename: Vincent
authors.initials: V
authors.lastname: Enouf
authors.forename: Valérie
authors.initials: V
authors.lastname: Caro
authors.forename: Alexandra
authors.initials: A
authors.lastname: Mailles
authors.forename: Didier
authors.initials: D
authors.lastname: Che
authors.forename: Jean-Claude
authors.initials: JC
authors.lastname: Manuguerra
authors.forename: Daniel
authors.initials: D
authors.lastname: Mathieu
authors.forename: Arnaud
authors.initials: A
authors.lastname: Fontanet
authors.forename: Sylvie
authors.initials: S
authors.lastname: van der Werf
mesh_terms: D017934:Coronavirus / Q000235:genetics; D018352:Coronavirus Infections / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000635:transmission / Q000821:virology; D003428:Cross Infection / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000635:transmission / Q000821:virology*; D017809:Fatal Outcome; D005602:France / Q000453:epidemiology; D006801:Humans; D055256:Infectious Disease Incubation Period; D008168:Lung / Q000000981:diagnostic imaging; D008297:Male; D008875:Middle Aged; D011859:Radiography; D060888:Real-Time Polymerase Chain Reaction; D014195:Travel