Severe acute respiratory syndrome: lessons from Singapore.An outbreak of severe acute respiratory syndrome Severe Acute Respiratory Syndrome (SARS) Definition Severe acute respiratory syndrome (SARS) is the first emergent and highly transmissible viral disease to appear during the twenty-first century. (SARS) occurred in Singapore in March 2003. To illustrate the problems in diagnosing and containing SARS in the hospital, we describe a case series and highlight changes in triage triage Division of patients for priority of care, usually into three categories: those who will not survive even with treatment; those who will survive without treatment; and those whose survival depends on treatment. and infection control practices that have resulted. By implementing these changes, we have stopped the nosocomial nosocomial /noso·co·mi·al/ (nos?o-ko´me-il) pertaining to or originating in a hospital. nos·o·co·mi·al adj. 1. Of or relating to a hospital. 2. transmission of the virus. ********** An outbreak of severe acute respiratory syndrome (SARS) was first recognized in Singapore on March 12, 2003. The index patient was hospitalized at Tan Tock Seng Hospital The Tan Tock Seng Hospital (Abbreviation: TTSH; Chinese: 陈笃生医院; Malay: Hospital Tan Tock Seng , which has since become the country's designated SARS hospital. The patient infected 20 other people (including patients and healthcare workers), who subsequently became the sources for secondary spread of the infection (1). As of June 12, 2003, a total of 206 cases and 31 deaths attributed to SARS had been reported in Singapore. We describe the important lessons learned during the triage and containment of SARS at the National University Hospital, Singapore. Both involved expanding isolation criteria to include all patients with undifferentiated fever (even in the absence of respiratory symptoms or chest x-ray chest x-ray, n an examination of the chest using x-rays. Routinely performed in patients complaining of chest pain to rule out respiratory or heart disease. chest X-ray Chest film, see there changes), improving contact-tracing methods, enforcing the use of fit-tested personal protective equipment in all patient-care areas, avoiding aerosol-generating procedures, and carefully monitoring all healthcare workers for fever or respiratory symptoms. We also highlight the impact of these measures on preventing the entry and nosocomial spread of infection. The Study From March 13 to May 5, 2003, we identified all epidemiologically linked patients whose disease met the Centers for Disease Control and Prevention's case definition of SARS issued on April 29, 2003 (2). Initial investigations included a complete blood count (with a differential count differential count Diff, white blood cell differential count Hematology The relative number of leukocytes–eg segmented and band forms of granulocytes, eosinophils, lymphocytes and monocytes in the peripheral circulation, expressed in percentages of the total ), serum biochemical measurements (including electrolytes, renal and liver function values, creatine kinase creatine kinase /cre·a·tine ki·nase/ (ki´nas) an enzyme that catalyzes the phosphorylation of creatine by ATP to form phosphocreatine. , and lactate dehydrogenase lactate dehydrogenase n. Abbr. LDH Any of a class of enzymes found in the liver, kidneys, striated muscle, and heart muscle that catalyze the reversible conversion of pyruvate and lactate. ), and a chest x-ray. Since the cause of the virus was not known at the onset of the outbreak, routine microbiologic cultures of sputum sputum /spu·tum/ (spu´tum) [L.] expectoration; matter ejected from the trachea, bronchi, and lungs through the mouth. sputum cruen´tum bloody sputum. , urine, and blood were done to rule out common bacterial causes of pneumonia. In addition, mycoplasma mycoplasma Any of the bacteria that make up the genus Mycoplasma. They are among the smallest of bacterial organisms. The cell varies from a spherical or pear shape to that of a slender branched filament. serology Serology The division of biological science concerned with antigen-antibody reactions in serum. It properly encompasses any of these reactions, but is often used in a limited sense to denote laboratory diagnostic tests, especially for syphilis. and urine Legionella Legionella /Le·gion·el·la/ (le?jah-nel´ah) a genus of gram-negative, aerobic, rod-shaped bacteria (family Legionellaceae), normal inhabitants of lakes, streams, and moist soil; they have often been isolated from cooling-tower water, antigen testing were carried out. When reverse transcriptase Reverse transcriptase Any of the deoxyribonucleic acid (DNA) polymerases present in particles of retroviruses which are able to carry out DNA synthesis using an RNA template. polymerase chain reaction polymerase chain reaction (pŏl`ĭmərās') (PCR), laboratory process in which a particular DNA segment from a mixture of DNA chains is rapidly replicated, producing a large, readily analyzed sample of a piece of DNA; the process is (RT-PCR RT-PCR reverse transcriptase-polymerase chain reaction. See PCR1. ) kits for coronavirus coronavirus /co·ro·na·vi·rus/ (ko-ro´nah-vi?rus) any virus belonging to the family Coronaviridae. Coronavirus /Co·ro·na·vi·rus/ (ko-ro´nah-vi?rus detection became available, later patients also provided samples for RT-PCR. Probable SARS was diagnosed in 14 patients and healthcare workers at National University Hospital. The median age of the patients (five men and nine women) was 58 years (range 21-84). Detailed patient characteristics, including background, medical histories, symptoms, and signs, are shown in Tables 1 and 2. Case Histories Case 2 A woman 43 years of age was admitted to the hospital on March 23; she had had fever, headache, vomiting, and coughing for 7 days and diarrhea on the first day of her illness, which spontaneously resolved. She reported no SARS contacts. The patient was admitted to an isolation room with the diagnosis of community-acquired pneumonia community-acquired pneumonia Pneumonia caused by an infection currently present in the community; CAP is the most common cause of infectious death–US, and number 6 killer overall; of the 57% of CAPs in which a pathogen is identified, S pneumoniae , but her condition rapidly deteriorated. She was transferred to the intensive care unit (ICU ICU intensive care unit. ICU abbr. intensive care unit ICU see intensive care unit. ICU ), where she died on March 31. On day 3 of her hospital stay, healthcare workers discovered that she had previously visited a friend with hepatitis at the Tan Tock Seng Hospital. Two unidentified SARS patients had been on that hospital ward. Case 3 Case-patient 3 was an ICU physician who performed a bronchoscopy Bronchoscopy Definition Bronchoscopy is a procedure in which a cylindrical fiberoptic scope is inserted into the airways. This scope contains a viewing device that allows the visual examination of the lower airways. on case-patient 2 on March 26. This procedure was performed in a negative-pressure room with gloves, gown, and an N95 mask. He became ill with fever, headache, and myalgia myalgia /my·al·gia/ (mi-al´jah) muscular pain.myal´gic epidemic myalgia see under pleurodynia. my·al·gia n. on March 29. His initial chest x-ray was clear, and his fever resolved transiently for 30 hours before recurring. Subsequent chest x-rays showed right lower-lobe infiltrates that went on to involve both lung fields. He eventually required intubation intubation /in·tu·ba·tion/ (in?too-ba´shun) the insertion of a tube into a body canal or hollow organ, as into the trachea. endotracheal intubation and ventilatory support in the ICU. He was successfully extubated and has since been discharged. Case 6 A man 63 years of age with coronary artery disease coronary artery disease, condition that results when the coronary arteries are narrowed or occluded, most commonly by atherosclerotic deposits of fibrous and fatty tissue. was admitted to the hospital on April 8 after he reported dizziness and shortness of breath Shortness of Breath Definition Shortness of breath, or dyspnea, is a feeling of difficult or labored breathing that is out of proportion to the patient's level of physical activity. . He had seen his general practitioner general practitioner n. Abbr. GP A physician whose practice consists of providing ongoing care covering a variety of medical problems in patients of all ages, often including referral to appropriate specialists. 2 days earlier with complaints of rhinorrhea, cough, and myalgia. He had a documented temperature of 37.7[degrees]C at the physician's office. On admission he was afebrile afebrile /afe·brile/ (a-feb´ril) without fever. a·feb·rile adj. Apyretic. afebrile without fever. afebrile adjective Feverless , and his chest x-ray showed cardiomegaly cardiomegaly /car·dio·meg·a·ly/ (-meg´ah-le) abnormal enlargement of the heart. car·di·o·meg·a·ly n. Enlargement of the heart. Also called macrocardia, megalocardia. with bilateral lung infiltrates. He was admitted to the general medical ward with probable congestive heart failure congestive heart failure, inability of the heart to expel sufficient blood to keep pace with the metabolic demands of the body. In the healthy individual the heart can tolerate large increases of workload for a considerable length of time. . However, a transthoracic transthoracic /trans·tho·rac·ic/ (-thah-ras´ik) through the thoracic cavity or across the chest wall. trans·tho·rac·ic adj. Across or through the thoracic cavity or chest wall. echocardiogram ech·o·car·di·o·gram n. A visual record produced by echocardiography. Echocardiogram A non-invasive ultrasound test that shows an image of the inside of the heart. showed a normal ejection fraction ejection fraction n. The blood present in the ventricle at the end of diastole and expelled during the contraction of the heart. Ejection fraction . Within 12 hours, he became critically ill and was transferred to the ICU, where he was intubated. His repeat chest x-ray showed worsening bilateral infiltrates consistent with acute respiratory distress syndrome acute respiratory distress syndrome n. See adult respiratory distress syndrome. . The patient had visited an ill brother at the Singapore General Hospital The Singapore General Hospital (abbrev: SGH; Chinese: 新加坡中央医院; Malay: Hospital Besar Singapura) is the (hitherto a SARS-free hospital). The brother had previously been in Tan Tock Seng Hospital, on March 9 31, and was subsequently identified as the index case-patient for the outbreak at the Singapore General Hospital (3). Case-patient 6 went on to infect 15 other people. Case 11 Case-patient 11 was the on-call physician who assessed case-patient 6 and transferred him to the ICU. She had worn a gown, gloves, and N95 mask, despite no requirement to do so on the general ward at that time. She had fever, headache, and myalgia 3 days later. Her chest x-ray on admission was clear. Respiratory and chest x-ray changes occurred on day 5 of illness; the patient was discharged after 12 days. Course of Illness Most of the patients had a prodrome prodrome /pro·drome/ (pro´drom) a premonitory symptom; a symptom indicating the onset of a disease.prodro´malprodro´mic pro·drome n. pl. of fevers and myalgias with no respiratory or chest x-ray changes until several days later. Their illnesses ran a steady course, lasting a median of 11 days. In case-patient 3, the illness exhibited a biphasic bi·pha·sic adj. Having two distinct phases: a biphasic waveform; a biphasic response to a stimulus. pattern with a brief resolution of fever, followed by the return of high temperature and progression of respiratory and chest x-ray changes. A subset of these patients had a fulminant ful·mi·nant adj. Occurring suddenly, rapidly, and with great severity or intensity, usually of pain. ful course with rapidly progressing respiratory failure Respiratory Failure Definition Respiratory failure is nearly any condition that affects breathing function or the lungs themselves and can result in failure of the lungs to function properly. requiring intubation and mechanical ventilation mechanical ventilation n. A mode of assisted or controlled ventilation using mechanical devices that cycle automatically to generate airway pressure. . Hematologic hematological, hematologic pertaining to or emanating from blood cells. hematological tests total and differential white cell counts, hematocrit estimation, erythrocyte count. and Biochemical Findings The hematologic and biochemical findings of the case-patients on admission are summarized in Tables 3 and 4. Leukocyte count leukocyte count see White cell count was normal in nine case-patients. Mild leukopenia leukopenia /leu·ko·pe·nia/ (-pe´ne-ah) reduction of the number of leukocytes in the blood below about 5000 per cubic mm.leukope´nic basophilic leukopenia basophilopenia. was observed in one case-patient, and leukocytosis Leukocytosis Definition Leukocytosis is a condition characterized by an elevated number of white cells in the blood. Description Leukocytosis is a condition that affects all types of white blood cells. was observed in another. Lymphopenia (defined as <1.50 X [10.sup.-9]/L) was observed in all patients. We found mild thrombocytopenia Thrombocytopenia Definition Thrombocytopenia is an abnormal drop in the number of blood cells involved in forming blood clots. These cells are called platelets. in two case-patients. The lactate Lactate A salt or ester of lactic acid (CH3CHOHCOOH). In lactates, the acidic hydrogen of the carboxyl group has been replaced by a metal or an organic radical. Lactates are optically active, with a chiral center at carbon 2. dehydrogcnase levels were elevated in eight case-patients. The C-reactive protein C-Reactive Protein Definition C-reactive protein (CRP) is a protein produced by the liver and found in the blood. Purpose C-reactive protein is not normally found in the blood of healthy people. was elevated in 7 of 11 case-patients, and the procalcitonin was raised in four of five case-patients. Radiologic Changes We saw a variety of chest x-ray changes in these patients (Tables 3 and 4). The primary abnormalities were patchy unilateral or bilateral consolidation. Opacities were predominantly in the lower lung zones in most patients. Three patients had upper lobe infiltrates. However, live of the patients were admitted to the hospital with normal chest x-ray results. Conclusions On March 18, 2003, our emergency department began screening all febrile febrile /feb·rile/ (feb´ril) pertaining to or characterized by fever. feb·rile adj. Of, relating to, or characterized by fever; feverish. patients with respiratory complaints for possible SARS (2). All suspected SARS patients were admitted to a negative-pressure isolation room for monitoring. Probable SARS case-patients were transferred to Tan Tock Seng Hospital for further management to keep the hospital free of the SARS virus. The varied clinical signs and symptoms of SARS have limited the success of such a triage system (4-8). We have observed that current diagnostic guidelines may not be sufficiently sensitive for assessing patients before admission to hospital. For example, although a temperature of >38[degrees]C is part of the diagnostic criteria (2), this symptom was notably absent in two patients. The lack of a fever in case-patient 4 may have been the result of long-term steroid use. Case-patient 6 never had a documented temperature [greater than or equal to] 37.7[degrees]C and was hypothermic hy·po·ther·mi·a n. Abnormally low body temperature. [hypo- + Greek therm throughout his hospitalization. In addition, a subset of patients may have fever and myalgias without respiratory complaints or chest x-ray changes until later (cases 3 and 11). Booth et al., in a retrospective analysis of 144 patients with SARS, reported that 11% of patients had no respiratory symptoms and would not meet current criteria for SARS, despite having fever, contact history, and chest x-ray infiltrates (9). Rainer et al., in a study of 515 patients attending a SARS screening clinic, found that current World Health Organization guidelines, which emphasize respiratory tract respiratory tract n. The air passages from the nose to the pulmonary alveoli, including the pharynx, larynx, trachea, and bronchi. Respiratory tract symptoms, had a low sensitivity of 26% (10). We expanded our isolation criteria to include all patients with undifferentiated febrile illness and chest x-ray infiltrates with or without fever or respiratory symptoms until an alternative diagnosis is made, or until they defervesce de·fer·ves·cence n. The abatement of a fever. [From Latin d  ferv and serial chest x-ray findings are normal.The nonspecific nonspecific /non·spe·cif·ic/ (non?spi-sif´ik) 1. not due to any single known cause. 2. not directed against a particular agent, but rather having a general effect. nonspecific 1. symptoms of this illness often require establishing a history of contact with a SARS patient as a critical clue to the diagnosis (2). However, a contact history may not be forthcoming at the initial interview. In Singapore, SARS is an imported infection in which the epidemiology remains well defined with clear lines of secondary spread in the hospitals and community (3). Emphasis is placed on using local epidemiologic clues to elicit a history of visits or previous admissions to Tan Tuck Seng Hospital or other healthcare facilities and to inquire whether any family members are ill or hospitalized. Patients without a contact history are still isolated if the clinical suspicion clinical suspicion A working hypothesis about a Pt's diagnosis, which is then tested with appropriately targeted tests to arrive at a definitive diagnosis; a CS is based on a constellation of findings in a Pt that suggests to the physician a limited palette of is high. A national computerized database of SARS patients and their contacts has been established to assist with this process. An epidemiology team is also used to perform more exhaustive contact tracing In epidemiology, contact tracing is the identification and diagnosis of persons who may have come into contact with an infected person. For sexually transmitted diseases, this is generally limited to sexual partners but for highly virulent diseases such as Ebola and tuberculosis, a and liaisons with other healthcare facilities. This team also monitors and investigates any clusters of pneumonias within our hospital. Suspected case-patients are then immediately transferred to the isolation area for further investigation. Our initial infection-control policy first required staff working in the emergency department, ICU, and isolation rooms to wear full personal protection equipment (PPE PPE (Brit) n abbr (Univ) (= philosophy, politics, and economics) → Studiengang bestehend aus Philosophie, Politologie und Volkswirtschaft PPE n abbr (BRIT ) (SCOL ), which included an N95 mask, disposable gloves, and long-sleeve gowns. Virus transmission is likely due to droplet infection drop·let infection n. An infection transmitted from one individual to another by droplets of moisture expelled from the upper respiratory tract through sneezing or coughing. , but fecal-oral transmission has also been reported (11). The role of fomites fomites see fomes. has yet to be defined; preliminary data suggest that the virus can remain viable at room temperature for at least 2 days. Recognizing that patients with unsuspected cases of SARS could slip through our triage system onto the general wards (see case 6), all hospital staff with direct patient contact were required to wear full PPE beginning April 8. In addition, all patients are now examined with the use of dedicated equipment. Despite the use of PPE, two of our physicians were infected with the virus. The first physician performed an invasive procedure (bronchoscopy) on case-patient 2. The outlet port of the patient's ventilator was later discovered to have malfunctioned during the procedure, exposing the physician to a large jet of exhaled air. Reports of protected healthcare workers becoming infected during intubation of SARS patients have also emerged from Canada (12). The recommendations on the use of PPE are likely insufficient for procedures that may promote aerosolization of respiratory secretions (13). Therefore, these procedures are now performed in a negative-pressure room (with an anteroom) using a positive air purifying respirator respirator /res·pi·ra·tor/ (res´pi-ra?ter) ventilator (2). cuirass respirator see under ventilator. suit. The second physician (case-patient 11) may have become infected because the N95 mask was poorly fitting. Alternatively, transmission may have occurred through the conjunctival con·junc·ti·val adj. Relating to the conjunctiva. conjunctival pertaining to or emanating from conjunctiva. congenital conjunctival membrane mucosa. All healthcare workers are now required to use eye protection when examining patients. Fit-testing of N95 masks is also mandatory, in addition to training on the correct use and disposal of PPE. SARS has demonstrated remarkably efficient transmission in the hospital environment (76% of Singapore cases were nosocomially acquired) (3). At our hospital, nosocomial transmission occurred in nine persons. Our hospital structure of open wards with large numbers of beds separated by curtains may have been a contributory factor to the spread of the virus. These wards are subdivided into cubicles of four to eight beds and have open windows and ceiling fans with no controlled airflow patterns. Another likely factor was the failure to implement a policy of universal PPE use early in the outbreak. Where such measures were implemented (i.e., isolation rooms), no nosocumial transmission occurred. In addition, because hospital staff are a recognized source of secondary transmission (3,4,6), all healthcare workers are now required to monitor their temperatures three times a day. Anyone with a respiratory illness or a temperature >37.5[degrees]C is removed from duty, pending further evaluation. This policy has successfully prevented the secondary transmission of SARS from affected healthcare workers. The lessons gathered from our hospital outbreak have resulted in dramatic changes to our triage and infection-control policies. All patients with undifferentiated febrile illness, respiratory" complaints, or chest x-ray infiltrates are isolated, screened for SARS contacts, and nursed with full PPE. Despite continued community transmission of SARS in Singapore (the last community case was identified on May 10, 2003), the measures implemented since April 8, 2003, enabled us to identify and contain eight additional SARS cases and prevent the nosocomial transmission of the virus.
Table 1. Admitting clinical characteristics of patients 1 through 7
with severe acute respiratory syndrome
Patient
Characteristic 1 2
Sex F F
Age 71 43
Source of virus Community Community
Admission diagnosis Meningitis Pneumonia
Co-illnesses IHD; DM; Hypertension
hypothyroidism
Symptoms
Cough - +
Dyspnea - +
Rhinorrhea - -
Sore throat - +
Headache - +
Myalgia - -
Fever +
Others Confusion Vomiting,
diarrhea
Temp on admission ([degrees]C) 38.7 38.9
Physical signs
Crackles + +
Chest x-ray findings Right basal Bibasilar
infiltrates infiltrates
RT-PCR ND ND
Outcome Survived Died
Patient
Characteristic 3 4
Sex M F
Age 40 78
Source of virus HCW Community
Admission diagnosis Suspect Interstitial
SARS lung disease
Co-illnesses IHD, ypertension;
chronic renal
failure;
CTD on steroids
Symptoms
Cough + -
Dyspnea - +
Rhinorrhea - -
Sore throat - -
Headache + -
Myalgia + -
Fever + -
Others
Temp on admission ([degrees]C) 36.8 36.0
Physical signs
Crackles + +
Chest x-ray findings Right basal Right basal
infiltrates infiltrates
RT-PCR Positive ND
Outcome Survived Died
Patient
Characteristic 5 6
Sex F M
Age 53 63
Source of virus Community Community
Admission diagnosis Pneumonia Congestive
heart failure
Co-illnesses IHD
Hypertension
Symptoms
Cough + +
Dyspnea + -
Rhinorrhea - +
Sore throat - -
Headache - -
Myalgia - +
Fever + +
Others Dizziness
Temp on admission ([degrees]C) 39.6 35.1
Physical signs
Crackles + +
Chest x-ray findings Bilateral Bilateral
infiltrates infiltrates
RT-PCR Positive Positive
Outcome Died Died
Patient
Characteristic 7
Sex M
Age 84
Source of virus Inpatient
Admission diagnosis Pneumonia
SARS contact
Co-illnesses IHD
Cerebrovascular
disease
Symptoms
Cough -
Dyspnea +
Rhinorrhea -
Sore throat -
Headache -
Myalgia -
Fever +
Others
Temp on admission ([degrees]C) 38.0
Physical signs
Crackles +
Chest x-ray findings Right upper lobe
infiltrates
RT-PCR ND
Outcome Died
(a) F, female; M, male; HCW, healthcare worker; SARS, severe acute
respiratory syndrome; IHD, ischemic heart disease: DM, diabetes
mellitus; CTD, connective tissue disease; RT-PCR, reverse
transcriptase polymerase chain reaction; ND, not done.
Table 2. Admitting clinical characteristics of patients 8 through 14
with severe acute respiratory syndrome
Patient
Characteristic 8 9
Sex M F
Age 63 74
Source Inpatient Inpatient
Admission diagnosis Pneumonia; Escherichia
SARS coli UTI;
contact SARS contact
Co-illnesses IHD; DM; IHD; DM;
hypertension hypertension;
cerebrovascular
disease
Symptoms
Cough - -
Dyspnea - -
Rhinorrhea - -
Sore throat - -
Headache - -
Myalgia - -
Fever + +
Others
Temp. on admission ([degrees]C) 38.5 38.0
Physical signs
Crackles + -
Chest x-ray findings Right basil Bibasilar
infiltrates infiltrates
RT-PCR ND Positive
Outcome Survived Died
Patient
Characteristic 10 11
Sex M F
Age 72 28
Source Inpatient HCW
Admission diagnosis Pneumonia. Suspect
SARS contact SARS
Co-illnesses Dilated None
cardiomyopathy;
hypertension;
chronic renal
failure
Symptoms
Cough - -
Dyspnea - -
Rhinorrhea - -
Sore throat - -
Headache - +
Myalgia - +
Fever + +
Others
Temp. on admission ([degrees]C) 38.5 38.2
Physical signs
Crackles + -
Chest x-ray findings Right basal Right basal
infiltrates infiltrates
RT-PCR Positive Positive
Outcome Survived Survived
Patient
Characteristic 12 13
Sex F F
Age 24 28
Source HCW HCW
Admission diagnosis Suspect Suspect
SARS SARS
Co-illnesses None None
Symptoms
Cough - -
Dyspnea - -
Rhinorrhea - -
Sore throat + -
Headache - -
Myalgia + -
Fever + +
Others
Temp. on admission ([degrees]C) 38.0 38.5
Physical signs
Crackles - -
Chest x-ray findings Right basil Right upper
infiltrates lobe infiltrates
RT-PCR Positive Positive
Outcome Survived Survived
Patient
Characteristic 14
Sex F
Age 21
Source HCW
Admission diagnosis Suspect
SARS
Co-illnesses None
Symptoms
Cough -
Dyspnea -
Rhinorrhea -
Sore throat -
Headache +
Myalgia +
Fever +
Others
Temp. on admission ([degrees]C) 38.8
Physical signs
Crackles -
Chest x-ray findings Left upper
lobe infiltrates
RT-PCR Positive
Outcome
(a) M, male: F, female; HCW, healthcare worker: SARS, severe acute
respiratory syndrome; UTI, urinary tract infection; IHD, ischemic
heart disease: DM, diabetes mellitus; RT-PCR reverse transcriptase
polymerase chain reaction: temp., temperature; ND, not done.
Table 3. Laboratory data for patients 1 through 7 admitted with severe
acute respiratory syndrome
Patient 1 2 3
Hemoglobin (g/dL) 10.9# 12.5 13.4
Leukocyte count (X[10.sup.-9]/L) 4.52 19.34# 5.3
Lymphocyte count (X[10.sup.-9]/L) 0.78# 0.94# 0.71#
Platelet count (X[10.sup.-9]/L) 117# 149 189
ALT (U/L) 55 37 23
AST (U/L) 65# 108# 39
CK 290 183 213
LDH 747# 2,513# 518 (b)#
C-reactive protein 5.2# 34.0# 141.4#
Procalcitonin 0.14 1.45# ND
Patient 4 5 6
Hemoglobin (g/dL) 14.1 12.0 16.3
Leukocyte count (X[10.sup.-9]/L) 14.65# 5.41 9.29
Lymphocyte count (X[10.sup.-9]/L) 1.02# 0.53# 0.63#
Platelet count (X[10.sup.-9]/L) 180 176 136
ALT (U/L) 22 76# 35
AST (U/L) 102# 121# 92#
CK 86 1,045# 124
LDH 1,032# 2,248# 2,015#
C-reactive protein 27.4# ND ND
Procalcitonin 1.27# ND 15.21#
Patient 7
Hemoglobin (g/dL) 12.1
Leukocyte count (X[10.sup.-9]/L) 10.14
Lymphocyte count (X[10.sup.-9]/L) 0.21#
Platelet count (X[10.sup.-9]/L) 82#
ALT (U/L) 210#
AST (U/L) 58#
CK 499#
LDH 955#
C-reactive protein 7.4#
Procalcitonin ND
(a) ALT, alanine aminotransferase; AST, aspartate aminotransfense;
CK creatine kinase; LDH, lactate dehydrogenase; ND, not done; values
in boldface are abnormal.
(b) Normal value for LDH at this laboratory was <500.
Note: Values indicated with # are abnormal.
Table 4. Laboratory data for patients 8 through 14 admitted with
severe acute respiratory syndrome
Patient 8 9 10
Hemoglobin (g/dL) 15.0 8.4 11.2
Leukocyte count (X[10.sup.-9]/L) 3.73 7.2 4.94
Lymphocyte count (X[10.sup.-9]/L) 0.83 1.34 1.04
Platelet count (X[10.sup.-9]/L) 121 163 167
ALT (U/L) 51 31 20
AST (U/L) 68 52 19
CK 35 192 73
LDH 685 1,034 390
C-reactive protein 3.1 4.3 0.9
Procalcitonin ND 1.27 ND
Patient 11 12 13
Hemoglobin (g/dL) 12.5 14.3 13.2
Leukocyte count (X[10.sup.-9]/L) 6.3 3.6 6.2
Lymphocyte count (X[10.sup.-9]/L) 0.30 0.84 1.13
Platelet count (X[10.sup.-9]/L) 231 176 184
ALT (U/L) 10 15 19
AST (U/L) 21 21 21
CK 68 85 88
LDH 280 275 319
C-reactive protein <0.7 <0.7 <0.7
Procalcitonin ND ND ND
Patient 14
Hemoglobin (g/dL) 13.5
Leukocyte count (X[10.sup.-9]/L) 6.76
Lymphocyte count (X[10.sup.-9]/L) 11.97
Platelet count (X[10.sup.-9]/L) 240
ALT (U/L) 8
AST (U/L) 25
CK 56
LDH 696
C-reactive protein <0.7
Procalcitonin ND
(a) ALT, alanine aminotransferase; AST, aspartate aminotransferase;
CK, creatine kinase; LDH, lactate dehydrogenase; ND, not done.
References (1.) Hsu Li-Yang, Lee CC, Green JA, Ang B, Paton N, Lee L, et al. Severe acute respiratory syndrome (SARS) in Singapore: features of index patient and initial contacts. Emerg Infect Dis 2003:9:713-7. (2.) Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. . Updated interim surveillance case definition for severe acute respiratory syndrome (SARS)--United States, April 29, 2003. MMWR MMWR Morbidity & Mortality Weekly Report Epidemiology A news bulletin published by the CDC, which provides epidemiologic data–eg, statistics on the incidence of AIDS, rabies, rubella, STDs and other communicable diseases, causes of mortality–eg, Morb Mortal Wkly Rep 2003;52:391-3. (3.) Centers for Disease Control and Prevention. Severe acute respiratory syndrome--Singapore, 2003. MMWR Morb Mortal Wkly Rep 2003;52:405-12. (4.) Tsang KW, Ho PL, Ooi GC, Yet WK, Wang T, Chan-Yeung M, et al. A cluster of cases of severe acute respiratory syndrome in Hong Kong. N Engl J Med 2003;348:1977-85. (5.) Poutanen SM, Low DE, Henry B, Finkelstein S, Rose D, Green K, et al. Identification of severe acute respiratory syndrome in Canada. N Engl J Med 2003;348:1995-2005. (6.) Centers for Disease Control and Prevention. Preliminary clinical description of severe acute respiratory syndrome. MMWR Morb Mortal Wldy Rep 2003;52:255-6. (7.) Peiris JSM JSM Journal of Sexual Medicine JSM Just Shoot Me (sitcom) JSM Journal of Sport Management JSM Journal of Software Maintenance JSM Jabber Session Manager JSM John Sidney McCain JSM JEOL Scanning Microscope , Chu CM, Cheng VCC An electronics designation that refers to voltage from a power supply connected to the "collector" terminal of a bipolar transistor. In an NPN bipolar (BJT) transistor, it would be +Vcc, while in a PNP transistor, it would be -Vcc. , Chan KS, Hung IF, Poon poon n. Any of several trees of the genus Calophyllum, of southern Asia, having light hard wood used for masts and spars. [Sinhalese p LL, et al. Clinical progression and viral load viral load n. The concentration of a virus, such as HIV, in the blood. viral load, n a measure of the number of virus particles present in the bloodstream, expressed as copies per milliliter. in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet 2003;361:1767-72. (8.) Fisher DA, Lim TK, Lim YT, Singh KS, Tambyah PA. Atypical presentations of SARS. Lancet 2003;361:1740. (9.) Booth CM, Matukas LM, Tomlinson GA, Rachlis AR, Rose DB, Dwash IIA (1) (Information Industry Association, Washington, DC) In 1999, IIA merged with SPA (Software Publishers Association) to become the Software & Information Industry Association. See SIIA. , et al. Clinical features and short-term outcomes of 144 patients with SARS in the greater Toronto area The Greater Toronto Area (widely abbreviated as the GTA) is the most populous metropolitan area in Canada. The GTA is a provincial planning area with a population of 5,555,912 at the 2006 Canadian Census. . JAMA JAMA abbr. Journal of the American Medical Association 2003;289:1-9. (10.) Rainer TH, Cameron PA, Smit D, Ong KL, Hung AN, Nin DC, et al. Evaluation of WHO criteria for identifying patients with severe acute respiratory syndrome out of hospital: prospective observational study. BMJ BMJ n abbr (= British Medical Journal) → vom BMA herausgegebene Zeitschrift 2003;326:1354-8. (11.) Hong Kong Department of Health. Atypical pneumonia atypical pneumonia n. See primary atypical pneumonia. atypical pneumonia Chest medicine A clinically 'atypical' form of pneumonia, which lacks the classic signs and Sx of pneumonia Types Chlamydia pneumonia, . Available from: URL URL in full Uniform Resource Locator Address of a resource on the Internet. The resource can be any type of file stored on a server, such as a Web page, a text file, a graphics file, or an application program. : http://www.info.gov.hk/dh/ap.htm (12.) Cluster of severe acute respiratory syndrome cases among protected healthcare workers--Toronto, April 2003. Canada Communicable Diseases Report. Available from: URL: http://www.he-sc.gc.ca (13.) Centers for Disease Control and Prevention. Updated interim domestic guidelines for triage and disposition of patients who may have severe acute respiratory syndrome (SARS). Available from: URL: http://www.cdc.gov/ncidod/sars/triage_interim_guidance Kamaljit Singh, * Li-Yang Hsu, ([dagger]) Jorge S. Villacian, ([dagger]) Abdulrazaq Habib, * Dale Fisher,* and Paul A. Tambyah * * National University Hospital, Singapore; and ([dagger]) Tan Tock Seng Hospital, Singapore Dr. Singh is an associate consultant in infectious diseases and microbiology at file National University Hospital. His research interests include serologic se·rol·o·gy n. pl. se·rol·o·gies 1. The science that deals with the properties and reactions of serums, especially blood serum. 2. assays for file diagnosis of severe acute respiratory syndrome, and molecular epidemiology molecular epidemiology Molecular medicine An evolving field that combines the tools of standard epidemiology–case studies, questionnaires and monitoring of exposure to external factors with the tools of molecular biology–eg, restriction endonucleases, , and polymerase chain reaction for the rapid diagnosis of dengue virus dengue virus n. A virus of the genus Flavivirus that is the cause of dengue. . Address for correspondence: Kamaljit Singh, Department of Medicine, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074; fax: (65) 67750127; email: kamalsingh@lycos.com Use of trade names is for identification only and does not imply endorsement by the Public Health Service or by the U.S. Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979 Health and Human Services, HHS . |
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