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Clear Clinical Presentation Helps Physicians Quickly Identify, Manage SARS

Clinical and laboratory features associated with adverse clinical outcomes in patients with suspected severe acute respiratory syndrome (SARS) can help physicians quickly recognize, isolate, and appropriately treat patients in the absence of a good diagnostic test, reports a recent study from Hong Kong.

With the growing spread of SARS worldwide, and the mounting morbidity and mortality in its wake, examination of the outbreaks in particular regions is important to gain an understanding of the clinical course of the disease and ways to reduce its spread and improve identification and treatment of those affected.

To examine the clinical, laboratory, and radiologic features of suspected SARS cases in Hong Kong, Dr. Nelson Lee and colleagues analysed data of 66 men and 72 women admitted to the isolation ward of the Prince of Wales Hospital, Hong Kong, between March 11 and 25, 2003. They had symptoms suggestive of SARS after exposure to an index patient. Of these patients, 69 were health care workers, 16 were medical students, and 53 were patients in the same medical ward or had been visitor to the ward. Coexisting health conditions included cardiovascular disease (n=4), myelodysplastic syndrome (n=2), chronic liver disease (n=3), diabetes (n=5), chronic renal failure (n=2) and chronic pulmonary disease (n=3).

All patients had a fever, as well as other clinical and laboratory signs that included chills, rigor, or both (73.2%), myalgia (60.9%), cough and headache (50%), lymphopenia (69.6%), thrombocytopenia (44.8%), elevated lactate dehydrogenase (71%), and elevated creatine kinase levels (32.1%).

Of the total 138 patients, 32 (23.2%) were admitted to the intensive care unit because of respiratory failure and 5 patients died, all of whom had a previous coexisting condition.

Factors predictive of hospital admission and/or death by univariate analysis were older age, male sex, elevations in the lactate dehydrogenase level, creatine kinase value, and initial absolute neutrophil count, and a low serum sodium level. Pre-existing conditions did not predict for a worse clinical outcome. On multivariate analysis, only advanced age, high peak lactate dehydrogenase level, and absolute neutrophil count that exceeded the upper limit of normal range were statistically associated with worse outcomes.

Based on these findings, the authors suggest that a clear clinical presentation based on identifying clinical, laboratory, and radiologic features associated with SARS will help physicians quickly recognize and appropriately manage these patients.
N Engl J Med 2003;348:1986-1994.

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