Middle East Respiratory Syndrome Coronavirus (MERS-CoV)

Epidemiology

  • History: first identified in 2012 in a patient with fatal pneumonia in Jeddah, Saudi Arabia (NEJM, 2012) [MEDLINE]
  • Prevalence and Geographic Features
    • 834 Laboratory-Confirmed MERS-CoV were Reported Between 2012-July, 2014 (NEJM, 2012) [MEDLINE]
      • High Fatality Rate: 288 of these cases were fatal
    • Known Cases Were All Linked to Countries in the Arabian Peninsula (MBio, 2014) [MEDLINE]
      • Jordan
      • Qatar
      • Saudi Arabia
      • United Arab Emirates

Clinical Risk Factors (Ann Intern Med, 2014) [MEDLINE]

  • Cardiovascular Disease
    • Cardiac Surgery: present in 25% of cases
    • Congestive Heart Failure (CHF) (see Congestive Heart Failure, [[Congestive Heart Failure]]): present in 17% of cases
    • Hypertension (see Hypertension, [[Hypertension]]): present in 50% of cases
    • Myocardial Infarction: present in 33% of cases
    • Valvular Disease: present in 8% of cases
  • Diabetes Mellitus (DM) (see Diabetes Mellitus, [[Diabetes Mellitus]]): present in 67% of cases
  • Pulmonary Disease
    • Asthma (see Asthma, [[Asthma]]): present in 8% of cases
  • Renal Disease
    • Chronic Kidney Disease (CKD) (see Chronic Kidney Disease, [[Chronic Kidney Disease]]): present in 42% of cases
  • Vascular Disease
  • Other
    • Melanoma (see Melanoma, [[Melanoma]]): present in 8% of cases
    • Neuromuscular Disease: present in 8% of cases
    • Obesity (see Obesity, [[Obesity]]): present in 25% of cases
    • Renal/Liver Transplant (see Renal Transplant, [[Renal Transplant]] and Liver Transplant, [[Liver Transplant]]): present in 8% of cases

Microbiology

  • Middle East Respiratory Syndrome Coronavirus (MERS-CoV) (see Coronaviruses, [[Coronaviruses]])

Transmission

  • Person-to-Person Transmission: has been documented (NEJM, 2014) [MEDLINE]
    • Rate of Secondary Transmission to Household Contacts was 5% (NEJM, 2014) [MEDLINE]
    • Hospital Outbreaks Have Been Reported (NEJM, 2013) [MEDLINE]

Diagnosis

Arterial Blood Gas (ABG) (see Arterial Blood Gas, [[Arterial Blood Gas]])

Chest X-Ray (see Chest X-Ray, [[Chest X-Ray]])

  • xxx

Chest CT (see Chest Computed Tomography, [[Chest Computed Tomography]])

  • xxxx

Lower Respiratory Tract Specimen MERS-CoV Real-Time Reverse Transcriptase Polymerase Chain Reaction (rRT-PCR)

  • Samples
    • Bronchoalveolar Lavage (BAL) Fluid (see Bronchoscopy, [[Bronchoscopy]])
    • Endotracheal Aspirate
    • Sputum
  • Recommended as First Line Testing by the CDC

Upper Respiratory Tract Specimen

  • Samples
    • Nasopharyngeal Aspirate
  • Should Also Be Obtained

Acute and Convalescent Paired Serum Samples

  • Should Be Obtained: not helpful in acute setting, but may yield useful epidemiologic data

Stool Sample

  • May Give Information Regarding the Pattern of Viral Shedding: pattern is currently unknown

Blood MERS-CoV Polymerase Chain Reaction (PCR)

  • May Be Diagnostic

Clinical Manifestations

General Comments

  • Incubation Time: 5.2 days (2-14 days)
  • Clinical Features: resemble that of the Severe Acute Respiratory Syndrome Coronavirus (SAR-CoV) (see Severe Acute Respiratory Syndrome Coronavirus, [[Severe Acute Respiratory Syndrome Coronavirus]]) [MEDLINE]: severe hypoxemia, failure of NIPPV, etc
    • However, Cases of MERS-CoV Reported All Had Underlying Co-Morbid Diseases (As Noted Above) (Ann Intern Med, 2014) [MEDLINE]
    • In Addition, All MERS-CoV Cases Required ICU Care (Ann Intern Med, 2014) [MEDLINE]
      • In contrast, in Canadian series of SARS-CoV, only 19% of cases reqired ICU care (JAMA, 2003) [MEDLINE]

Cardiovascular Manifestations

  • Hypotension/Septic Shock (see Sepsis, [[Sepsis]])

Gastrointestinal Manifestations

Neurologic Manifestations

  • Headache (see Headache, [[Headache]]): present in 17% of cases (Ann Intern Med, 2014) [MEDLINE]

Otolaryngologic Manifestations

Pulmonary Manifestations

Renal Manifestations

  • Acute Kidney Injury (AKI) (see Acute Kidney Injury, [[Acute Kidney Injury]]): AKI requiring dialysis was reported in 58% of cases [MEDLINE]

Rheumatologic Manifestations

  • Arthralgias/Myalgias (see Arthralgias, [[Arthralgias]] and Myalgias, [[Myalgias]]): present in 25% of cases (Ann Intern Med, 2014) [MEDLINE]

Other Manifestations

  • Chills (see Chills, [[Chills]])
  • Fever (see Fever, [[Fever]]): present in 67% of cases (Ann Intern Med, 2014) [MEDLINE]
  • Rigors (see Rigors, [[Rigors]])

Treatment

Supportive Care

Ribavirin and Interferon-Beta (see Ribavirin, [[Ribavirin]] and xxxx, [[xxxx]])

  • Data support use in SAR-CoV, but efficacy in MERS-CoV is unknown

Inhaled Nitric Oxide (iNO) (see Nitric Oxide, [[Nitric Oxide]])

  • While this has been shown to inhibit in vitro replication of SARS-CoV,its effect on MERS-CoV is unknown

References

  • Critically ill patients with severe acute respiratory syndrome. JAMA. 2003 Jul 16;290(3):367-73 [MEDLINE]
  • Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia. N Engl J Med. 2012;367:1814–1820 [MEDLINE]
  • Patient with new strain of coronavirus is treated in intensive care at London hospital. BMJ. 2012;345:e6455. doi: 10.1136/bmj.e6455 [MEDLINE]
  • Person-to-person spread of the MERS coronavirus—an evolving picture. N Engl J Med 2013;369(5):466-467 [MEDLINE]
  • Hospital outbreak of Middle East respiratory syndrome coronavirus. N Engl J Med 2013;369(5):407-416 [MEDLINE]
  • Middle East respiratory syndrome coronavirus (MERS-CoV): announcement of the Coronavirus Study Group. J Virol. 2013;87:7790–7792 [MEDLINE]
  • Clinical features and virological analysis of a case of Middle East respiratory syndrome coronavirus infection. Lancet Infect Dis. 2013;13:745-51 [MEDLINE]
  • Spread, circulation, and evolution of the Middle East respiratory syndrome coronavirus. MBio 2014;5(1) [MEDLINE]
  • Clinical Course and Outcomes of Critically Ill Patients With Middle East Respiratory Syndrome Coronavirus. Ann Intern Med. 2014 Jan 28 [MEDLINE]
  • Transmission of MERS-coronavirus in household contacts. N Engl J Med. 2014;371:828–835 [MEDLINE]