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The Lancet. Clinical features and viral diagnosis of two cases of infection with Middle East Respiratory Syndrome coronavirus: a report of nosocomial transmission
[Source: The Lancet, full PDF document: (LINK). Abstract, edited.]
Clinical features and viral diagnosis of two cases of infection with Middle East Respiratory Syndrome coronavirus: a report of nosocomial transmission
Benoit Guery, Julien Poissy, Loubna el Mansouf, Caroline S?journ?, Nicolas Ettahar, Xavier Lemaire, Fanny Vuotto, Anne Goffard, Sylvie Behillil, Vincent Enouf, Val?rie Caro, Alexandra Mailles, Didier Che, Jean-Claude Manuguerra, Daniel Mathieu, Arnaud Fontanet, Sylvie van der Werf, and the MERS-CoV study group*
Summary
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.
Findings
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.
Interpretation
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.
Funding
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.
Published Online May 29, 2013 - http://dx.doi.org/10.1016/S0140-6736(13)60982-4
*Members listed at end of paper Service de Gestion du Risque Infectieux, Vigilances et Infectiologie, Hopital Huriez, Pavillon Fourrier, Centre Hospitalier R?gional et Universitaire de Lille, Universit? de Lille 2, Lille Cedex, France (Prof B Guery PhD, F Vuotto MD);P?le de R?animation, H?pital Roger Salengro, Centre Hospitalier R?gional et Universitaire de Lille, Universit? de Lille 2, Lille Cedex, France (J Poissy MD, Prof D Mathieu PhD); Service de Maladies Infectieuses, Centre Hospitalier de Douai, Douai, France (L el Mansouf MD, X Lemaire MD); Service de R?animation, Centre Hospitalier de Douai, Douai, France (C S?journ? MD); Unit? de Maladies Infectieuses, Centre Hospitalier de Valenciennes, Valenciennes, France (N Ettahar MD); Laboratoire de Virologie, Centre de Biologie Pathologie, Centre Hospitalier R?gional et Universitaire de Lille, Universit? de Lille 2, Lille Cedex, France (A Goffard MD);Institut Pasteur, National Reference Center for Influenza Viruses and Unit of Molecular Genetics of RNA Viruses, Paris, France (S Behillil PharmD, V Enouf PhD, Prof S van der Werf PhD); Universit? Paris Diderot Sorbonne Paris Cit?, Unit of Molecular Genetics of RNA Viruses, Paris, France (S Behillil, V Enouf, Prof S van der Werf); Centre National de la Recherche Scientifique UMR3569, Paris, France (S Behillil, V Enouf, Prof S van der Werf);Institut Pasteur, Cellule d?Intervention Biologique d?Urgence, Paris, France (V Caro PhD, J-C Manuguerra PhD); Institut de veille Sanitaire, Saint-Maurice, France (A Mailles PhD, D Che MPH); Conservatoire National des Arts et M?tiers, Paris, France (Prof A Fontanet PhD); and Institut Pasteur, Emerging Diseases Epidemiology Unit, Paris, France (Prof A Fontanet)
Correspondence to: Dr Sylvie van der Werf, Institut Pasteur, National Reference Center for Influenza Viruses and Unit of Molecular Genetics of RNA Viruses, 75015 Paris, France sylvie.van-der-werf@pasteur.fr or Dr Benoit Guery, Service de Gestion du Risque Infectieux, Vigilances et Infectiologie, Hopital Huriez, Pavillon Fourrier, 59045 Lille Cedex, France bguery@invivo.edu
For the Munich/Abu_Dhabi/2012 sequence see http://www.virology-bonn.de/
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Clinical features and viral diagnosis of two cases of infection with Middle East Respiratory Syndrome coronavirus: a report of nosocomial transmission
Benoit Guery, Julien Poissy, Loubna el Mansouf, Caroline S?journ?, Nicolas Ettahar, Xavier Lemaire, Fanny Vuotto, Anne Goffard, Sylvie Behillil, Vincent Enouf, Val?rie Caro, Alexandra Mailles, Didier Che, Jean-Claude Manuguerra, Daniel Mathieu, Arnaud Fontanet, Sylvie van der Werf, and the MERS-CoV study group*
Summary
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.
Findings
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.
Interpretation
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.
Funding
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.
Published Online May 29, 2013 - http://dx.doi.org/10.1016/S0140-6736(13)60982-4
*Members listed at end of paper Service de Gestion du Risque Infectieux, Vigilances et Infectiologie, Hopital Huriez, Pavillon Fourrier, Centre Hospitalier R?gional et Universitaire de Lille, Universit? de Lille 2, Lille Cedex, France (Prof B Guery PhD, F Vuotto MD);P?le de R?animation, H?pital Roger Salengro, Centre Hospitalier R?gional et Universitaire de Lille, Universit? de Lille 2, Lille Cedex, France (J Poissy MD, Prof D Mathieu PhD); Service de Maladies Infectieuses, Centre Hospitalier de Douai, Douai, France (L el Mansouf MD, X Lemaire MD); Service de R?animation, Centre Hospitalier de Douai, Douai, France (C S?journ? MD); Unit? de Maladies Infectieuses, Centre Hospitalier de Valenciennes, Valenciennes, France (N Ettahar MD); Laboratoire de Virologie, Centre de Biologie Pathologie, Centre Hospitalier R?gional et Universitaire de Lille, Universit? de Lille 2, Lille Cedex, France (A Goffard MD);Institut Pasteur, National Reference Center for Influenza Viruses and Unit of Molecular Genetics of RNA Viruses, Paris, France (S Behillil PharmD, V Enouf PhD, Prof S van der Werf PhD); Universit? Paris Diderot Sorbonne Paris Cit?, Unit of Molecular Genetics of RNA Viruses, Paris, France (S Behillil, V Enouf, Prof S van der Werf); Centre National de la Recherche Scientifique UMR3569, Paris, France (S Behillil, V Enouf, Prof S van der Werf);Institut Pasteur, Cellule d?Intervention Biologique d?Urgence, Paris, France (V Caro PhD, J-C Manuguerra PhD); Institut de veille Sanitaire, Saint-Maurice, France (A Mailles PhD, D Che MPH); Conservatoire National des Arts et M?tiers, Paris, France (Prof A Fontanet PhD); and Institut Pasteur, Emerging Diseases Epidemiology Unit, Paris, France (Prof A Fontanet)
Correspondence to: Dr Sylvie van der Werf, Institut Pasteur, National Reference Center for Influenza Viruses and Unit of Molecular Genetics of RNA Viruses, 75015 Paris, France sylvie.van-der-werf@pasteur.fr or Dr Benoit Guery, Service de Gestion du Risque Infectieux, Vigilances et Infectiologie, Hopital Huriez, Pavillon Fourrier, 59045 Lille Cedex, France bguery@invivo.edu
For the Munich/Abu_Dhabi/2012 sequence see http://www.virology-bonn.de/
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