The
Middle East Respiratory Syndrome Coronavirus (MERS-COV)
Firdous Jahan (1)
Ali Abdullah Al Maqbali
(2)
(1) Dr Firdous Jahan,
Associate Professor ,Chair Family Medicine Department,
Oman Medical College
Sohar, Sultanate of Oman
(2) Dr Ali Abdullah
Al Maqbali, Specialist Public Health,
Saham Hospital, Ministry of Health, Sultanate
of Oman
Correspondence:
Dr Firdous Jahan,
Associate Professor ,Chair Family Medicine Department,
Oman Medical College
Sohar, Sultanate of Oman
Tel:+968-26844004 ext. 311
Mobile:+968 95786705 Fax: +968 26843545
Email:
firdous@omc.edu.om
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Abstract
Introduction:
Middle East Respiratory Syndrome coronavirus
(MERS-CoV) , was first identified in 2012
in Saudi Arabia. Coronaviruses are a large
family of enveloped, single-stranded RNA
viruses that infect a number of different
species, including humans. They predominantly
cause mild self-limiting upper respiratory
tract infections, but can cause pneumonia
and serious illness in older people, people
with heart disease, diabetes or immune
compromised patients. Pneumonia has been
the most common clinical presentation
and appears to be the result of repeated
introductions of the virus.
WHO has been informed of an additional
laboratory-confirmed case of Middle East
Respiratory Syndrome coronavirus (MERS-CoV)
in Oman.
Case presentation: A 59 year old
chronic smoker admitted with fever cough
and dyspnea. With rapidly progressing
symptoms and right sided pneumonia he
was shifted to intensive care where he
died. The diagnosis of corona virus infection
was made after his death when endotracheal
aspirate transcriptase polymerase chain
reaction (RT-PCR) became positive.
Conclusion: This infection is a
rapidly progressing disease which requires
up to date awareness and information regarding
its spread and precaution. Urgent epidemiologic
investigations are required to better
understand the transmission patterns of
this virus.
Key words:
Middle East Respiratory Syndrome coronavirus,
Oman
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INTRODUCTION / BACKGROUND |
Coronaviruses are a large family of viruses
that cause a range of illnesses in humans, from
the common cold to the Severe Acute Respiratory
Syndrome (SARS); it can infect both animals
and humans[1-2].
In September 2012, a novel coronavirus was isolated
from a patient in Saudi Arabia who had died
of an acute respiratory illness and renal failure[3].
February 2013, 12 laboratory-confirmed cases
had been reported with 6 fatalities. This new
virus strain is causing sporadic infection in
the Middle East. Coronaviruses are a large family
of enveloped, single-stranded RNA viruses that
infect a number of different species, including
humans. They are usually species specific, however
interspecies transmission of coronaviruses can
occur [4].
The most common initial symptoms reported are
fever, cough and shortness of breath. Patients
may rapidly progress to severe pneumonia and
renal failure[5]. Diagnosis is done by confirmation
using reverse transcription PCR (RT-PCR) on
Broncho alveolar lavage, sputum and tracheal
aspirates [6-7].
A possible case was defined as follows[8]: (i)
any patient with a history of travel in an at-risk
country, who presented with clinical signs and/or
imaging consistent with acute respiratory distress
syndrome (ARDS) or pulmonary infection, encompassing
fever >
38°C and cough within 10 days after return;
(ii) any contact of a symptomatic possible or
confirmed case, presenting with acute respiratory
infection, whatever the severity, with an onset
of symptoms within 10 days of the last contact
with a possible/confirmed case while symptomatic.
The list of at-risk countries, as defined in
European Centre for Disease Prevention and Control
(ECDC) rapid risk assessment dated 7 December
2012, included, Bahrain, Iran, Iraq, Israel,
Jordan, Kuwait, Lebanon, Palestine, Oman, Qatar,
Saudi Arabia, Syria, United Arab Emirates, and
Yemen. A confirmed case is defined as a possible
case with a positive MERS-CoV RT-PCR on respiratory
samples.
Droplet precautions should be added to the standard
precautions when providing care to all patients
with symptoms of acute respiratory infection.
Contact precautions and eye protection should
be added when caring for probable or confirmed
cases of MERS-CoV infection. Airborne precautions
should be applied when performing aerosol generating
procedures.
Patients should be managed as potentially infected
when the clinical and epidemiological clues
strongly suggest MERS-CoV, even if an initial
test on a nasopharyngeal swab is negative. Repeat
testing should be done when the initial testing
is negative, preferably on specimens from the
lower respiratory tract.
Ministry of Health Oman has published a comprehensive
assessment of clinical cases as well as infection
prevention and control awareness and implementation
measures to prevent the possible spread of MERS-CoV
in health care facilities. It is important that
health care workers apply standard precautions
consistently with all patients, regardless of
their diagnosis, in all work practices, all
of the time. Droplet precautions should be added
to the standard precautions when providing care
to any patient with symptoms of acute respiratory
infection [9].
Detected confirmed
case in Oman
A 59 years old Omani male
who became sick with fever,
cough and shortness of
breath on 20th December
2013 was admitted to hospital
in North Batinha Governorate
on 24th December 2014.
There is no history of
weight loss or any chronic
disease. He was a heavy
smoker for more than 40
years. The patient had
a history of daily exposure
to camels and other farm
animals with participation
in camel race events.
There was no history of
similar illness within
the family or visitors
with the same complaint.
There was no history of
any animal sickness or
death within their animals
or in the area.
On 28th December 2014
the patient became very
sick, febrile and distressed
(BP = 136/70, Temp. =
39.6, Pulse = 109, SPO2:
92%, chest examination
revealed crepitation and
crackles. Chest X ray
showed right upper lobe
opacity (attached). He
was admitted to an intensive
care unit with diagnoses
of pneumonia.
During his hospitalization,
the patient was managed
with supportive care.
Hydration, empirical antibiotic
and antiviral were started.
Swabs were taken and culture
was done for blood, urine
and secretion; endotracheal
secretion sample was taken
on 29th December. Patient
was ventilated with all
measurements of supporting
life. He was fully isolated
in the ICU and full infectious
control was emphasized
from the admission. Patient
died on 30th December.
(Chest x ray of the
patient taken on 24th
December 2013)
The laboratory confirmation
of MERS-CoV was made on
1st January 2014 by real-time
reverse transcriptase
polymerase chain reaction
(RT-PCR).
The original source
of infection and mode
of transmission to humans
is unclear. Cases were
reported to have visited
farms and may have had
contact with animals,
thus a zoonotic infection
is a possibility [10].
People handling or working
with camels are at increased
risk of infection with
MERS-CoV compared with
people who do not have
contact with camels.
Some studies provide
evidence that camels
are a likely primary
source of the MERS-CoV
that is infecting humans.
Studies showing that
SARS-CoV was most likely
to have derived from
bats and camels also
supports a zoonotic
origin for this new
coronavirus [11]. Our
unfortunate patient
was a farm worker and
had close contact with
animals, specially camels.
Human to human and nosocomial
transmission is another
possibility as reported
in the literature [12-13].
Clinical features are
reported as rapidly
progressing respiratory
symptoms with fever.
The largest, most complete
clinical case series
published included 47
patients; most had fever
(98%), cough (83%),
and shortness of breath
(72%). Many also had
gastrointestinal symptoms
(26% had diarrhea, and
21% had vomiting). All
but two patients (96%)
had one or more chronic
medical conditions,
including diabetes (68%),
hypertension (34%),
heart disease (28%),
and kidney disease (49%).
Thirty-four (72%) had
more than one chronic
condition[14].
Ministry of Health Oman
continues to recommend
that patients with severe
acute respiratory illness
(e.g., fever and pneumonia
requiring hospitalization)
be evaluated and reported
to local and state public
health departments.
If the illnesses remain
unexplained, particularly
if the cluster includes
health-care providers,
testing for MERS-CoV
should be considered
as mentioned in guidelines
published by the health
department.
Confirmation of diagnosis
of MERS-CoV with real-time
polymerase chain reaction
(RT-PCR), is done by
using the recommended
sampling technique (nasopharyngeal
swab and tracheal aspirates
or bronchoalveolar lavage
in intubated patients).
In suspected cases with
negative RT-PCR results,
the test should be repeated.
The literature supports
the screening of patients
and family members who
were potentially exposed
to MERS-CoV [15].
As a general precaution
everyone should practice
general hygiene measures,
including regular hand
washing after touching
animals, avoiding touching
eyes, nose or mouth
with hands, and avoiding
contact with sick animals.
The consumption of raw
or undercooked animal
products, including
milk and meat, carries
a high risk of infection
from a variety of organisms
that might cause disease
in humans.
This
emerging
public
health
problem
needs
more
investigation
identifying
the
possible
zoonotic
hosts
or
environmental
sources
which
may
act
as
modes
of
transmission
between
camels
and
humans.
So
far
only
one
confirmed
case
has
been
reported
from
Oman.
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