Haemorrhagic-fever-like changes and normal chest radiograph in a doctor with SARS.

A 33-year-old doctor contracted severe acute respiratory syndrome presenting with features of disseminated intravascular coagulopathy without changes in the chest radiograph initially. A CT scan of his chest showed marked lung changes. His condition improved with intravenous methylprednisolone 500 mg daily and ribavirin 1.2 g orally thrice daily. The case illustrates the importance of a break in fever between the viraemic and lung inflammatory phases of the illness that occurs before radiographic changes and which may obscure diagnosis. Careful quarantine and follow-up of these patients are necessary. Coagulopathy is usually uncomplicated and early CT of the chest may elucidate hidden lung changes and facilitate a rapid diagnosis.

The index case of severe acute respiratory syndrome (SARS) was admitted to ward 8A in the Prince of Wales Hospital, Hong Kong, on the March 4, 2003. On March 10, 2003, a 33-year-old doctor (EBW, figure ) working on ward 8A developed a fever of 39·6°C. He was examined by JJYS. His fever had gone by March 12, and his chest radiograph was normal. His platelet count was 94×109/L and white-cell count was 3·4×109/L (monocytes 0·4×109/L). A nasopharyngeal swab grew no pathogens. He was admitted to the SARS triage ward on March 13, and was started on oseltamivir phosphate 75 mg twice a day and levofloxacin 500 mg daily. Further blood tests showed disseminated intravascular coagulopathy (platelets 61×109/L, D-dimer 630 ng/mL, prothrombin time 11·1s, activated partial thromboplastin time (APTT) 43·3s). His white-cell count was 1·8×109/L (neutrophils 1×1×109/L, lymphocytes 0·5×109/L, and monocytes 0·2×109/L. His chest radiograph showed a prominent right hilum. CT of his thorax showed an ill-defined opacity with an air bronchogram in the apical posterior segment of the right lower lobe and diffusely in the right middle lobe. He was started on oral ribavirin 1·2 g thrice daily and intravenous methylprednisolone 500 mg daily. His fever settled the next morning and his coagulopathy improved (APTT 40·7 s, platelet count 105×109/L, and D-dimer of 564 ng/mL). On March 19, 2003, oral prednisolone 1 mg/kg was started.

Figure

Eugene B Wu

On the evening of March 20, he had a fever of 38·9°C. His white blood cell count rose to 15·7×109/L (predominantly due to an increase in neutrophils). A secondary bacterial chest infection was suspected, and cefipime 2 g was given intravenously. Over the next 2 days he became increasingly breathless and his coagulopathy became worse (D-dimer 716 ng/mL, prothrombin time 11·9 s, platelets 199×109/L). The patient was given a single dose of methylprednisolone 500 mg intravenously and 4 L/min of oxygen. After this, he began to get better. Coagulation parameters returned to normal, he was weaned off of oxygen, and was discharged from hospital on March 31, 2003, on 0·3 mg/kg prednisolone and ribavirin 600 mg orally three times a day. On April 7, his chest radiograph showed worsening consolidation of the consolidation of the right middle zone and the prednisolone was increased to 0·5 mg/kg.

This illness shows several characteristic features of SARS. There is often a break in the fever between the viraemic stage (days 1–3) and the lung inflammation phase of the illness. Patients who become apyrexial for several days still need up to 10 days of quarantine and follow-up. Haemorrhagic-fever-like illness with disseminated intravascular coagulopathy does occur but is usually mild. Although 78·3% of SARS patients in our centre had an abnormal chest radiographs when feverish, some can have relatively normal radiographs. As shown in this case, a chest CT can show hidden pneumonic changes and facilitate a rapid diagnosis.