Tuesday, March 4, 2014
Middle East Respiratory Syndrome Coronavirus: the latest lethal germ
In 2003 a brand new virus named severe acute respiratory syndrome coronavirus (SARS-CoV) caused an outbreak of serious illness in Asia. The outbreak sickened over 8,000 people and killed over 700. Many of the infected were health care workers.
In February of 2013 a similar but distinct virus was identified in Saudi Arabia, the Middle East respiratory syndrome coronavirus (MERS-CoV). Here's what MERS-CoV particles look like as seen by electron microscopy (Credit: CDC/Wikipedia). Since that time about 200 people have been sickened by MERS, all linked to 6 countries in or near the Arabian Peninsula. The World Health Organization (WHO) has confirmed 180 cases (143 in Saudi Arabia) and 77 deaths (59 in Saudi Arabia). There have been no cases thus far in the U.S. No specific treatment or vaccine exists for MERS-CoV.
Annals of Internal Medicine published a report by researchers in Saudi Arabia describing 12 patients admitted to ICUs with MERS-CoV. The description of the illness that emerges from details they report is scary. Eight of the patients contracted the illness in the community. Three patients were in the ICU for other reasons and were infected in the ICU, and one was a health care worker who presumably contracted the illness at work. The patients ranged in age from 36 to 83. The average time from the onset of symptoms to presentation to the emergency department was 1 day, and to ICU admission was 2 days.
The majority of patients presented with shortness of breath, cough, and fever. Many of the patients had chronic illnesses, such as diabetes, high blood pressure, heart disease and kidney disease. All of them required being on a ventilator (a breathing machine). Their chest X-rays (which you can check out yourself in the article) looked horrible. They spent an average of 16 days on the ventilator. Seven patients had kidney failure requiring temporary dialysis. Eight patients had dangerously low blood pressure requiring medication to elevate it. Seven patients (about half) died.
MERS-CoV is definitely transmitted from person to person, but the specific mode of transmission is still uncertain. It’s not clear if the virus is transmitted in respiratory droplets, or by direct contact. Thus far MERS-CoV appears to be much more lethal but much less infectious than SARS was. That’s another way of saying that it’s a younger virus, since germs tend to get less lethal and more infectious as they evolve. (A mutation that makes a virus more infectious will spread much faster than a mutation that makes it less infectious. Similarly a mutation that makes it less lethal will give the patient longer to infect others.)
Neither the Centers for Disease Control (CDC) nor the World Health Organization recommends that anyone change their travel plans because of MERS. For now, it seems geographically quite localized and fairly difficult to catch. But no one can say what the future holds, and whether a few mutations from now MERS will be coming to an airport near you. If that happens, the rapid development of a vaccine will be critical.
The small lesson is that MERS is an emerging pathogen that deserves our attention, and that what is simmering on the other side of the globe this year can be a global pandemic next year. The big lesson is that nature is a mixed bag. Nature brings us both rainbows and tsunamis, both my 10-year-old daughter’s amazing eyes and the norovirus that is keeping her home from school today. And every now and then Mother Nature invents brand new ways to kill some of us.
Middle East Respiratory Syndrome (MERS) (Centers for Disease Control and Prevention page)
A Novel Coronavirus Called “MERS-CoV” in the Arabian Peninsula(Centers for Disease Control and Prevention travel recommendations)
Middle East respiratory syndrome coronavirus (MERS-CoV) – update(World Health Organization)
New MERS death raises Saudi toll to 59 (AFP)
Clinical Course and Outcomes of Critically Ill Patients With Middle East Respiratory Syndrome Coronavirus Infection (Annals of Internal Medicine article, free without subscription)
Medusa’s Ugly Head Again: From SARS to MERS-CoV (Annals of Internal Medicine editorial, subscription required)
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.
Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.
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Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.
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Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.
Technology in (Medical)
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.
Peter A. Lipson,
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.
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Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.
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Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.
Other blogs of note:
American Journal of
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.