Atypical presentations of MERS-CoV infection in immunocompromised hosts

Abstract

During the 2015 Korean MERS outbreak, we experienced atypical presentations of MERS-CoV infections in three immunocompromised hosts that warranted exceptional management. Case 1 showed delayed symptom development after a four-day asymptomatic period, Case 2 experienced a 20-day incubation period, and Case 3 exhibited persistent viral shedding without clinical deterioration. Recognizing these exceptions is extremely important in the management of MERS-CoV-exposed or -infected patients and for control of potential MERS outbreaks.

Middle East respiratory syndrome

“…The clinical presentation of patients infected with MERS-CoV ranges from asymptomatic or mild upper respiratory illness to rapidly progressive pneumonitis, respiratory failure, acute respiratory distress syndrome, septic shock, and multiorgan failure with fatal outcome (figure 5). 2,10,11,[61][62][63][64][65][66][67][68][69][70] It is not possible to distinguish patients with a legitimate asymptomatic MERS-CoV infection from those who develop mild disease because reports to WHO provide signs and symptoms information only at the time of reporting. Many individuals remain asymptomatic whereas some go on to develop mild disease, which is why WHO classifies these individuals as mild or asymptomatic.…”

“…The signs and symptoms associated with MERS are non-specific, with or without multisystem involvement, and thus could be mistaken for other causes of respira tory tract or gastrointestinal illnesses. 2,10,11,[61][62][63][64][65][66][67][68][69][70] Therefore, the clinical diagnosis of MERS can be easily missed. Patients with MERS can typically present with fever, chills, rigors, headache, a non-productive cough, sore throat, arthralgia, and myalgia followed by dyspnoea.…”

“…Some patients with MERS can present with atypical symptoms of mild respiratory illness without a fever and a gastrointestinal illness that precedes the develop ment of pneumonia. 64,67,68 Neuromuscular manifestations include hypersomnolence, weakness, and tingling in the extremities similar to Guillain-Barré syndrome or virusrelated sensory neuropathy. 68 Co-infection of MERS-CoV with other respiratory viruses (such as parainfluenza The pathogen: MERS-CoV • Anti-viral therapeutics including host-directed therapies or immune-based therapies are in development.…”

“…Immunocompromised patients or patients with chronic heart, liver, and kidney disease can present with atypical features, such as a longer incubation period, a longer period from initial PCR positivity to symptom onset, persistent prolonged viral shedding, and increased mortality. [64][65][66][67][68][69][70] MERS-CoV causes more severe disease in people older than 60 years, and those with chronic comorbid diseases such as renal disease, cancer, chronic lung disease, immunosuppression, and diabetes.…”

“…75 MERS should be kept on the differential diagnosis list for ill travellers returning home from MERS-CoV endemic areas who present with acute febrile illness (temperature ≥38°C), aches and pains, headache, cough, dyspnoea, diarrhoea, nausea, vomiting, unexplained leucopenia (white blood cell count <3·5 × 110⁹/L), and thrombocytopenia (platelets <150 × 10⁹/L)-either with or without prominent respiratory symptoms. 2,10,11,[61][62][63][64][65][66][67][68][69][70] It is important that clinicians are alert to the possibility that patients could have MERS in all health-care settings where the virus is circulating so that an accurate diagnosis can be made and infection control measures implemented efficiently. 76…”