DEPARTMENT OF EMERGENCY MEDICINE

(MED 5064)

CASE WRITE UP / EVIDENCE BASED MEDICINE

SEVERE SEPSIS SECONDARY TO

COMMUNITY ACQUIRED
PNEUMONIA TRO MERS COV

NAME: MOHAMMAD FAIZ TAQIYUDDIN B MOHD NOR

MATRIC NO.: MBBS 1411-5964
GROUP: 3 (C)
SUPERVISOR: ASC. PROF. DR. MUHAMMAD RADHI AHMAD
 A. Case Summary

Suut b Syawal, a 57 years old Sarawakian male with no known medical illness referred from
Menara KLIA clinic to rule out cerebrovascular accident (CVA). Upon arrival to KLIA as he
just went back from umrah, his nephew noticed that he had slurred speech and weakness over
bilateral limbs.

2 weeks prior, he had history of fever, productive cough and runny nose. The fever was
intermittent with no chills, rigor, myalgia or arthralgia. The cough produces clear to
yellowish sputum; however he denies night sweat or lost of weight, although he had lost of
appetite. He had sought medical treatment at Mecca for last 3 days and discharged with
T.Cefuroxime 500mg BD, patient took it for 1 day. The blood pressure upon arrival to KLIA
was 94/59. The patient was alert, responsive with GCS 15/15.

On further examination at Emergency Department, he is still alert and conscious with GCS
15/15, pupils reactive bilaterally 3mm/3mm, not on respiratory distress with respiratory rate
18 breaths per minute, warm peripheries, CRT less than 2 seconds, tongue slightly coated.
Other vital sign taken are as below:

- BP : 107/71 - SpO2 : 98% under room air

- PR : 88 - T : 36.7C
-
Lungs examination show bibasal crepitation with good air entry, cardiac auscultation reveal
dual rhythm with no murmur, abdomen is soft and non-tender, however he had bilateral pedal
edema up to ankle. There is no facial asymmetry noted. Musculoskeletal system review show
normal power, tone and reflex on bilateral upper and lower limb.

Investigation show high white cell count on full blood count with reading of 15.7 x 109/L
(Neutrophil = 78.9 ; lymphocyte = 21.1). Extended FAST scan shows B-line and under
volume of left ventricular noted. The serum sodium and calcium is also low with reading of
113 and 1.79 mmol/L respectively. ECG give reading of atrial flutter and mobile Chest X-
ray shows cardiomegaly, batwing appearance and fluid in fissure in right lungs.

The impression given was severe sepsis secondary to community acquired pneumonia (CAP),
with hyponatremia and hypocalcemia, to rule out CVA and MERS-COV infection. The plan
in ED was VS monitoring every 15 minutes, IVD 1 pint of normal saline for 4 hour, strict I/O
chart with CBD insertion, IV rocephine 2g STAT, 1 amp of calcium gluconate in 100cc over
1hour and refer medical team as planned.
 B. DISCUSSION

1. What is the criteria for diagnosis of Middle East Respiratory Syndrome

Coronavirus (MERS-COV)?
2. And how we manage such cases in emergency department?

A brief background regarding the virus, Coronaviruses are enveloped RNA viruses classified
in alpha, beta and gamma genera that can be found globally in birds, humans and other
mammals. MERS-COV is a novel virus among the genus beta-coronavirus. The first case was
identified in Saudi Arabia in June 2012, followed by another case from Qatar that was treated
in the United Kingdom. Subsequently, a hospital cluster of pneumonia among healthcare
worker in Jordan was traced retrospectively to this virus. As of 24 April 2014, 254
laboratory-confirmed cases of MERS-CoV including 93 deaths, involving 12 countries,have
been notified to the WHO1.

A wide clinical spectrum of MERS-CoV infection has been reported ranging from
asymptomatic infection to acute upper respiratory illness, and rapidly progressive
pneumonitis, respiratory failure, septic shock and multi-organ failure resulting in death. Most
MERS-CoV cases have been reported in adults (median age approximately 50 years, male
predominance), although children and adults of all ages have been infected (range 0 to 109
years). Most hospitalized MERS-CoV patients have had chronic co-morbidities. Among
confirmed MERS-CoV cases reported to date, the case fatality proportion is approximately
35%2. Due to inability to definitively diagnose the disease based on clinical examination
alone, WHO had categorized the patient into 3 categories, which is3:

i. Suspected case (patients who should be tested for MERS-CoV)

I. A person with fever and community-acquired pneumonia or acute respiratory distress

syndrome based on clinical or radiological evidence. OR

II. A hospitalized patient with healthcare associated pneumonia based on clinical and
radiological evidence. OR

III. A person with 1) acute febrile (38C) illness, AND 2) body aches, headache,
diarrhea, or nausea/vomiting, with or without respiratory symptoms, AND 3) unexplained
leucopenia (white blood cells OR

IV. A person (including health care workers) who had protected or unprotected
exposured to a confirmed or probable case of MERS-CoV infection and who presents
with uppere or lowerf respiratory illness within 2 weeks after exposure.

ii. Probable case

A probable case is a patient in category I or II above with absent or inconclusive laboratory

results for MERS-CoV and other possible pathogens who is a close contacth of a laboratory-
confirmed MERS-CoV case or who works in a hospital where MERS-CoV cases are cared
for.
 iii. Confirmed case

A confirmed case is a suspect case with laboratory confirmationi of MERS-CoV infection.

Therefore, MERS is to be suspected when a patient presents to Triage Counter with the
following: A person with an acute respiratory infection, with history of fever and cough and
indications of pulmonary parenchymal disease based on clinical or radiological evidence,
who within 14 days before onset of symptoms has history of residing in / travel from the
Middle East / other affected countries with active transmission of MERS.However, we need
to consider the possibility of atypical presentations in patients who are immunocompromised.

In order to manage this case, according to Guideline on MERS management in Malaysia,if

the patient is under investigation (PUI) for MERS-COV,we need refer patient for
consultation with the Rapid Assessment Team (RAT) representative of the respective District
Health Office (PKD), then healthcare involved should maintain appropriate infection and
control measures and to notify using to6:

1) The National CPRC

2) The respective State Health Department

3) The respective District Health Office

Should a patient fulfill the description, to institute infection prevention and control measures
as the following4:

Place patients at least 1 metre away from other patients or health care workers.
Emergency Departments are to prepare an isolation area / room for patients.
Ensure strict hand hygiene for all clinic staff and suspected patient.
Provide surgical mask to patients if not contraindicated.
Personal protective equipment as per recommendation should be worn at all times.
After the encounter, ensure proper disposal of all PPE described above.

Viral testing should be done by reverse-transcriptase polymerase chain reaction (RT-PCR)

assay if possible, as it is the gold standard for detection of Coronavirus5. Initially, include
testing for other respiratory viruses, such as influenza A and B including zoonotic influenza
A viruses (eg. avian H5 or H7); RSV, parainfluenza viruses, rhinoviruses, adenoviruses,
enterovirus (EVD68) human metapneumovirus, and non-SARS coronaviruses. In those with
serious illness and/or pneumonia, the most appropriate specimens for MERS-CoV testing are
Lower respiratory Tract (LRT) specimens. LRT samples are more likely to be positive than
Upper Respiratory Tract (URT) specimens and virus can be detected in LRT specimens for
longer periods than in URT specimens.

Currently, there is no definitive treatment for MERS-COV, except supportive treatment, as

the pathogenesis of disease is incompletely understood, and there is no proven MERS-CoV-
specific treatment or vaccine. Life-threatening manifestations of MERS-CoV infection
include severe pneumonia, ARDS, sepsis and septic shock. Early recognition of these clinical
syndromes allows for timely initiation of Infection and Prevention Control (IPC) as well as
therapeutics.

C. REFERENCES

I. Danielsson, N. and Catchpole, M., 2012. Novel coronavirus associated with severe
respiratory disease: case definition and public health measures. Eurosurveillance,
17(39), p.20282.
II. Cauchemez, S., Van Kerkhove, M.D., Riley, S., Donnelly, C.A., Fraser, C. and
Ferguson, N.M., 2013. Transmission scenarios for Middle East Respiratory Syndrome
Coronavirus (MERS-CoV) and how to tell them apart. Euro surveillance: bulletin
Europeen sur les maladies transmissibles= European communicable disease bulletin,
18(24).
III. Madani, T.A., Althaqafi, A.O. and Alraddadi, B.M., 2014. Infection prevention and
control guidelines for patients with Middle East respiratory syndrome coronavirus
(MERS-CoV) infection. Saudi Med J, 35(8), pp.897-913.
IV. Devi, J.P., Noraini, W., Norhayati, R., Kheong, C.C., Badrul, A.S., Zainah, S.,
Fadzilah, K., Hirman, I., Hakim, S.L. and Hisham, A.N., 2014. Laboratory-confirmed
case of Middle East respiratory syndrome coronavirus (MERS-CoV) infection in
Malaysia: preparedness and response, April 2014. Euro Surveill, 19(18), p.pii20797.
V. World Health Organization, 2015. Clinical management of severe acute respiratory
infection when Middle East respiratory syndrome coronavirus (MERS-CoV) infection
is suspected: interim guidance.
VI. Guidelines on MERS management in Malaysia. [online] Available at:
http://www.moh.gov.my/index.php/file_manager/dl_item/5455565355793144623159
764d6a41784e53394e52564a54583064316157526c62476c755a5335775a47593d
[Accessed 1 Dec. 2017]