eMedicine Specialties > Infectious Diseases > Lower Respiratory Tract Infections

Severe Acute Respiratory Syndrome (SARS)

Author: Richard L Oehler, MD, FACP, Assistant Professor, Department of Internal Medicine, Division of Infectious Diseases and Tropical Medicine, Univ of South Florida College of Medicine; Assistant Epidemiologist, Division of Infectious Diseases, Tampa VA Medical Center
Coauthor(s): Nicholas Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants; Asim A Jani, MD, MPH, FACP, Clinician-Educator and Epidemiologist, Consultant and Senior Physician, Florida Department of Health; Assistant Professor, University of Central Florida College of Medicine; Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Contributor Information and Disclosures

Updated: Feb 23, 2010

Introduction

Background

Severe acute respiratory syndrome (SARS) is a serious, potentially life-threatening viral infection caused by a previously unrecognized virus from the Coronaviridae family. This virus has been named the SARS-associated coronavirus (SARS-CoV). Previously, Coronaviridae were best known as the second most common cause of the common cold.

SARS initially manifests as a flulike syndrome that may progress to pneumonia, respiratory failure, and, in some cases, death. The mortality rate associated with SARS is significantly higher than that of influenza or other common respiratory tract infections.

The SARS coronavirus strain is believed to have originated in Guangdong province in southern China prior to its spread to Hong Kong, neighboring countries in Asia, and Canada and the United States during the 2002-2003 outbreak. In early 2004, several new cases of SARS were investigated in Beijing and in the Anhui province of China. All of these cases were epidemiologically linked to the National Institute of Virology in Beijing, where the outbreak is thought to have originated. The most recent outbreak was believed to have been successfully contained without spread into the general population. Despite concerns that new cases of SARS would emerge in the region, no new cases had been reported as of July 1, 2007. The world's attention has instead focused on the potential for a global avian influenza pandemic due to the H5N1 influenza strain.

The World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC) have posted guidelines and medical information (in both online and traditional forms) for health care professionals to help decrease the transmission of the SARS virus, to ensure appropriate isolation or quarantine of individuals suspected or confirmed to have SARS-CoV infection, and to guide the evaluation and treatment of the disease.1,2

Pathophysiology

Coronaviruses cause diseases in pigs, birds, and other animals. Preliminary research indicates that SARS-CoV may have originated in livestock (eg, chickens, ducks) or small mammals. Chinese horseshoe bats, which carry SARS-like viruses with genetic homology to SARS-CoV, may have also had a role. From its reservoir, the virus may have mutated, allowing transmission to and infection of humans, perhaps facilitated by the proximity in which humans and livestock live in rural southern China.

As shown in the image below, the 3 existing coronaviruses include mammalian and avian viruses. These contribute to numerous veterinary diseases (eg, feline infectious peritonitis, avian infectious bronchitis). The coronaviruses can also cause both upper and, more commonly, lower respiratory tract illness in humans (group 1 [human coronavirus 229E] and group 2 [human coronavirus OC43]).

Coronaviruses. Image adapted from the University ...

Coronaviruses. Image adapted from the University of Leicester Microbiology & Immunology Web site.

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Coronaviruses. Image adapted from the University ...

Coronaviruses. Image adapted from the University of Leicester Microbiology & Immunology Web site.


The 1997 avian flu epidemic in Hong Kong, which originated in poultry and spread to humans (resulting in the slaughter of 1.5 million chickens and ducks), is a prime example of this type of zoonotic transmission. Another theory holds that the SARS-CoV originated in small weasel-like animals called civet cats (see image below). Closely related to mongooses, these mammals were sold in Guangdong province wet markets as a delicacy. Close contact with the animals themselves, or with their saliva or feces, could have transmitted a mutated form of the virus to humans.

One theory holds that the severe acute respirator...

One theory holds that the severe acute respiratory syndrome–associated coronavirus originated in small weasel-like animals called civet cats. Closely related to mongooses, these mammals were sold in a Guangdong (China) marketplace as a delicacy. Close contact with the animals themselves, or with their saliva or feces, could have transmitted a mutated form of the virus to humans.

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One theory holds that the severe acute respirator...

One theory holds that the severe acute respiratory syndrome–associated coronavirus originated in small weasel-like animals called civet cats. Closely related to mongooses, these mammals were sold in a Guangdong (China) marketplace as a delicacy. Close contact with the animals themselves, or with their saliva or feces, could have transmitted a mutated form of the virus to humans.


The 2002-2003 SARS outbreak predominantly affected mainland China, Hong Kong, Singapore, and Taiwan. In Canada, a significant outbreak occurred in the area around Toronto, Ontario. In the United States, 8 individuals contracted laboratory-confirmed SARS. All patients had traveled to areas where active SARS-CoV transmission had been documented.

SARS is thought to be primarily transmitted via close person-to-person contact. Most cases have involved persons who lived with or cared for a person with SARS or who had exposure to contaminated secretions from a patient with SARS. Some affected patients may have acquired SARS-CoV infection after their skin, respiratory system, or mucous membranes came into contact with infectious droplets propelled into the air by a coughing or sneezing patient with SARS. SARS may also be spread when a person touches infectious secretions or a contaminated surface or object and then directly contacts his or her own eyes, nose, or mouth.

The WHO reported that leaky, backed-up sewage pipes, fans, and a faulty ventilation system were likely responsible for a severe outbreak of SARS in the Amoy Gardens residential complex in Hong Kong. However, an analysis by the WHO, entitled " Status of the outbreak and lessons for the immediate future," on the distribution of cases at this development has suggested that transmission may have occurred within the complex via airborne, virus-laden aerosols.3

In May 2003, the WHO reported that only 16 of the more than 7800 people infected with SARS-CoV had contracted the virus on airplanes. All of these cases had occurred before airlines began screening passengers for symptoms (including fever). The strict screening of passengers appeared to be effective in preventing transmission of SARS-CoV in the months following the original outbreak.

Frequency

United States

As of July 1, 2007, only 8 laboratory-confirmed cases of SARS had been reported in the United States—all related to the original outbreak. No SARS-related deaths have been reported in the United States. Current statistics can be reviewed at the Centers for Disease Control and Prevention Web site.2

International

Worldwide numbers of SARS cases from the original outbreak (November 2002 through July 31, 2003) included 8096 cases, 774 deaths, and 7295 recoveries. Individual country statistics are as follows:

  • Mainland China - 5327 cases, 349 deaths
  • Hong Kong - 1755 cases, 299 deaths
  • Taiwan - 346 cases, 37 deaths
  • Canada (primarily around Toronto, Ontario) - 251 cases, 43 deaths
  • France - 7 cases, 1 death
  • Malaysia - 5 cases, 2 deaths
  • Philippines - 14 cases, 2 deaths
  • Singapore - 238 cases, 14 deaths
  • South Africa - 1 case, 1 death
  • Thailand - 9 cases, 2 deaths
  • Vietnam - 63 cases, 5 deaths

Current statistics can be accessed from the WHO Web site.1 See below for a map showing the worldwide distribution of SARS cases during the 2002-2003 outbreak.

World map of severe acute respiratory syndrome (S...

World map of severe acute respiratory syndrome (SARS) distribution from the 2002-2003 outbreak infection. The greatest number of past and new cases of SARS are in mainland China, Hong Kong, Taiwan, and Singapore (red). Canada, more specifically Toronto, Ontario (yellow), is the fifth-ranked area, although community transmission of SARS now appears to be contained, according to the US Centers for Disease Control and Prevention. Green represents the other countries reporting SARS cases.

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World map of severe acute respiratory syndrome (S...

World map of severe acute respiratory syndrome (SARS) distribution from the 2002-2003 outbreak infection. The greatest number of past and new cases of SARS are in mainland China, Hong Kong, Taiwan, and Singapore (red). Canada, more specifically Toronto, Ontario (yellow), is the fifth-ranked area, although community transmission of SARS now appears to be contained, according to the US Centers for Disease Control and Prevention. Green represents the other countries reporting SARS cases.


Mortality/Morbidity

SARS can result in significant illness and medical complications that require hospitalization, intensive care treatment, and mechanical ventilation.

  • The mortality rate of SARS is higher than that of non-H5N1 influenza strains or other common respiratory tract infections.
  • The overall mortality rate of SARS has been approximately 10%. According to the CDC and the WHO, the death rate among individuals older than 65 years exceeds 50%.
  • The WHO has set the SARS containment period at 20 days. If no new cases of SARS are reported in a given area over a 20-day period, given the relatively short incubation period of the disease, the WHO considers SARS infections in that area to be contained.

Race

All races are equally affected.

Sex

Both sexes are equally affected.

Age

SARS-CoV infection has no predilection for any age group; however, as stated above, morbidity and mortality rates are greater in elderly patients.

Clinical

History

In addition to the clinical presentation outlined below, epidemiological statistics and exposure history are also critical to the diagnosis of severe acute respiratory syndrome (SARS). Although secondary SARS cases from the original outbreak occurred around the world, subsequent cases were confined to China. Note that the case definition for SARS is an essential tool from an epidemiological perspective that is continually updated by the CDC (see Updated Interim US Case Definition for Severe Acute Respiratory Syndrome).4

  • Exposure history
    • Anyone who has close personal contact with a person with known or suspected SARS within 10 days of symptom onset (eg, health care workers, family members, caregivers) is at high risk of SARS-CoV infection.
    • Close contact is defined as caring for or living with a person known to have SARS or having a high likelihood of direct contact with respiratory secretions or body fluids from a patient known to have SARS. Examples of close contact include kissing, embracing, sharing eating or drinking utensils, conversing closely (<3 ft [1 m]), performing a physical examination, or sharing any other direct physical contact. Close contact does not include walking by a person or briefly sitting across a waiting room or office.
    • Research suggests that the major modes of SARS transmission are contact- and droplet-based. Fecal-oral transmission may also be possible via diarrhea. Evidence indicates that SARS may also be transmitted through airborne, virus-containing aerosols.
    • Traveling to an area where community transmission of SARS has been recently documented or suspected (including visiting an airport) within 10 days of symptom onset in that area is a risk factor.
  • Clinical presentation
    • The images below show the CDC's clinical and reporting criteria for SARS.

    • Severe acute respiratory syndrome case definition...

      Severe acute respiratory syndrome case definition put forth by the US Centers for Disease Control and Prevention (CDC) on April 29, 2003. Courtesy of the CDC.

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      Severe acute respiratory syndrome case definition...

      Severe acute respiratory syndrome case definition put forth by the US Centers for Disease Control and Prevention (CDC) on April 29, 2003. Courtesy of the CDC.


    • Clinical and laboratory criteria for severe acute...

      Clinical and laboratory criteria for severe acute respiratory syndrome cases and infection per the US Centers for Disease Control and Prevention (CDC) on April 29, 2003. Courtesy of the CDC.

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      Clinical and laboratory criteria for severe acute...

      Clinical and laboratory criteria for severe acute respiratory syndrome cases and infection per the US Centers for Disease Control and Prevention (CDC) on April 29, 2003. Courtesy of the CDC.

    • The exposure and incubation (asymptomatic) period is 2-7 days, although it may be as long as 10 days. An incubation period of up to 14 days has been reported.
    • Stage 1 is a flulike prodrome that begins 2-7 days after incubation and is characterized by fever (>100.4°F [38°C]), fatigue, headaches, chills, myalgias, malaise, anorexia, and, in some cases, diarrhea. This stage lasts 3-7 days.
    • Stage 2 is the lower respiratory tract phase and begins 3 or more days after incubation. Patients experience a dry cough, dyspnea, and, in many cases, progressive hypoxemia. Chest radiography findings may initially be normal, and 7 days or longer may elapse before findings become abnormal. Radiographs may show focal interstitial infiltrates that may progress to a more patchy, generalized distribution. Respiratory failure that requires mechanical ventilation may occur.
    • Documentation of a temperature of more than 100.4°F (38°C) is preferred for diagnosis, but clinical judgment is important in the absence of this finding. Extenuating circumstances for which this preference may be set aside include patients' subjective self-reports of fever, use of antipyretics, presence of conditions or therapies that induce a relative immunocompromised state, lack of access to health care, or inability to obtain a measured temperature.
    • Features consistent with respiratory illness, such as cough, wheezing, dyspnea, and other breathing difficulties, are noted.

Physical

Physical examination findings in patients with SARS are consistent with those of a combined mild-to-severe respiratory tract infection and influenzalike illness. However, from a respiratory standpoint, patients can deteriorate quickly and may require mechanical ventilation during hospitalization.

  • Fever, typically higher than 100.4°F (38°C), is present.
  • Moderate respiratory illness is indicated by fever (see Clinical presentation) and 1 or more clinical findings of respiratory illness (eg, hypoxia, cough, dyspnea, breathing difficulties).
  • Severe respiratory illness is indicated by fever (see Clinical presentation), 1 or more clinical findings of respiratory illness (eg, hypoxia, cough, dyspnea, breathing difficulties), and radiographic evidence of pneumonia or respiratory distress syndrome or autopsy findings consistent with pneumonia or respiratory distress syndrome without an identifiable cause.
  • Note that the cough associated with SARS can be mild to severe and tends to be dry and nonproductive.
  • Less common findings in SARS include diarrhea, pharyngitis, chills, rigors, nausea, vomiting, and rhinorrhea.
  • Chest auscultation results can be unremarkable. If abnormal, findings are more commonly upper respiratory tract in nature as opposed to lower respiratory tract.

Causes

The greatest number of SARS cases have occurred in China. Confirming exposure or possible exposure to SARS-CoV is critical in making an initial diagnosis. Morbidity and mortality rates among persons with SARS worsen with increasing age, especially in the elderly population (ie, >65 y). Coexisting chronic illnesses and immunosuppression are also likely to increase the probability of morbidity and mortality among persons with SARS.

More on Severe Acute Respiratory Syndrome (SARS)

Overview: Severe Acute Respiratory Syndrome (SARS)
Differential Diagnoses & Workup: Severe Acute Respiratory Syndrome (SARS)
Treatment & Medication: Severe Acute Respiratory Syndrome (SARS)
Follow-up: Severe Acute Respiratory Syndrome (SARS)
Multimedia: Severe Acute Respiratory Syndrome (SARS)
References
Further Reading
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Keywords

severe acute respiratory syndrome, SARS, Coronaviridae, coronavirus, coronaviruses, SARS genome, SARS-associated coronavirus, SARS-CoV, human coronavirus 229E, HCV-229E, human coronavirus OC43, HCV-OC43, human metapneumovirus, HMP, respiratory syncytial virus, RSV, single-stranded RNA viruses, pneumonia, respiratory tract infection, respiratory failure, bronchiolitis obliterans-organizing pneumonia, BOOP, flulike syndrome, ribavirin, SARS virus, zoonotic virus transmission, zoonotic viral transmission, quarantinable disease, quarantinable communicable disease, communicable diseases

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Contributor Information and Disclosures

Author

Richard L Oehler, MD, FACP, Assistant Professor, Department of Internal Medicine, Division of Infectious Diseases and Tropical Medicine, Univ of South Florida College of Medicine; Assistant Epidemiologist, Division of Infectious Diseases, Tampa VA Medical Center
Richard L Oehler, MD, FACP is a member of the following medical societies: American College of Physicians, American Medical Association, Infectious Diseases Society of America, and Society for Healthcare Epidemiology of America
Disclosure: Nothing to disclose.

Coauthor(s)

Nicholas Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

Asim A Jani, MD, MPH, FACP, Clinician-Educator and Epidemiologist, Consultant and Senior Physician, Florida Department of Health; Assistant Professor, University of Central Florida College of Medicine
Asim A Jani, MD, MPH, FACP is a member of the following medical societies: American College of Physicians, American Medical Association, American Public Health Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital
Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Charles V Sanders, MD, Edgar Hull Professor and Chairman, Department of Internal Medicine, Professor of Microbiology, Immunology and Parasitology, Louisiana State University School of Medicine at New Orleans; Medical Director, Medicine Hospital Center, Charity Hospital and Medical Center of Louisiana at New Orleans; Consulting Staff, Ochsner Medical Center
Charles V Sanders, MD is a member of the following medical societies: Alliance for the Prudent Use of Antibiotics, Alpha Omega Alpha, American Association for the Advancement of Science, American Association of University Professors, American Clinical and Climatological Association, American College of Physician Executives, American College of Physicians, American Federation for Medical Research, American Foundation for AIDS Research, American Geriatrics Society, American Lung Association, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Association for Professionals in Infection Control and Epidemiology, Association of American Medical Colleges, Association of American Physicians, Association of Professors of Medicine, Infectious Disease Society for Obstetrics and Gynecology, Infectious Diseases Society of America, Louisiana State Medical Society, Orleans Parish Medical Society, Royal Society of Medicine, Sigma Xi, Society of General Internal Medicine, Southeastern Clinical Club, Southern Medical Association, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Michael R Pinsky, MD, CM, FCCP, FCCM, Professor of Critical Care Medicine, Bioengineering, Cardiovascular Disease and Anesthesiology, Vice-Chair, Academic Affairs, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center
Michael R Pinsky, MD, CM, FCCP, FCCM is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American Heart Association, American Thoracic Society, Association of University Anesthetists, Shock Society, and Society of Critical Care Medicine
Disclosure: LiDCO Ltd Honoraria Consulting; iNTELOMED Intellectual property rights Board membership; Edwards Lifesciences Honoraria Consulting; Applied Physiology, Ltd Honoraria Consulting; Cheetah Medical Consulting fee Consulting

 
 
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