Page 112 - Journal of Special Operations Medicine - Winter 2015

include leukopenia, usually lymphopenia along with obtained by bronchoscopy are not possible, both naso-
thrombocytopenia, and elevated lactate dehydrogenase pharyngeal and oropharyngeal specimens should be ob-
and transaminase levels. Risk factors for severe illness tained. Various DoD laboratories located in the United
2
5
include immunosuppression, obesity, diabetes, and pre- States, Republic of Korea, Germany, and the Middle
existing heart, lung, or kidney disease. In addition to East are equipped for MERS-CoV testing and are listed
2
comorbidities, severe illness and mortality appear to be in the DoD guideline. 5
associated with low albumin concentration, age older
than 65 years, and development of concomitant infec- Management
tions, particularly ventilator-acquired respiratory infec-
tions. The mean time from onset of symptoms until Upon suspecting a case of MERS, providers should
2
death is 11.5 days. 2 immediately provide the patient with a medical mask,
place the patient on droplet and contact precautions,
and ensure strict universal precautions by providers.
4
Diagnosis
If possible, MERS patients should be placed in an ad-
Infection with MERS-CoV generally should be sus- equately ventilated single room away from other patient
pected in patients presenting with a febrile respiratory care areas. If patients receive treatments that risk aero-
4
illness who have had either a recent travel history to solization of pathogens (including nebulizer treatments,
the Arabian Peninsula or neighboring countries, or who high-flow nasal cannula, and chest physiotherapy), they
had contact with a traveler with fever and respiratory should additionally be placed on airborne precautions.
4
symptoms. Additionally, symptomatic patients with a Because there are no proven therapies for MERS-CoV,
5
history of being in a healthcare facility in the Republic management is largely supportive. Hypoxia should be
4
of Korea should also be suspected. The Department of managed with supplemental oxygen, high-flow devices,
5
Defense (DoD) Armed Forces Health Surveillance Cen- and mechanical ventilation, if necessary. Hemodynamic
ter provides guidelines for the detection and reporting of support may also be required with intravenous fluid re-
cases of MERS-CoV infection. This guideline references suscitation and vasopressors; however, in the absence of
5
the Centers for Disease Control and Prevention (CDC) shock, intravenous fluids should be given judiciously to
and World Health Organization guidelines for case defi- avoid respiratory impairment. Empiric corticosteroids
4
nitions and diagnosis (Figure 1). Patients who meet and other adjunctive therapies are discouraged unless in
4–6
the aforementioned criteria (Figure 1) are considered the context of a clinical trial. Prior investigations with
4
patients under investigation and should be tested for steroids in the treatment of the severe acute respiratory
common respiratory pathogens in addition to MERS- syndrome virus yielded worse outcomes. 2
CoV. At least three specimen types (ideally, two respira-
5
tory specimens and a serum sample) should be obtained Several drugs have been shown to inhibit MERS-
for laboratory testing. If lower respiratory specimens CoV in vitro, including cyclosporine, mycophenolate,
5
Figure 1 CDC case definitions of Middle East respiratory syndrome coronavirus.
Clinical Features Epidemiologic Risk
Severe illness and A history of travel from countries in or near the Arbian Peninsula within 14
1
2
Fever and pneumonia or acute days before symptom onset, or close contact with a sympotomatic traveler who
respiratory distress syndrome developed fever and acute respiratory illness (not necessarily pneumonia within
1
(based on clinical or radiological 14 days after traveling from countries in or near the Arbian Peninsula .
evidence) OR
A history of being in a healthcare facility (as a patient, worker or visitory) in the
Republic of Korea within 14 days before symptom onset.
OR
A member of a cluster of patients with severe acture respiratort illness (e.g. fever
and pneumonia requiring hospitalization) of unknown etiology in which MERS-
CoV is being evaluated, in consultation with state and local health departments in
the US.
Milder illness and A history of being in a healthcare facility (as a patient, worker or visitor) within
Fever and symptoms of respiratory 14 days before symptom onset in a country or territory in or near the Arbian
illness (not necessarily pneumonia; Peninsula in which recent healthcare-associated cases of MERS have been
1
e.g., cough, shortness or breath) identified.
2
Fever or symptoms of respiratory and Close contact with a confirmed MERS case while the case was ill
illness (not necessarily pneumonia;
e.g., cough, shortness or breath)
Adapted from CDC. 6

100 Journal of Special Operations Medicine Volume 15, Edition 4/Winter 2015