Clinical presentation and outcome of severe acute respiratory syndrome in dialysis patients

Abstract

There was a major outbreak of severe acute respiratory syndrome (SARS) affecting more than 300 patients occurring in a private housing estate in Hong Kong, in which an infected renal patient was suspected to be the primary source. It is unknown whether renal patients would represent a distinct group of patients who share some characteristics that could predispose them to have higher infectivity. In this context, we have encountered 4 dialysis patients contracting SARS in a minor outbreak, which involved 11 patients and 4 health care workers, in a medical ward of a regional hospital. Of these 4 dialysis patients, 1 patient was receiving hemodialysis while the other 3 patients were on continuous ambulatory peritoneal dialysis. Fever and radiological changes were their dominant presenting features. All were having positive results for SARS-associated coronavirus ribonucleic acid by reverse transcriptase-polymerase chain reaction performed on their nasopharyngeal aspirates or stool samples. It appeared that treatment with high-dose intravenous ribavirin and corticosteroids could only resolve the fever, but it could not stop the disease progression. All 4 patients developed respiratory failure requiring mechanical ventilation on days 9 through 12. At the end, all of the patients died from sudden cardiac arrest, which was associated with acute myocardial infarction in 2 cases. From this small case series, it appeared that dialysis patients might have an aggressive clinical course and poor outcome after contracting SARS. However, a large-scale study is required to further examine this issue, and further investigation into the immunologic abnormalities associated with the uremic state in this group of patients is also warranted.

Fig 1

Diagram showing the floor plan of the ward where the SARS outbreak occurred.

Fig 2

Cross-sectional view of rooms 6 and 8 showing the locations of ventilation ducts.

Fig 3

Diagram showing the dimensions of rooms 6 and 8 and the bed locations of the SARS cases related to the first SARS patient.

Fig 4

Diagram showing the bed locations of the SARS patients related to the readmission of patient 1 in room 6.

Fig 5

Serial chest radiographs of patient 4, who presented with fever and cough. (A) Ill-defined air-space opacities over bilateral lower zones on day 1 of presentation. (B) Apparent resolution of initial presenting lung opacities on day 3. (C) Subsequent reappearance of bilateral lower zones opacities.