冯力民　　王保国　　刘小春
李晶华　　焦　强*
首都医科大学附属北京天坛医院，北京 100050
*中国中医研究院望京医院
Clinical Analysis of 61 Patients with SARS
Li-min Feng, Bao-guo Wang, Xiao-chun Liu, Jing-hua Li, and Jiao Qiang*
Beijing Tiantan Hospital, Capital University of Medical Sciences, Beijing 100050
Wangjing Hospital, China Acadamy of Traditional Chinese Medicine, Beijing 

Abstract

　Objective：To describe the clinical characteristics and short-term outcomes of 61 patients with severe acute respiratory syndrome(SARS).
　Methods：Retrospective analysis of 61 patients with SARS admitted between April 23 and May 25, 2003. The diagnosis was made if the patient had a fever(>38℃), a known exposure to SARS patient(s), and respiratory symptoms or infiltrates observed on chest radiograph.
　Results：Of the 61 patients, 47(77%) had been exposed clearly to SARS patient(s). The most common clinical presentations in these patients on admission were self-reported fever in 54(88.5%), nonproductive cough in 7(11.5%), myalgia and headache in 24(39.3%), diarrhea in 8(13.1%), and dyspnea in 1(1.6%) cases respectively. Chi-square test showed that the absolute value of lymphocyte, leukocyte, neutrophil, lactate dehydrogenase and aspartate aminotransferase on admission, two weeks after falling ill and discharge were significantly different respectively. Two weeks after falling ill is considered to be the most serious stage of SARS. 56/61(91.8%) were treated with methylprednisolone and 54/61(88.5%) with ribavirin, although its use was associated with significant toxicity, including decrease in hemoglobin of 2g/dl (24/54,44.4%)，tachycardia(100 bpm) happened in 23/57(40.4%) cases. Of the 6 patients who died, 5 were aged(68.6±4.2 yrs), and all had underlying diseases, such as hypertension, diabetes, chronic obstructive pulmonary disease, etc. The other one was a young female nurse, who committed suicide in hospital. The first abnormal chest radiograph was diagnosed in 8.6±5.9 days（1～24） after the symptoms first appeared. The abnormal chest radiograph returned to normal in 17.1±6.2(5～35) days.
　Conclusion：SARS is a complex disease, which affects almost all organs and systems. From the clinical observation, it is necessary that glucocorticoid be administered early with suitable dose for SARS patients. We should pay more attention to the side effects resulting from excessive dosage of glucocorticoid and ribavirin.
　Key words：severe acute respiratory syndrome (SARS)
　Corresponding author: Baoguo Wang, M.D.；wbgttyy@sina.com<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

　　注：本课题为国家科技部“十五”863计划重大项目“非典型肺炎防治关键技术与产品研制”立项资助课题（课题编号2003AA208101）

　　As of April 28, 2003, severe acute respiratory syndrome (SARS) has been reported in 28 countries involving 5050 individuals and causing 217 deaths^[1]. On the basis of the criteria for SARS set by WHO, the suspected case should have a fever (>38℃), respiratory symptoms such as cough or dyspnea, a history of exposure to a index patient or having traveled to an epidemic area, a chest radiograph probably showing evidence of pneumonia, the respiratory distress syndrome (RDS) in advanced stage of the disease, or a death resulting from unidentified disease of respiratory system. Our retrospective study is to describe the clinical presentation, laboratory investigation and the short-term outcomes of 61 SARS cases.<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

Study Population and Data Analysis

　　Our diagnostic criteria was consistent with that set by WHO^[1] : a fever (temperature, >38℃), a known exposure to SARS patient(s), respiratory symptoms including cough, dyspnea and hypoxemia (oxygen saturation <95%), and infiltrates observed on chest radiograph.
　　There were 22 male and 39 female patients aged 34.6±12.9 yrs. A total of 6 patients had serious underlying diseases: chronic obstructive pulmonary disease (COPD) in 3, hypertension in 1, diabetes mellitus(DM) in 1 and hepatitis combined with cirrhosis in 1.
　　Statistical analysis was performed using SPSS 10.0.  Independent-Samples t-test was performed to compare the effect of the different treatments. Paired-Samples t-test was performed to identify the change in laboratory investigation before and after treatment. Chi-square test was performed to compare the normal and abnormal rate of laboratory investigation at different stage of disease. A P value of less than 0.05 was considered to indicate statistical significance. All probabilities are two-tailed.

Results<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

　　Epidemiological Investigation:
　　The history of exposure to SARS included close contact(health care workers who participated in the care of SARS patients, people who lived together had a face-to-face contact with SARS patient ), and exposure to epidemic area or hospital. Of the 61 cases, 41 (77%) had known exposure to SARS patients(7 doctors, 18 nurses and 6 allied health workers, 7 who contracted the disease from their family members, 1 contracted it while traveling and 8 visited epidemic hospitals.
　　Clinical presentation
　　At first clinical visit, 54(88.5%) patients had a fever, which was the most common clinical presentation, 24 (39.3%) with myalgia and/or headache, 21(34.9%) with tachycardia (>100bpm), 8(13.1%) with diarrhea, 7(11.5%) with dry cough and 1(1.6%) with dyspnea.
　　Of 54 patients who had complete laboratory investigation data, Chi-square test was performed to compare the normal and abnormal rate of absolute count of lymphocyte, leukocyte, the ratio of neutropil, lactate dehydrogenase(LDH), glutamic oxalacetic transaminase (GOT) at three different stages (i.e., admission, two weeks after falling ill and discharge). Significant differences were observed (Table 1).


　　Based on the statistical analysis, we concluded that two weeks after falling ill was the most serious stage of the disease. At this time, count of lymphocyte and leukocyte had a further decrease, and the ratio of neutrophil had a relative increase.

　　Psychotherapy for SARS patients
　　In human medicine history, SARS was a new and serious disease, which eventually added heavy psychological burden on the patients. Probably, it could induce some psychological disorder. Through our clinical observation, at the early phase of illness, patients had suffered from nervousness and fear. Some patients even committed suicide. Therefore, it is urgent need to give psychological help to reassure the patients and strengthen their confidence in conquering the disease. Because the status of being isolated and protection uniforms won by medical staff made it very difficult for face-to-face communication, the psychological help by phone was an advisable way. At the phase of recovery, what the patients，worried  mostly was whether they were still infectious to their family or people around them and whether the disease would recur after discharge. Through one month of follow-up, no related evidence was found, and chest radiograph of all our patients remained. As for psychological guide and recovery, further observation and study is needed.<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />

REFERENCES

1. World Health Organization. Cumulative number of reported probable cases of　severe acute respiratory syndrome (SARS). Accessed April 29, 2003.
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3. Nelson Lee, David Hui, Alan Wu, et al. A Major Outbreak of Severe Acute　Respiratory Syndrome in Hong Kong. The New England J Medicine.2003,348(20),1986-1994.

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