Clinical features and virological analysis of a case of Middle East respiratory syndrome coronavirus infection

BACKGROUND

The Middle East respiratory syndrome coronavirus (MERS-CoV) is an emerging virus involved in cases and case clusters of severe acute respiratory infection in the Arabian Peninsula, Tunisia, Morocco, France, Italy, Germany, and the UK. We provide a full description of a fatal case of MERS-CoV infection and associated phylogenetic analyses.

METHODS

We report data for a patient who was admitted to the Klinikum Schwabing (Munich, Germany) for severe acute respiratory infection. We did diagnostic RT-PCR and indirect immunofluorescence. From time of diagnosis, respiratory, faecal, and urine samples were obtained for virus quantification. We constructed a maximum likelihood tree of the five available complete MERS-CoV genomes.

FINDINGS

A 73-year-old man from Abu Dhabi, United Arab Emirates, was transferred to Klinikum Schwabing on March 19, 2013, on day 11 of illness. He had been diagnosed with multiple myeloma in 2008, and had received several lines of treatment. The patient died on day 18, due to septic shock. MERS-CoV was detected in two samples of bronchoalveolar fluid. Viral loads were highest in samples from the lower respiratory tract (up to 1·2 × 10(6) copies per mL). Maximum virus concentration in urine samples was 2691 RNA copies per mL on day 13; the virus was not present in the urine after renal failure on day 14. Stool samples obtained on days 12 and 16 contained the virus, with up to 1031 RNA copies per g (close to the lowest detection limit of the assay). One of two oronasal swabs obtained on day 16 were positive, but yielded little viral RNA (5370 copies per mL). No virus was detected in blood. The full virus genome was combined with four other available full genome sequences in a maximum likelihood phylogeny, correlating branch lengths with dates of isolation. The time of the common ancestor was halfway through 2011. Addition of novel genome data from an unlinked case treated 6 months previously in Essen, Germany, showed a clustering of viruses derived from Qatar and the United Arab Emirates.

INTERPRETATION

We have provided the first complete viral load profile in a case of MERS-CoV infection. MERS-CoV might have shedding patterns that are different from those of severe acute respiratory syndrome and so might need alternative diagnostic approaches.

FUNDING

European Union; German Centre for Infection Research; German Research Council; and German Ministry for Education and Research.

[Postoperative responsiveness following halothane- or enflurane-anaesthesia for short operative procedures (author's transl)]

A comparative study was carried out on 139 patients, divided into eight groups. Either halothane or enflurane were given as inhalational agent, and for induction either Trapanal or Brevimytal were given. Some groups received a standard premedication, other not. The post-operative level of consciousness, responsiveness and motor performance were assessed, and venous halothane/enflurane levels measured. No marked differences were found in the level of consciousness, responsiveness, or motor performance, between the halothane and enflurane groups. The respective plasma levels of halothane and enflurane were practically identical at corresponding time intervals of measurement. In those groups which were not premedicated, no difference could be found following induction with either Trapanal or Brevimytal. In the premedicated groups those patients who had been given Brevimytal woke earlier, and showed a greater degree of responsiveness.