Middle east respiratory syndrome - Symptoms, Causes, Images, and Treatment Options

Diseases

Highlights & Basics

Key Highlights

Middle East respiratory syndrome (MERS) should be considered when a severe respiratory illness occurs in the 2 weeks following residence in or travel to the Middle East or areas of outbreak, and/or close contact with infected individuals.
The majority of cases are the result of human-to-human transmission, with peaks of confirmed cases occurring during nosocomial outbreaks. Clinical presentation ranges from asymptomatic to severe, rapidly progressive, potentially fatal pneumonia.
Clues on routine laboratory testing include leukopenia, lymphopenia, thrombocytopenia, and evidence of acute kidney injury. Confirmation of infection requires specialized laboratory testing including real-time reverse transcription polymerase chain reaction (RT-PCR) on respiratory samples and serum.
Treatment is supportive; however, several promising virus-specific therapies are under investigation. Vaccines are undergoing trials.
Epidemic potential is considered low at present unless the virus mutates.

Electron micrograph of a thin section of Middle East respiratory syndrome coronavirus (MERS-CoV) showing the spherical particles within the cytoplasm of an infected cell

Centers for Disease Control and Prevention (CDC)

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History & Exam
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Definition

Epidemiology

Etiology

Pathophysiology

Images

Electron micrograph of a thin section of Middle East respiratory syndrome coronavirus (MERS-CoV) showing the spherical particles within the cytoplasm of an infected cell
Negative stain electron microscopy showing Middle East respiratory syndrome coronavirus (MERS-CoV) particles with characteristic club-like projections from the viral membrane
Algorithm for testing cases under investigation by reverse transcription polymerase chain reaction (RT-PCR)

Citations

Key Articles

Assiri A, Al-Tawfiq JA, Al-Rabeeah AA, et al. Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: a descriptive study. Lancet Infect Dis. 2013 Sep;13(9):752-61.[Abstract][Full Text]
Saad M, Omrani AS, Baig K, et al. Clinical aspects and outcomes of 70 patients with Middle East respiratory syndrome coronavirus infection: a single-center experience in Saudi Arabia. Int J Infect Dis. 2014;29:301-6.[Abstract][Full Text]
Alraddadi BM, Watson JT, Almarashi A, et al. Risk factors for primary Middle East respiratory syndrome coronavirus illness in humans, Saudi Arabia, 2014. Emerg Infect Dis. 2016;22:49-55.[Abstract][Full Text]
World Health Organization. Clinical management of severe acute respiratory infection when Middle East respiratory syndrome coronavirus (MERS-CoV) infection is suspected. Interim guidance. Jan 2019 [internet publication].[Full Text]
Cevik M, Tate M, Lloyd O, et al. SARS-CoV-2, SARS-CoV, and MERS-CoV viral load dynamics, duration of viral shedding, and infectiousness: a systematic review and meta-analysis. Lancet Microbe. 2021 Jan;2(1):e13-e22.[Abstract][Full Text]
Arabi YM, Balkhy HH, Hayden FG, et al. Middle East respiratory syndrome. N Engl J Med. 2017 Feb 9;376(6):584-94.[Abstract][Full Text]
Arabi YM, Asiri AY, Assiri AM, et al. Interferon beta-1b and lopinavir-ritonavir for Middle East respiratory syndrome. N Engl J Med. 2020 Oct 22;383(17):1645-56.[Abstract][Full Text]

Other Online Resources

Centers for Disease Control and Prevention (CDC): Middle East respiratory syndrome (MERS)
World Health Organization (WHO): Middle East respiratory syndrome coronavirus (MERS-CoV)
World Health Organization (WHO): MERS-CoV - initial interview questionnaire of cases
Centers for Disease Control and Prevention (CDC): interim patient under investigation (PUI) guidance and case definitions
World Health Organization (WHO): case definition for reporting to WHO
Ministry of Health (Saudi Arabia): case definition
Centers for Disease Control and Prevention (CDC): interim guidelines for collecting, handling, and testing clinical specimens from patients under investigation for MERS-CoV
World Health Organization (WHO): laboratory testing for Middle East respiratory syndrome coronavirus (MERS-CoV)
World Health Organization (WHO): surveillance for human infection with Middle East respiratory syndrome coronavirus (MERS-CoV)
Ministry of Health (Saudi Arabia): coronavirus (MERS-CoV)
Centers for Disease Control and Prevention (CDC): information about MERS - fact sheet
World Health Organization (WHO): Middle East respiratory syndrome coronavirus (MERS-CoV) fact sheet
World Health Organization (WHO): technical guidance on travel and mass gatherings

Referenced Articles

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78. Memish ZA, Al-Tawfiq JA, Makhdoom HQ, et al. Respiratory tract samples, viral load, and genome fraction yield in patients with Middle East respiratory syndrome. J Infect Dis. 2014;210:1590-1594.[Abstract][Full Text]
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83. Ajlan AM, Ahyad RA, Jamjoom LG, et al. Middle East respiratory syndrome coronavirus (MERS-CoV) infection: chest CT findings. AJR Am J Roentgenol. 2014;203:782-787.[Abstract][Full Text]
84. Reuss A, Litterst A, Drosten C, et al. Contact investigation for imported case of Middle East respiratory syndrome, Germany. Emerg Infect Dis. 2014;20:620-625.[Abstract][Full Text]
85. Shalhoub S, Al-Zahrani A, Simhairi R, et al. Successful recovery of MERS CoV pneumonia in a patient with acquired immunodeficiency syndrome: a case report. J Clin Virol. 2015;62:69-71.[Abstract]
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87. Hui DS, Memish ZA, Zumla A. Severe acute respiratory syndrome vs. the Middle East respiratory syndrome. Curr Opin Pulm Med. 2014;20:233-241.[Abstract]
88. Christian MD, Poutanen SM, Loutfy MR, et al. Severe acute respiratory syndrome. Clin Infect Dis. 2004;38:1420-1427.[Abstract][Full Text]
89. Memish ZA, Al-Tawfiq JA, Makhdoom HQ, et al. Screening for Middle East respiratory syndrome coronavirus infection in hospital patients and their healthcare worker and family contacts: a prospective descriptive study. Clin Microbiol Infect. 2014;20:469-474.[Abstract][Full Text]
90. Drosten C, Meyer B, Muller MA, et al. Transmission of MERS-coronavirus in household contacts. N Engl J Med. 2014;371:828-835.[Abstract][Full Text]
91. Raoult D, Charrel R, Gautret P, et al. From the Hajj: it's the flu, idiot. Clin Microbiol Infect. 2014;20:O1.[Abstract]
92. Memish ZA, Assiri A, Almasri M, et al. Prevalence of MERS-CoV nasal carriage and compliance with the Saudi health recommendations among pilgrims attending the 2013 Hajj. J Infect Dis. 2014;210:1067-1072.[Abstract][Full Text]
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100. Al-Hameed F, Wahla AS, Siddiqui S, et al. Characteristics and outcomes of Middle East respiratory syndrome coronavirus patients admitted to an intensive care unit in Jeddah, Saudi Arabia. J Intensive Care Med. 2016;31:344-348.[Abstract]
101. Alshahrani MS, Sindi A, Alshamsi F, et al. Extracorporeal membrane oxygenation for severe Middle East respiratory syndrome coronavirus. Ann Intensive Care. 2018 Jan 10;8(1):3.[Abstract][Full Text]
102. Arabi YM, Mandourah Y, Al-Hameed F, et al. Corticosteroid therapy for critically ill patients with Middle East respiratory syndrome. Am J Respir Crit Care Med. 2018 Mar 15;197(6):757-767.[Abstract]
103. Centers for Disease Control and Prevention. Preventing MERS-CoV from spreading to others in homes and communities. Aug 2019 [internet publication].[Full Text]
104. World Health Organization. Home care for patients with Middle East respiratory syndrome coronavirus (MERS-CoV) infection presenting with mild symptoms and management of contacts. Interim guidance. June 2018 [internet publication].[Full Text]
105. Centers for Disease Control and Prevention. Middle East respiratory syndrome (MERS). Implementing home care and isolation or quarantine of people not requiring hospitalization for MERS-CoV. March 2020 [internet publication].[Full Text]
106. Arabi YM, Balkhy HH, Hayden FG, et al. Middle East respiratory syndrome. N Engl J Med. 2017 Feb 9;376(6):584-94.[Abstract][Full Text]
107. Arabi YM, Shalhoub S, Mandourah Y, et al. Ribavirin and interferon therapy for critically ill patients with Middle East respiratory syndrome: a multicenter observational study. Clin Infect Dis. 2020 Apr 15;70(9):1837-44.[Abstract][Full Text]
108. Arabi YM, Asiri AY, Assiri AM, et al. Interferon beta-1b and lopinavir-ritonavir for Middle East respiratory syndrome. N Engl J Med. 2020 Oct 22;383(17):1645-56.[Abstract][Full Text]
109. Arabi YM, Deeb AM, Al-Hameed F, et al. Macrolides in critically ill patients with Middle East respiratory syndrome. Int J Infect Dis. 2019 Apr;81:184-90.[Abstract][Full Text]
110. Chan JF, Chan KH, Kao RY, et al. Broad-spectrum antivirals for the emerging Middle East respiratory syndrome coronavirus. J Infect. 2013;67:606-616.[Abstract]
111. Falzarano D, de Wit E, Martellaro C, et al. Inhibition of novel beta coronavirus replication by a combination of interferon-alpha2b and ribavirin. Sci Rep. 2013;3:1686.[Abstract][Full Text]
112. Falzarano D, de Wit E, Rasmussen AL, et al. Treatment with interferon-alpha2b and ribavirin improves outcome in MERS-CoV-infected rhesus macaques. Nat Med. 2013;19:1313-1317.[Abstract][Full Text]
113. Al-Tawfiq JA, Momattin H, Dib J, et al. Ribavirin and interferon therapy in patients infected with the Middle East respiratory syndrome coronavirus: an observational study. Int J Infect Dis. 2014;20:42-46.[Abstract][Full Text]
114. Khalid M, Al Rabiah F, Khan B, et al. Ribavirin and interferon (IFN)-alpha-2b as primary and preventive treatment for Middle East respiratory syndrome coronavirus (MERS-CoV): a preliminary report of two cases. Antivir Ther. 2015;20:87-91.[Abstract]
115. Al-Ghamdi M, Mushtaq F, Awn N, et al. MERS CoV infection in two renal transplant recipients: case report. Am J Transplant. 2015;15:1101-1104.[Abstract]
116. Li HS, Kuok DIT, Cheung MC, et al. Effect of interferon alpha and cyclosporine treatment separately and in combination on Middle East Respiratory Syndrome Coronavirus (MERS-CoV) replication in a human in-vitro and ex-vivo culture model. Antiviral Res. 2018 Jul;155:89-96.[Abstract][Full Text]
117. Hart BJ, Dyall J, Postnikova E, et al. Interferon-beta and mycophenolic acid are potent inhibitors of Middle East respiratory syndrome coronavirus in cell-based assays. J Gen Virol. 2014;95:571-577.[Abstract][Full Text]
118. Chu CM, Cheng VC, Hung IF, et al. Role of lopinavir/ritonavir in the treatment of SARS: initial virological and clinical findings. Thorax. 2004;59:252-256.[Abstract][Full Text]
119. Chan JF, Yao Y, Yeung ML, et al. Treatment with lopinavir/ritonavir or interferon-beta1b improves outcome of MERS-CoV infection in a nonhuman primate model of common marmoset. J Infect Dis. 2015;212:1904-1913.[Abstract]
120. Spanakis N, Tsiodras S, Haagmans BL, et al. Virological and serological analysis of a recent Middle East respiratory syndrome coronavirus infection case on a triple combination antiviral regimen. Int J Antimicrob Agents. 2014;44:528-532.[Abstract]
121. de Wilde AH, Raj VS, Oudshoorn D, et al. MERS-coronavirus replication induces severe in vitro cytopathology and is strongly inhibited by cyclosporin A or interferon-alpha treatment. J Gen Virol. 2013;94:1749-1760.[Abstract][Full Text]
122. Pan Q, de Ruiter PE, Metselaar HJ, et al. Mycophenolic acid augments interferon-stimulated gene expression and inhibits hepatitis C Virus infection in vitro and in vivo. Hepatology. 2012;55:1673-1683.[Abstract]
123. Cheng KW, Cheng SC, Chen WY, et al. Thiopurine analogs and mycophenolic acid synergistically inhibit the papain-like protease of Middle East respiratory syndrome coronavirus. Antiviral Res. 2015;115:9-16.[Abstract]
124. Mailles A, Blanckaert K, Chaud P, et al. First cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infections in France, investigations and implications for the prevention of human-to-human transmission, France, May 2013. Euro Surveill. 2013;18:20502.[Abstract][Full Text]
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