Almost 20% of patients develop worsening respiratory distress with persistent or progressive hypoxia requiring ICU admission. Most of these patients require intubation and mechanical ventilatory support.
Radiological evidence of ARDS in the presence of a mild to moderate respiratory illness is a marker of severe respiratory illness in SARS, and ARDS is a common cause of death in patients with SARS.
Antiprotease combinations (e.g., lopinavir/ritonavir) added to corticosteroids and/or ribavirin early in the course of SARS coronavirus (CoV) infection have been shown to reduce the progression to ARDS as well as the death rate.
A low-tidal volume strategy for the protection of the lungs has been used for the ventilation of SARS patients developing ARDS. Evidence B
spontaneous or iatrogenic barotrauma
Pneumomediastinum and pneumothorax, often spontaneous but also during positive-pressure ventilation, complicate extensive disease. Air leakage is usually caused by rupture of subpleural cysts formed by diffuse alveolar damage and fibrosis.
Signs and symptoms of barotrauma during mechanical ventilation include worsening of hypoxaemia, tracheal deviation, and hypotension.
Chest x-ray confirms the presence of pneumothorax or pneumomediastinum.
Treatment includes drainage with insertion of a chest tube.
Critically ill patients are often complicated with superimposed bacterial infections resulting in sepsis and sepsis-induced organ dysfunction or tissue hypoperfusion.
Treatment includes antibiotics and supportive therapy to prevent multiple organ failure.
multiple organ failure
Renal and cardiac compromise, along with respiratory failure, are common manifestations of multiple organ failure complicating severely ill patients with SARS.
Treatment involves specific supportive therapy for each organ affected.
persistent muscle weakness
May be present up to 1 year after infection. It is probably related to prolonged bed rest, systemic effects of the acute disease, or exposure to high doses of corticosteroids. Rehabilitation programmes may improve this symptom.
Chronic post-SARS syndrome is characterised by chronic fatigue, diffuse myalgia, weakness, depression, and sleep disturbance.
Psychological distress with the inability to concentrate, poor memory, depression, and anxiety are frequently reported in patients who have recovered from SARS.
Important decrements in mental health, with reduced quality of life as well as notable utilisation of psychiatric and psychological services, were reported in the 1-year follow-up period.
During the illness, many patients experience stress due to quarantine and isolation, fear for their physical health, and concern about the possibility of transmission to their family. In addition, there may be stress related to social stigmatisation, the loss of anonymity through the media, the death of relatives, and the inability to attend funerals of close relatives due to strict quarantine rules.
Haematological changes such as lymphopenia, thrombocytopenia, and, occasionally, leukopenia and anaemia are common in the acute phase. A notable drop in CD4 and CD8 lymphocyte counts occurs early in the course of the syndrome. A mild degree of anaemia is commonly seen at the early follow-up period.
Few patients in critical condition develop frank DIC with signs of spontaneous bleeding.
Treatment is symptomatic and includes fresh frozen plasma and blood transfusion when required.
abnormal lung function
Pulmonary function testing following hospital discharge reveals mild or moderate restrictive ventilatory defects with a mild decrease in carbon monoxide diffusion capacity. These findings are consistent with fibrotic lung changes.
Lung function and radiological abnormalities tend to improve spontaneously over time.
Axonopathic polyneuropathy, myopathy, rhabdomyolysis with associated renal failure, and large artery ischaemic stroke with poor prognosis have been described in SARS patients.
Treatment is symptomatic with haemodialysis for renal failure.
In women infected during pregnancy, spontaneous miscarriage, preterm delivery, and intrauterine growth restriction are frequent complications.
corticosteroid-related adverse effects
Avascular necrosis of the femoral head has been reported in some SARS patients and is strongly associated with corticosteroid use.
Treatment is surgical and includes decompression with bone grafting, arthroplasty, or replacement of the femoral head.
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