A 50-year-old man presents with a 4-day history of fever, progressive dyspnea, and dry cough, and a 2-day history of nausea and diarrhea. His history is significant for smoking and type 2 diabetes mellitus. He reports arriving in the US from the Arabian Peninsula, where he lives, 10 days ago for the purpose of a vacation. He reports recent contact with his brother, a camel herder, who is currently in the hospital being investigated for an acute viral respiratory infection. Examination reveals a temperature of 100.8°F, a respiratory rate of 22 breaths per minute, and oxygen saturation of 88%. Chest examination is normal. Laboratory workup reveals leukopenia, lymphopenia, thrombocytopenia, elevated ALT, and elevated creatinine.
The majority of patients present with fever and respiratory symptoms (e.g., cough, dyspnea); however, some patients may present with gastrointestinal symptoms only (e.g., nausea, vomiting, diarrhea, abdominal pain). Other symptoms include myalgia, arthralgia, headache, chills/rigors, sore throat, and rhinorrhea. Fever may be absent in older patients, immunocompromised patients, pregnant women, and patients with end-stage renal disease, diabetes mellitus, or hemochromatosis. Some patients, particularly young, healthy patients, may be asymptomatic or present with mild respiratory symptoms and a normal chest x-ray. However, others, particularly older patients or those with comorbidities, may present with severe, rapidly progressive pneumonia, acute respiratory distress syndrome, septic shock, or multiorgan failure resulting in death. A patient who presented with acute renal failure caused a superspreader event in Riyadh (Saudi Arabia) in 2017, highlighting the difficulties in diagnosing pneumonia in patients with renal and cardiac failure. Infection in children is rare.
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