A 34-year-old man presents to the emergency department with a 3-day history of fever, chills, headache, dry cough, myalgia, dyspnea, and diarrhea. He reports that he returned from an area with a recently documented cluster of SARS cases 5 days prior to the onset of his symptoms. He is hypoxic, and the initial chest x-ray reveals multifocal bilateral infiltrates. Laboratory findings show a moderate leukopenia (in particular, lymphopenia) and thrombocytopenia along with elevated creatinine kinase, lactate dehydrogenase, and aminotransferase levels. He is isolated in a negative pressure chamber and gradually improves over the next 4 days. On day 5, the fever and diarrhea relapse and subsequent chest x-rays reveal new infiltrations. The patient develops respiratory failure and hemodynamic instability. He is transferred to the ICU, where mechanical ventilation is initiated. As clinical deterioration continues, he progresses to acute respiratory distress syndrome (ARDS) and dies 6 days later.
The typical febrile response may be absent in older patients, who may present with malaise, loss of appetite, delirium, or even an episode of a fall with an associated fracture. Infants and children present with milder symptoms and associated rhinorrhea in 50% of cases.
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