Middle East
Respiratory Syndrome
(MERS-COV)
Done by : Fatimah Al-Shehri
Intern pharmacist
Supervised by : Dr . Sahal Khoshhal
Infectious disease clinical pharmacy specialist
Outline:
• Case review .
•
•
•
•
•
•
Definition
Signs and symptoms
Transmission pathway
Epidemiology
Complications
Treatment.
• Case follow up .
• Prevention and control.
Case review :
• 28 years old male admitted to the hospital on 30/3/2014 complaining of
productive cough , generalized body pain , nausea , vomiting , sever
headache, high grade fever, dysphasia and sever respiratory failure .
•
•
•
•
•
PMH:
Hx of glucose 6 phosphate deficiency (G6PD) .
Mild sulpha drugs allergy .
Medically free.
The patient is an orthopedic resident and he has a history of working in
environment (KFH ) in which CORONA virus was detected.
• After admission:
•
pneumonia was suspected since the X-ray was done that day and showed
right middle zone infiltration and right middle lob pneumonia but then
PCR was done and the viral DNA of CORONA VIRUS was extracted
from the patient’s plasma so MERS-coV was confirmed .
• The patient developed acute kidney injury , rhabdomyolysis , sever
respiratory distress ,liver injury , increase in cardiac enzymes .
X-ray on
3/4/2014
FINDINGS:
Examination compared with 28 March 2014.
Interval development of bilateral air-space disease involving both middle lungs and the left
lower lung likely related to chest infection, for clinical correlation and follow-up..
X-ray 4/4/2014
.
FINDINGS:
-Comparison was
made to the
previous study done
yesterday.
-Appearance of
airspace opacity is
noted in the middle
zone of the right
lung and middle
zone of left lung.
X-ray 16/4/2014
• FINDINGS:
-Comparison was made
to the previous study
dated April 16, 2014.
Redemonstration of the
previously seen bilateral
diffuse scattered
consolidation with better
aeration of both lungs.
-Bilateral interval
decrease of pleural
effusion.
Tubes and lines are noted
in satisfactory position.
The laboratory value and vital signs since confirmation of
MERS COV :
Items
6/4
7/4
8/4
9/4
10/4
13/4
14/4
Temp
38.6
38.2
37.5
39.1
36.3
36.3
36.8
BP
110/48
100/58
133/85
128/63
112/56
107/51
130/70
99/32
116/23
109/38
88/14
83/16
89/13
HR/RR 44/23
BUN
2.4
2.3
5.7
9
7.1
2.8
Na
135
133
135
138
146
143
K
3.4
4.3
5.2
5.1
3.6
3.7
Cl
104
102
100
103
109
107
Co2
20
23
21
21
26
25
G
7.4
5
5.2
8
7
5.5
Cr
72
76
136
103
79
71
CrCl
183.17
164.69
96.97
128.04
156.54
183.53
200.66
The laboratory value and vital signs since confirmation of
MERS COV :
Items
6/4
7/4
Ca
2.10
2.17
phos
1.31
Mg
0.7
Bili
11.6
22.1
ALK
63
Alb
8/4
9/4
10/4
13/4
2.31
2.32
2.24
0.96
0.41
0.84
1.12
0.8
29.9
61.2
82.4
66
107
81
66
26
25
20
23
25
AST
82
104
124
147
120
103
ALT
56
61
61
50
35
46
WBC
2.5
7
11.6
12.3
7
7.3
9.8
HGB
16
14.5
14.6
12.3
11
9.4
10.1
087
38.6
14/4
The laboratory value and vital signs since confirmation of
MERS COV :
Items
6/4
CPK
7/4
8/4
9/4
10/4
13/4
126
883
2553
933
LDH
747
1548
1792
797
HCT
48.3
45.6
46.4
39.9
PLT
203
257
217
14/4
32.8%
28.8
31.0
207
207
212
Medications:
Anesthesia :
Analgesia :
Ulcer prophylaxix
-Midazolam HCl 10mg IV -Morphine 50 IV push
Push.
-Acetaminophen 1000mg IV
push.
-Esomprazole 80mg IV push.
Corticosteroides:
Antibiotics :
Antivirals:
-Dexamethasone 8mg IV -Ribavirin (600mg susp q
push.
8hrs).
-peginterferon 190mcg subcut
q1w.
-Oseltamivir 75mg cap BID.
-Linezolid 600mg IV BID
-Augmentin 1200mg IV push
-Meropenem 1g IV push q 8
-Vancomycin Hcl 1g IV push
Duretics :
Muscles relaxants:
Thrompolytic:
-Albumin 100ml IV push. -Heparin 5000 Units IV Push.
-Furosemide40mg IV
Push.
-Cistatracurium besyalate
20mg IV push.
Respiration aid:
Inotrops:
Prokinetics:
-Salbutamol.
-ECMO.
-NE 15mg/250ml.
-Metoclopramide 10mg IV
Q8hrs.
CORONAVIRUSIS :
• MERS (middle east respiratory syndrome):
It’s a viral respiratory
illness first reported in
Saudi Arabia in 2012.
• SARS ( Severe acute respiratory syndrome):
It’s caused by a virus that
was first identified in 2003.
It causes acute respiratory
distress and sometimes death.
Signs and symptoms :
•
•
•
•
•
•
•
Fever
Cough
Sneezing
Shortness of breath
Generalized body pain
Vomiting
Mayalgia
Transmission pathway:
Viruses classification
Classification of corona viruses:
Distribution of cases of MERS-CoV reported worldwide by month of
disease onset, outcome and place of infection, as of 14 May 2013.
Distribution of cases of MERS-CoV by gender and
age, April 2012 – 13 May 2013.
MERS- coV cases in KSA June 2012-June2013
Cases of MERS-CoV reported in the Arabian Peninsula and
Jordan, April 2012 to 15 May 2013 .
Distribution of confirmed cases of MERS-CoV
byreporting country, 1 – 30 April 2014 .
Distribution of confirmed cases of MERS-CoV by age and sex,
March 2012 – 31 March 2014 (n=206*) and 01 April - 30 April
2014.
Distribution of confirmed cases of MERS-CoV by month of onset* and place
of reporting, March 2012 – 30 April 2014 .
Distribution of confirmed cases of MERS-CoV by reporting country,
March 2012 – 30 April 2014 (n=424)
Middle East:
Europe:
-UK: 4 cases / 3 deaths
-Germany: 2 cases / 1
death
-France: 2 cases / 1 death
-Italy: 1 case / 0 deaths
-Greece: 1 case/ 0 deaths
-Saudi Arabia: 342 cases / 105 deaths
-UAE: 49 cases / 9 deaths
-Qatar: 7 cases / 4 deaths
-Jordan: 5 cases / 3 deaths
-Oman: 2 cases / 2 deaths
-Kuwait: 3 cases / 1 death
-Egypt: 1 case/ 0 deaths
Africa:
-Tunisia: 3 cases / 1 death
Complications:
• Multi-organ damage .
Treatment:
Treatment :
• Supportive care .
• Chloroquine:
• which has potent antiviral activity against the SARS-CoV
(HCoV-229E and against HCoV-OC43 both in cultured
cells and in a mouse model).
Treatment:
•
•
•
•
Respiratory aids.
Antivirals .
Patients in ICU (FAST HUG MAIDENS).
Monitoring of the kidney, liver, heart
functions.
• Monitoring of myoglobin ??
Respiratory aids:
• Mechanical ventilation .
• ECMO.
ECMO: Extracorporeal membrane
oxygenation
Indications:
• Respiratory distress syndrome.
• Primary pulmonary hypertension in newborn.
• Congenital diaphragmatic hernia(CDH).
Antivirals :
• Ribavirin : Antihepaciviral, Nucleoside (Anti-HCV)
• Mechanism of action:
Ribavirin
Ribavirin
• Doses :
- Recommended therapy duration:
- Genotype 1: 48 weeks.
- Genotypes 2,3: 24 weeks.
- <66 kg: 800 mg daily (400 mg in the morning and evening)
- 66-80 kg: 1000 mg daily (400 mg in the morning, 600 mg in the
evening)
- 81-105 kg: 1200 mg daily (600 mg in the morning, 600 mg in the
evening)
- >105 kg: 1400 mg daily (600 mg in the morning, 800 mg in the
evening).
Ribavirin
•
•
•
•
Ribavirin :
2000 mg as loading dose then:
1200mg q 8 hrs for 4 days .
600 mg po q 8hrs for 4-6 days .
• Peginterferon :
• 1.5 mg/kg once /w for 2 doses.
Ribavirin:
• Use :
- Treatment of hospitalized infants and young children with
respiratory syncytial virus (RSV) specially indicated for treatment
of severe lower respiratory tract RSV infections in patients with an
underlying compromising condition.
- In combination with interferon alfa 2b (pegylated or nonpegylated)
injection for the treatment of chronic hepatitis C .
• Use - Unlabeled:
- Treatment for RSV in adult hematopoietic stem cell or heart/lung
transplant recipients.
- Used in other viral infections including influenza A and B and
adenovirus.
Interferon alpha:
Interferons (IFNs):
proteins made and released by host cells in response to the
presence of pathogens such as
viruses ,bacteria, parasites or tumor cells.
Interferon alpha:
Mechanism of action :
Treatment:
Replication of novel human corona virus hCoV-EMC/2012 in
response to combined treatment with interferon alpha and
Ribavirin in vetro cells.
Results :
Effects of (a) mycophenolic acid, (b) ribavirin, and (c)
interferons (Intron A, Avonex, Rebif, and Betaferon) on
MERS-CoV replication in Vero cells.
Effects of (a) mycophenolic acid, (b) ribavirin, and (c)
interferons (Intron A, Avonex, Rebif, and Betaferon) on
MERS-CoV replication in Vero cells.
Conclusion:
• Compared with ribavirin and interferons,
mycophenolic acid exhibits a number of
attributes that support its practical use in
MERS-CoV infection.
• Interferon beta 1b with mycophenolic acid
should be cosidered in the treatmern trials
of MERS .
Follow-up:
Items :
5/5
8/5
BUN
3.7
3.6
Na
137
136
K
3.7
3.5
Cl
101
100
Co2
27
26
G
5
5
Cr
59
60
211.34
211
WBCs
7.4
7
HGB
9.4
9
PLT
265
265
HCT
30.7%
30.7%
CrCl
MERS PCR
Negative (not detdected) Negative (not detdected)
Follow-up
FINDINGS:
No significant interval changes noted since the previous examination dated
May 1, 2014.
Prevention and control
Prevention and control:
• Health‐care workers apply standard precautions
consistently with all patients regardless of their diagnosis
in all work practices all the time.
Prevention and control:
• Avoid contact with camels, good hand hygiene, and
avoiding drinking raw milk or eating food that may be
contaminated with animal secretions or products unless
they are properly washed, peeled, or cooked.
Prevention and control:
• For the general public, when visiting a farm or a barn,
general hygiene measures, such as regular hand washing
before and after touching animals, avoiding contact with
sick animals, and following food hygiene practices, should
be adhered to.
Prevention and control:
• WHO recommends increasing efforts to raise awareness of MERS
among travelers going to and travelling from MERS‐affected
countries.
References :