Middle East Respiratory Syndrome

(MERS-COV)

Done by : Fatimah Al-ShehriIntern pharmacist

Supervised by : Dr . Sahal KhoshhalInfectious 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 :

14/4 13/4 10/4 9/4 8/4 7/4 6/4 Items

36.8 36.3 36.3 39.1 37.5 38.2 38.6 Temp

130/70 107/51 112/56 128/63 133/85 100/58 110/48 BP

89/13 83/16 88/14 109/38 116/23 99/32 44/23 HR/RR

2.8 7.1 9 5.7 2.3 2.4 BUN

143 146 138 135 133 135 Na

3.7 3.6 5.1 5.2 4.3 3.4 K

107 109 103 100 102 104 Cl

25 26 21 21 23 20 Co2

5.5 7 8 5.2 5 7.4 G

71 79 103 136 76 72 Cr

200.66 183.53 156.54 128.04 96.97 164.69 183.17 CrCl

The laboratory value and vital signs since confirmation of MERS COV :

14/4 13/4 10/4 9/4 8/4 7/4 6/4 Items

2.24 2.32 2.31 2.17 2.10 C a

0.84 0.41 0.96 1.31 phos

0.8 1.12 087 0.7 Mg

82.4 61.2 29.9 38.6 22.1 11.6 Bili

66 81 107 66 63 ALK

25 23 20 25 26 Alb

103 120 147 124 104 82 AST

46 35 50 61 61 56 ALT

9.8 7.3 7 12.3 11.6 7 2.5 WBC

10.1 9.4 11 12.3 14.6 14.5 16 HGB

The laboratory value and vital signs since confirmation of MERS COV :

14/4 13/4 10/4 9/4 8/4 7/4 6/4 Items

933 2553 883 126 CPK

797 1792 1548 747 LDH

31.0 28.8 32.8% 39.9 46.4 45.6 48.3 HCT

212 207 207 217 257 203 PLT

Medications:Ulcer prophylaxix Analgesia: Anesthesia:

-Esomprazole 80mg IV push. -Morphine 50 IV push -Acetaminophen 1000mg IV

push.

-Midazolam HCl 10mg IV Push.

Antibiotics: Antivirals: Corticosteroides:

-Linezolid 600mg IV BID -Augmentin 1200mg IV push

-Meropenem 1g IV push q 8-Vancomycin Hcl 1g IV push

-Ribavirin (600mg susp q 8hrs).

-peginterferon 190mcg subcut q1w.

-Oseltamivir 75mg cap BID.

-Dexamethasone 8mg IV push.

Muscles relaxants : Thrompolytic: Duretics:

-Cistatracurium besyalate 20mg IV push.

-Heparin 5000 Units IV Push. -Albumin 100ml IV push.

-Furosemide40mg IV Push.

Prokinetics: Inotrops: Respiration aid:

-Metoclopramide 10mg IV Q8hrs.

-NE 15mg/250ml. -Salbutamol.-ECMO.

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:-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

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

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:

8/5 5/5 Items :

3.6 3.7 BUN

136 137 Na

3.5 3.7 K

100 101 Cl

26 27 Co2

5 5 G

60 59 Cr

211 211.34 CrCl

7 7.4 WBCs

9 9.4 HGB

265 265 PLT

30.7% 30.7% HCT

Negative (not detdected) Negative (not detdected) MERS PCR

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 :