Management of Severe Acute Respiratory Syndrome (SARS) in Children

Prof. T. F. Fok
Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong

Diagnosis

The predominant and most consistent symptom of SARS is fever, which is present in all the patients so far diagnosed to have SARS. Other symptoms include coryza, and running nose. Chills, rigor, myalgia, and malaise, which are common in adult patients, may also be present in older children and adolescents, but are absent in young children. Some patients, adults and children alike, may present with diarrhea. Young children appear to have milder disease with more speedy resolution, while the disease pattern in older children is more similar to that of the adults.

Since the presentation is non-specific and often indistinguishable from other childhood infections, the diagnosis is often difficult unless there is clear history of contact with an infected patient. The CDC and WHO have promulgated case definition for SARS, and the Hospital Authority has issued criteria for reporting to HA SARS registry. All these definitions and criteria, while being applicable to both adults and children, are based mainly on adult experience. An interim case definition for Paediatric SARS has been promulgated by Dr Leung Chi Wai (PMH) and Dr Li Chi Kong (PWH) on 25 March based on their experience with the first few cases of paediatric SARS. A revised definition was promulgated on 12 April 2003:

Children meeting the definition requiring specific treatment (Antiviral and Steroid) and "Strict" isolation:

  1. Fever (rectal temperature >38.5 deg C or oral temperature >38 deg C), AND
  2. Chest X-Ray findings of pneumonia or acute respiratory distress syndrome (ARDS), AND
  3. Suspected or probable contact with a person under investigation for or diagnosed with SARS, OR exposure to a locality with suspected or documented community transmission of SARS, either through travel or residence, within 10 days of onset of symptoms, AND
  4. One or more of the followings: Chills, malaise, myalgia, muscle fatigue, cough, dyspnea, tachypnea, hypoxia, lymphopenia, falling lymphocyte count, or failure to respond to antibiotics covering the usual pathogens of community acquired pneumonia (e.g. a broad spectrum beta-lactum plus a macrolide) after 2 days of therapy in terms of fever and general well being.
Note: Physical findings of prominent crepitations and/or rhonchi on auscultation of chest; Chest X -Ray of lobar consolidation or significant pulmonary effusion; Leukocytosis, neutrophilia or left shift of neutrophils with toxic granulations.

This case definition is extremely useful in guiding Paediatricians in decision making regarding treatment. However, since the early symptoms of Paediatric SARS are no different from other forms of upper or lower respiratory tract infections, the decision on admission, isolation, and treatment of children presenting with fever but without a definite contact history may still be difficult. Sometimes even the contact history may be misleading. In PWH, we have treated two children with symptoms of SARS and clear contact history, who were later diagnosed to have bacterial septicemia. At present, we isolate febrile children at three different levels according to their likelihood of having SARS. The likelihood assessment is based on contact history, symptoms, presence or absence of pneumonic changes on chest CXR, and investigation findings such as lymphopenia, thrombocytopenia, clotting profile, presence or absence of other pathogens from bacterial and viral cultures of body fluid.

Investigations

All suspected cases will be subjected to a battery of investigations: (1) microbiological studies to rule out common pathogens, including blood culture, nasopharyngeal aspirate for immunofluorescence and viral culture, and viral serology; (2) serial complete blood count and differential count which will be repeated daily; (3) serial liver and renal function tests, creatine kinase and lactate dehydrogenase levels; (4) serial clotting profile including prothrombin time, partial thromboplastin time, and D-dimer; and (3) daily chest radiograph. An important point of note is that obtaining nasopharyngeal aspirate is an aerosol generating procedure that may spread the virus. Staff performing the procedure should be adequately protected by wearing mask, gloves, gown, and face shield.

Lymphopenia is quite consistently present in children SARS. There may also be thrombocytopenia, moderately deranged clotting profile, elevated liver enzyme and LDH.

Similar to adults, children with early SARS may have normal chest radiograph but changes of typical airspace consolidation in their CT thorax. However we do not advocate routine CT thorax since this may lead to over-diagnosis as it is possible that other viral infections may also cause lower respiratory tract changes that may be detected by CT thorax. CT thorax will become useful in cases strongly suspected to have SARS (e.g. those with very definite contact history) but with normal chest radiograph.

Treatment

The treatment of children with suspected SARS should begin with antibiotics covering both common bacterial (e.g. a third generation cephalosporin such as Cefotaxime) and atypical pneumonia (e.g. Erythromycin or Clarithromycin). Our present practice is to add oral Ribavirin 40-60 mg/kg/day in 3 8-hourly doses if there is definite contact history making SARS very likely. If the symptoms, especially fever and general well being, do not respond to the treatment for 2 to 3 days, steroid will be commenced in form of prednisolone 1-2 mg/kg/day po in 2 divided doses or hydrocortisone 1-2 mg/kg iv 6 hourly. If fever persists or when there is clinical deterioration or progressive CXR change, pulse methylprednisolone 10 mg/kg/dose IV will be given q24h for up to 3 doses, depending on clinical response. Ribavirin will at the same time be changed to 20-60 mg/kg/day IV q8h. Steroid will be continued for a total of two weeks in form of prednisolone 1-2 mg/kg/day or hydrocortisone 1-2 mg/kg/dose IV q6h after methyl-prednisolone. If the child's condition improves, the steroid will be reduced to half the dose and gradually tapered off over a week. However, if CXR is still abnormal by day 21, low dose steroid will be continued for a longer time and slowly tapered off according to clinical and radiological assessment.

The above treatment regime is based on adult experience. The dose and timing of commencement of the two medications are under constant review. In the younger children in whom the infection appears to run a mild course, an obvious question is whether treatment with either medication, either alone or in combination, is of any benefit. This question can only be answered by properly conducted randomized controlled trial.

According to the present policy, all patients with SARS, including children, will be discharged home 21 days after onset provided their condition permits. It is possible that they may continue to shed the virus especially in their excreta after discharge. Instructions should be given to the parents on the proper disposal of excreta in order to prevent further transmission of the disease in the community.

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