This Article  • Full text  • PDF  • Correction  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citing articles on HighWire  • Contact me when this article is cited  Related Content  • Related article  • Similar articles in JAMA

Christopher M. Booth, MD; Larissa M. Matukas, MD; George A. Tomlinson, PhD; Anita R. Rachlis, MD; David B. Rose, MD; Hy A. Dwosh, MD; Sharon L. Walmsley, MD; Tony Mazzulli, MD; Monica Avendano, MD; Peter Derkach, MD; Issa E. Ephtimios, MD; Ian Kitai, MD; Barbara D. Mederski, MD; Steven B. Shadowitz, MD; Wayne L. Gold, MD; Laura A. Hawryluck, MD; Elizabeth Rea, MD; Jordan S. Chenkin, BSc; David W. Cescon, BSc; Susan M. Poutanen, MD; Allan S. Detsky, MD, PhD

JAMA. 2003;289:(doi:10.1001/jama.289.21.JOC30885).

Context  Severe acute respiratory syndrome (SARS) is an emerging infectious disease that first manifested in humans in China in November 2002 and has subsequently spread worldwide.

Objectives  To describe the clinical characteristics and short-term outcomes of SARS in the first large group of patients in North America; to describe how these patients were treated and the variables associated with poor outcome.

Design, Setting, and Patients  Retrospective case series involving 144 adult patients admitted to 10 academic and community hospitals in the greater Toronto, Ontario, area between March 7 and April 10, 2003, with a diagnosis of suspected or probable SARS. Patients were included if they had fever, a known exposure to SARS, and respiratory symptoms or infiltrates observed on chest radiograph. Patients were excluded if an alternative diagnosis was determined.

Main Outcome Measures  Location of exposure to SARS; features of the history, physical examination, and laboratory tests at admission to the hospital; and 21-day outcomes such as death or intensive care unit (ICU) admission with or without mechanical ventilation.

Results  Of the 144 patients, 111 (77%) were exposed to SARS in the hospital setting. Features of the clinical examination most commonly found in these patients at admission were self-reported fever (99%), documented elevated temperature (85%), nonproductive cough (69%), myalgia (49%), and dyspnea (42%). Common laboratory features included elevated lactate dehydrogenase (87%), hypocalcemia (60%), and lymphopenia (54%). Only 2% of patients had rhinorrhea. A total of 126 patients (88%) were treated with ribavirin, although its use was associated with significant toxicity, including hemolysis (in 76%) and decrease in hemoglobin of 2 g/dL (in 49%). Twenty-nine patients (20%) were admitted to the ICU with or without mechanical ventilation, and 8 patients died (21-day mortality, 6.5%; 95% confidence interval [CI], 1.9%-11.8%). Multivariable analysis showed that the presence of diabetes (relative risk [RR], 3.1; 95% CI, 1.4-7.2; P = .01) or other comorbid conditions (RR, 2.5; 95% CI, 1.1-5.8; P = .03) were independently associated with poor outcome (death, ICU admission, or mechanical ventilation).

Conclusions  The majority of cases in the SARS outbreak in the greater Toronto area were related to hospital exposure. In the event that contact history becomes unreliable, several features of the clinical presentation will be useful in raising the suspicion of SARS. Although SARS is associated with significant morbidity and mortality, especially in patients with diabetes or other comorbid conditions, the vast majority (93.5%) of patients in our cohort survived.

Author Affiliations: University of Toronto (Drs Booth, Matukas, Tomlinson, Rachlis, Rose, Dwosh, Walmsley, Mazzulli, Avendano, Derkach, Ephtimios, Kitai, Mederski, Shadowitz, Gold, Hawryluck, Rea, Poutanen, and Detsky and Messrs Chenkin and Cescon), Mount Sinai Hospital (Drs Tomlinson, Walmsley, Mazzulli, Hawryluck, Poutanen, and Detsky), Sunnybrook and Women's College Health Sciences Centre (Drs Rachlis and Shadowitz), Scarborough Hospital (Dr Rose), York Central Hospital (Dr Dwosh), University Health Network (Drs Tomlinson, Walmsley, Gold, Hawryluck, and Detsky), Westpark Healthcare Centre (Drs Avendano and Derkach), Markham-Stouffville Hospital (Dr Ephtimios), RougeValley Health System (Dr Kitai), North York General Hospital (Dr Mederski), and Toronto Public Health (Dr Rea), Toronto, Ontario.

RELATED ARTICLE

Severe Acute Respiratory Syndrome: Providing Care in the Face of Uncertainty
Henry Masur, Ezekiel Emanuel, and H. Clifford Lane
JAMA. 2003;289(21):2861-2863.
EXTRACT | FULL TEXT  

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

The management of coronavirus infections with particular reference to SARS
Wong and Yuen
J Antimicrob Chemother 2008;62:437-441.
ABSTRACT | FULL TEXT  

Mouse-Passaged Severe Acute Respiratory Syndrome-Associated Coronavirus Leads to Lethal Pulmonary Edema and Diffuse Alveolar Damage in Adult but Not Young Mice
Nagata et al.
Am. J. Pathol. 2008;172:1625-1637.
ABSTRACT | FULL TEXT  

Acute Febrile Respiratory Illness in the ICU: Reducing Disease Transmission
Sandrock and Stollenwerk
Chest 2008;133:1221-1231.
ABSTRACT | FULL TEXT  

Definitive Care for the Critically Ill During a Disaster: Current Capabilities and Limitations: From a Task Force for Mass Critical Care Summit Meeting, January 26-27, 2007, Chicago, IL
Christian et al.
Chest 2008;133:8S-17S.
ABSTRACT | FULL TEXT  

Respiratory Viruses Other than Influenza Virus: Impact and Therapeutic Advances
Nichols et al.
Clin. Microbiol. Rev. 2008;21:274-290.
ABSTRACT | FULL TEXT  

Severe Acute Respiratory Syndrome Coronavirus as an Agent of Emerging and Reemerging Infection
Cheng et al.
Clin. Microbiol. Rev. 2007;20:660-694.
ABSTRACT | FULL TEXT  

Severe Acute Respiratory Syndrome Coronavirus ORF6 Antagonizes STAT1 Function by Sequestering Nuclear Import Factors on the Rough Endoplasmic Reticulum/Golgi Membrane
Frieman et al.
J. Virol. 2007;81:9812-9824.
ABSTRACT | FULL TEXT  

Bringing chronic disease epidemiology and infectious disease epidemiology back together
Choi et al.
J. Epidemiol. Community Health 2007;61:802-802.
FULL TEXT  

One-Year Outcomes and Health Care Utilization in Survivors of Severe Acute Respiratory Syndrome
Tansey et al.
Arch Intern Med 2007;167:1312-1320.
ABSTRACT | FULL TEXT  

Encouraging medical students to do research and write papers
Detsky and Detsky
CMAJ 2007;176:1719-1721.
FULL TEXT  

Pathology and Pathogenesis of Severe Acute Respiratory Syndrome
Gu and Korteweg
Am. J. Pathol. 2007;170:1136-1147.
ABSTRACT | FULL TEXT  

Participation of both Host and Virus Factors in Induction of Severe Acute Respiratory Syndrome (SARS) in F344 Rats Infected with SARS Coronavirus
Nagata et al.
J. Virol. 2007;81:1848-1857.
ABSTRACT | FULL TEXT  

Ribavirin, human convalescent plasma and anti-beta3 integrin antibody inhibit infection by Sin Nombre virus in the deer mouse model
Medina et al.
J. Gen. Virol. 2007;88:493-505.
ABSTRACT | FULL TEXT  

Detection of Severe Acute Respiratory Syndrome Coronavirus in Stool Specimens by Commercially Available Real-Time Reverse Transcriptase PCR Assays
Louie et al.
J. Clin. Microbiol. 2006;44:4193-4196.
ABSTRACT | FULL TEXT  

Screening and Identification of Severe Acute Respiratory Syndrome-Associated Coronavirus-Specific CTL Epitopes
Zhou et al.
J. Immunol. 2006;177:2138-2145.
ABSTRACT | FULL TEXT  

Clinical prognostic rules for severe acute respiratory syndrome in low- and high-resource settings.
Cowling et al.
Arch Intern Med 2006;166:1505-1511.
ABSTRACT | FULL TEXT  

Paediatric emergency department staff perceptions of infection control measures against severe acute respiratory syndrome
Parker and Goldman
Emerg. Med. J. 2006;23:349-353.
ABSTRACT | FULL TEXT  

The rationale of fever surveillance to identify patients with severe acute respiratory syndrome in Taiwan
Wang et al.
Emerg. Med. J. 2006;23:202-205.
ABSTRACT | FULL TEXT  

Intubation of SARS patients: infection and perspectives of healthcare workers: [L'intubation de patients atteints du SRAS: infection et perspectives des travailleurs de la sante]
Caputo et al.
Canadian J. Anesthesia 2006;53:122-129.
ABSTRACT | FULL TEXT  

Chronic Cough Due to Acute Bronchitis: ACCP Evidence-Based Clinical Practice Guidelines
Braman
Chest 2006;129:95S-103S.
ABSTRACT | FULL TEXT  

Coronavirus Pathogenesis and the Emerging Pathogen Severe Acute Respiratory Syndrome Coronavirus
Weiss and Navas-Martin
Microbiol. Mol. Biol. Rev. 2005;69:635-664.
ABSTRACT | FULL TEXT  

Radiographic-Clinical Correlation in Severe Acute Respiratory Syndrome: Study of 1373 Patients in Hong Kong
Antonio et al.
Radiology 2005;237:1081-1090.
ABSTRACT | FULL TEXT  

Early Enhanced Expression of Interferon-Inducible Protein-10 (CXCL-10) and Other Chemokines Predicts Adverse Outcome in Severe Acute Respiratory Syndrome
Tang et al.
Clin. Chem. 2005;51:2333-2340.
ABSTRACT | FULL TEXT  

The Occupational and Psychosocial Impact of SARS on Academic Physicians in Three Affected Hospitals
Grace et al.
Psychosomatics 2005;46:385-391.
ABSTRACT | FULL TEXT  

American College of Chest Physicians and American Association for Bronchology Consensus Statement: Prevention of Flexible Bronchoscopy-Associated Infection
Mehta et al.
Chest 2005;128:1742-1755.
FULL TEXT  

Methods for Estimating the Case Fatality Ratio for a Novel, Emerging Infectious Disease
Ghani et al.
Am J Epidemiol 2005;162:479-486.
ABSTRACT | FULL TEXT  

Pulmonary Sequelae in Convalescent Patients after Severe Acute Respiratory Syndrome: Evaluation with Thin-Section CT
Chang et al.
Radiology 2005;236:1067-1075.
ABSTRACT | FULL TEXT  

Adverse Effects of Ribavirin and Outcome in Severe Acute Respiratory Syndrome: Experience in Two Medical Centers
Chiou et al.
Chest 2005;128:263-272.
ABSTRACT | FULL TEXT  

Aged BALB/c Mice as a Model for Increased Severity of Severe Acute Respiratory Syndrome in Elderly Humans
Roberts et al.
J. Virol. 2005;79:5833-5838.
ABSTRACT | FULL TEXT  

Impact of severe acute respiratory syndrome (SARS) on pulmonary function, functional capacity and quality of life in a cohort of survivors
Hui et al.
Thorax 2005;60:401-409.
ABSTRACT | FULL TEXT  

A Chain Multinomial Model for Estimating the Real-Time Fatality Rate of a Disease, with an Application to Severe Acute Respiratory Syndrome
Yip et al.
Am J Epidemiol 2005;161:700-706.
ABSTRACT | FULL TEXT  

Recombinant Modified Vaccinia Virus Ankara Expressing the Spike Glycoprotein of Severe Acute Respiratory Syndrome Coronavirus Induces Protective Neutralizing Antibodies Primarily Targeting the Receptor Binding Region
Chen et al.
J. Virol. 2005;79:2678-2688.
ABSTRACT | FULL TEXT  

Chest Radiograph Scores as Potential Prognostic Indicators in Severe Acute Respiratory Syndrome (SARS)
Antonio et al.
Am. J. Roentgenol. 2005;184:734-741.
ABSTRACT | FULL TEXT  

Clinical Issues and Research in Respiratory Failure from Severe Acute Respiratory Syndrome
Levy et al.
Am. J. Respir. Crit. Care Med. 2005;171:518-526.
ABSTRACT | FULL TEXT  

Does This Patient Have Influenza?
Call et al.
JAMA 2005;293:987-997.
ABSTRACT | FULL TEXT  

Severe Acute Respiratory Syndrome: Emergence of a New Pandemic
Sheth and Romanelli
Journal of Pharmacy Practice 2005;18:63-70.
ABSTRACT  

Natural History of a Recurrent Feline Coronavirus Infection and the Role of Cellular Immunity in Survival and Disease
de Groot-Mijnes et al.
J. Virol. 2005;79:1036-1044.
ABSTRACT | FULL TEXT  

Severe Acute Respiratory Syndrome in Pregnancy
Yudin et al.
Obstet Gynecol 2005;105:124-127.
ABSTRACT | FULL TEXT  

Severe Acute Respiratory Syndrome: Quantitative Assessment from Chest Radiographs with Clinical and Prognostic Correlation
Lai et al.
Am. J. Roentgenol. 2005;184:255-263.
ABSTRACT | FULL TEXT  

Plasma proteome of severe acute respiratory syndrome analyzed by two-dimensional gel electrophoresis and mass spectrometry
Chen et al.
Proc. Natl. Acad. Sci. USA 2004;101:17039-17044.
ABSTRACT | FULL TEXT  

Diagnosis and pharmacotherapy of severe acute respiratory syndrome: what have we learnt?
Tsang et al.
Eur Respir J 2004;24:1025-1032.
ABSTRACT | FULL TEXT  

Initial viral load and the outcomes of SARS
Chu et al.
CMAJ 2004;171:1349-1352.
ABSTRACT | FULL TEXT  

The impact of SARS on a tertiary care pediatric emergency department
Boutis et al.
CMAJ 2004;171:1353-1358.
ABSTRACT | FULL TEXT  

The Epidemiology of Severe Acute Respiratory Syndrome in the 2003 Hong Kong Epidemic: An Analysis of All 1755 Patients
Leung et al.
ANN INTERN MED 2004;141:662-673.
ABSTRACT | FULL TEXT  

Childhood Severe Acute Respiratory Syndrome in Taiwan and How to Differentiate It From Childhood Influenza Infection
Chang et al.
Arch Pediatr Adolesc Med 2004;158:1037-1042.
ABSTRACT | FULL TEXT  

Severe Acute Respiratory Syndrome: Prognostic Implications of Chest Radiographic Findings in 52 Patients
Ko et al.
Radiology 2004;233:173-181.
ABSTRACT | FULL TEXT  

Identification and Characterization of Severe Acute Respiratory Syndrome Coronavirus Replicase Proteins
Prentice et al.
J. Virol. 2004;78:9977-9986.
ABSTRACT | FULL TEXT  

Treatment of Severe Acute Respiratory Syndrome
Hui and Sung
Chest 2004;126:670-674.
FULL TEXT  

Effectiveness of Noninvasive Positive Pressure Ventilation in the Treatment of Acute Respiratory Failure in Severe Acute Respiratory Syndrome
Cheung et al.
Chest 2004;126:845-850.
ABSTRACT | FULL TEXT  

ACE2 Gene Polymorphisms Do Not Affect Outcome of Severe Acute Respiratory Syndrome
Chiu et al.
Clin. Chem. 2004;50:1683-1686.
FULL TEXT  

Evidence of Airborne Transmission of SARS
Tong et al.
NEJM 2004;351:609-611.
FULL TEXT  

Registries and Informed Consent
Clark et al.
NEJM 2004;351:612-614.
FULL TEXT  

SARS, Cough, and Fever--or Is It SARS, Fever, and Cough?
Apostolakos
Chest 2004;126:333-335.
FULL TEXT  

Clinical and Laboratory Features of Severe Acute Respiratory Syndrome Vis-A-Vis Onset of Fever
Liu et al.
Chest 2004;126:509-517.
ABSTRACT | FULL TEXT  

SEQUENTIAL CHANGES OF SERUM AMINOTRANSFERASE LEVELS IN PATIENTS WITH SEVERE ACUTE RESPIRATORY SYNDROME
WU et al.
Am J Trop Med Hyg 2004;71:125-128.
ABSTRACT | FULL TEXT  

Antiviral agents and corticosteroids in the treatment of severe acute respiratory syndrome (SARS)
Yu et al.
Thorax 2004;59:643-645.
FULL TEXT  

Severe acute respiratory syndrome: review and lessons of the 2003 outbreak
Parashar and Anderson
Int J Epidemiol 2004;33:628-634.
FULL TEXT  

Small molecules targeting severe acute respiratory syndrome human coronavirus
Wu et al.
Proc. Natl. Acad. Sci. USA 2004;101:10012-10017.
ABSTRACT | FULL TEXT  

Lupus pneumonitis or severe acute respiratory syndrome?
Mok and Ying
Lupus 2004;13:549-553.
ABSTRACT  

Correlation of High-Resolution CT, Symptoms, and Pulmonary Function in Patients During Recovery From Severe Acute Respiratory Syndrome
Hsu et al.
Chest 2004;126:149-158.
ABSTRACT | FULL TEXT  

Severe acute respiratory syndrome (SARS): epidemiology and clinical features
Hui et al.
Postgrad. Med. J. 2004;80:373-381.
ABSTRACT | FULL TEXT  

Identification of an HLA-A*0201-restricted CD8+ T-cell epitope SSp-1 of SARS-CoV spike protein
Wang et al.
Blood 2004;104:200-206.
ABSTRACT | FULL TEXT  

Public Health Measures to Control the Spread of the Severe Acute Respiratory Syndrome during the Outbreak in Toronto
Svoboda et al.
NEJM 2004;350:2352-2361.
ABSTRACT | FULL TEXT  

Rapid identification of coronavirus replicase inhibitors using a selectable replicon RNA
Hertzig et al.
J. Gen. Virol. 2004;85:1717-1725.
ABSTRACT | FULL TEXT  

Antisense Morpholino-Oligomers Directed against the 5' End of the Genome Inhibit Coronavirus Proliferation and Growth{dagger}
Neuman et al.
J. Virol. 2004;78:5891-5899.
ABSTRACT | FULL TEXT  

Transmission of Severe Acute Respiratory Syndrome during Intubation and Mechanical Ventilation
Fowler et al.
Am. J. Respir. Crit. Care Med. 2004;169:1198-1202.
ABSTRACT | FULL TEXT  

Severe acute respiratory syndrome: report of treatment and outcome after a major outbreak
Sung et al.
Thorax 2004;59:414-420.
ABSTRACT | FULL TEXT  

Laboratory-Acquired Severe Acute Respiratory Syndrome
Lim et al.
NEJM 2004;350:1740-1745.
FULL TEXT  

Prior Infection and Passive Transfer of Neutralizing Antibody Prevent Replication of Severe Acute Respiratory Syndrome Coronavirus in the Respiratory Tract of Mice
Subbarao et al.
J. Virol. 2004;78:3572-3577.
ABSTRACT | FULL TEXT  

Role of lopinavir/ritonavir in the treatment of SARS: initial virological and clinical findings
Chu et al.
Thorax 2004;59:252-256.
ABSTRACT | FULL TEXT  

Radiologic Pattern of Disease in Patients with Severe Acute Respiratory Syndrome: The Toronto Experience
Paul et al.
RadioGraphics 2004;24:553-563.
ABSTRACT | FULL TEXT  

Update in Infectious Diseases
Sande and Ronald
ANN INTERN MED 2004;140:290-295.
FULL TEXT  

Prognostic Significance of the Radiographic Pattern of Disease in Patients with Severe Acute Respiratory Syndrome
Paul et al.
Am. J. Roentgenol. 2004;182:493-498.
ABSTRACT | FULL TEXT  

Information for JAMA Authors--2004
Fontanarosa and DeAngelis
JAMA 2004;291:107-108.
FULL TEXT  

Why SARS will not return: a polemic
Low
CMAJ 2004;170:68-69.
FULL TEXT  

ADDITIONAL ARTICLES ABSTRACTED IN ACP JOURNAL CLUB
Evid. Based Med. 2004;9:3-3.
FULL TEXT  

Chest Radiographic Manifestations of Severe Acute Respiratory Syndrome in Health Care Workers: The Toronto Experience
Bitar et al.
Am. J. Roentgenol. 2004;182:45-48.
ABSTRACT | FULL TEXT  

Interferon Alfacon-1 Plus Corticosteroids in Severe Acute Respiratory Syndrome: A Preliminary Study
Loutfy et al.
JAMA 2003;290:3222-3228.
ABSTRACT | FULL TEXT  

Transmission of the Severe Acute Respiratory Syndrome on Aircraft
Olsen et al.
NEJM 2003;349:2416-2422.
ABSTRACT | FULL TEXT  

The Severe Acute Respiratory Syndrome
Peiris et al.
NEJM 2003;349:2431-2441.
FULL TEXT  

Corticosteroids: The "Terminator" of All Untreatable Serious Pulmonary Illness
Bernard
Am. J. Respir. Crit. Care Med. 2003;168:1409-1410.
FULL TEXT  

High-Dose Pulse Versus Nonpulse Corticosteroid Regimens in Severe Acute Respiratory Syndrome
Ho et al.
Am. J. Respir. Crit. Care Med. 2003;168:1449-1456.
ABSTRACT | FULL TEXT  

Infection control and anesthesia: lessons learned from the Toronto SARS outbreak: [La lutte anti-infectieuse et l'anesthesie : les lecons de l'eclosion du SRAS a Toronto]
Peng et al.
Canadian J. Anesthesia 2003;50:989-997.
ABSTRACT | FULL TEXT  

Antiviral treatment of SARS: Can we draw any conclusions?
Zhaori
CMAJ 2003;169:1165-1166.
FULL TEXT  

Outcomes and Prognostic Factors in 267 Patients with Severe Acute Respiratory Syndrome in Hong Kong
Choi et al.
ANN INTERN MED 2003;139:715-723.
ABSTRACT | FULL TEXT  

Severe acute respiratory syndrome: global initiatives for disease diagnosis
Groneberg et al.
QJM 2003;96:845-852.
ABSTRACT | FULL TEXT  

Severe Acute Respiratory Syndrome: Radiographic Evaluation and Clinical Outcome Measures
Ooi et al.
Radiology 2003;229:500-506.
ABSTRACT | FULL TEXT  

Severe Acute Respiratory Syndrome: Relationship between Radiologic and Clinical Parameters
Ooi et al.
Radiology 2003;229:492-499.
ABSTRACT | FULL TEXT  

Listening to SARS: Lessons for Infection Control
Wenzel and Edmond
ANN INTERN MED 2003;139:592-593.
FULL TEXT  

OTHER ARTICLES NOTED (25 Apr 2003 to 18 Jul 2003)
Evid. Based Nurs. 2003;6:e1-12.
FULL TEXT  

Children Hospitalized With Severe Acute Respiratory Syndrome-Related Illness in Toronto
Bitnun et al.
Pediatrics 2003;112:e261-261.
ABSTRACT | FULL TEXT  

Investigation of a nosocomial outbreak of severe acute respiratory syndrome (SARS) in Toronto, Canada
Varia et al.
CMAJ 2003;169:285-292.
ABSTRACT | FULL TEXT  

Management of Severe Acute Respiratory Syndrome: The Hong Kong University Experience
Tsang and Lam
Am. J. Respir. Crit. Care Med. 2003;168:417-424.
FULL TEXT  

Severe acute respiratory syndrome (SARS): breath-taking progress
Hawkey et al.
J Med Microbiol 2003;52:609-613.
ABSTRACT | FULL TEXT  

Short term outcome and risk factors for adverse clinical outcomes in adults with severe acute respiratory syndrome (SARS)
Chan et al.
Thorax 2003;58:686-689.
ABSTRACT | FULL TEXT