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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;289:2801-2809. Published online May 6, 2003 (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.

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