MERS Clinical Features
A wide clinical spectrum of MERS-CoV infection has been reported ranging from asymptomatic infection to acute upper respiratory illness, and rapidly progressive pneumonitis, respiratory failure, septic shock and multi-organ failure resulting in death. Most MERS-CoV cases have been reported in adults (median age approximately 50 years, male predominance), although children and adults of all ages have been infected (range 0 to 109 years). Most hospitalized MERS-CoV patients have had chronic co-morbidities. Among confirmed MERS-CoV cases reported to date, the case fatality proportion is approximately 35%.
Limited clinical data for MERS-CoV patients are available; most published clinical information to date is from critically ill patients. At hospital admission, common signs and symptoms include fever, chills/rigors, headache, non-productive cough, dyspnea, and myalgia. Other symptoms can include sore throat, coryza, nausea and vomiting, dizziness, sputum production, diarrhea, vomiting, and abdominal pain. Atypical presentations including mild respiratory illness without fever and diarrheal illness preceding development of pneumonia have been reported. Patients who progress to requiring admission to an intensive care unit (ICU) often have a history of a febrile upper respiratory tract illness with rapid progression to pneumonia within a week of illness onset.
The median incubation period for secondary cases associated with limited human-to-human transmission is approximately 5 days (range 2-14 days). In MERS-CoV patients, the median time from illness onset to hospitalization is approximately 4 days. In critically ill patients, the median time from onset to intensive care unit (ICU) admission is approximately 5 days, and median time from onset to death is approximately 12 days. In one series of 12 ICU patients, the median duration of mechanical ventilation was 16 days, and median ICU length of stay was 30 days, with 58% mortality at 90 days. Radiographic findings may include unilateral or bilateral patchy densities or opacities, interstitial infiltrates, consolidation, and pleural effusions. Rapid progression to acute respiratory failure, acute respiratory distress syndrome (ARDS), refractory hypoxemia, and extrapulmonary complications (acute kidney injury requiring renal replacement therapy, hypotension requiring vasopressors, hepatic inflammation, septic shock) has been reported.
Laboratory findings at admission may include leukopenia, lymphopenia, thrombocytopenia, and elevated lactate dehydrogenase levels. Co-infection with other respiratory viruses and a few cases of co-infection with community-acquired bacteria at admission has been reported; nosocomial bacterial and fungal infections have been reported in mechanically-ventilated patients. MERS-CoV virus can be detected with higher viral load and longer duration in the lower respiratory tract compared to the upper respiratory tract, and has been detected in feces, serum, and urine. However, very limited data are available on the duration of respiratory and extrapulmonary MERS-CoV shedding.
No specific treatment for MERS-CoV infection is currently available. Clinical management includes supportive management of complications and implementation of recommended infection prevention and control measures. For more information, see the World Health Organization guidance for clinical management of severe acute respiratory syndrome when MERS-CoV infection is suspectedExternal.
For additional information on MERS, see
- Interim Guidance for Health Professionals
- Case Definitions
- Infection Prevention and Control
- Preparedness Checklists and Resources
- Interim Home Care and Isolation Guidance
- Al-Tawfiq JA, Hinedi K, Ghandour J, Khairalla H, Musleh S, Ujayli A, et al. Middle East Respiratory Syndrome-Coronavirus (MERS-CoV): a case-control study of hospitalized patients. Clin Infect Dis. 2014 Apr 9. [Epub ahead of print]
- Albarrak AM, Stephens GM, Hewson R, Memish ZA. Recovery from severe novel coronavirus infection. Saudi Med J. 2012 Dec;33(12):1265-9.
- Arabi YM, Arifi AA, Balkhy HH, Najm H, Aldawood AS, Ghabashi A, et al. Clinical course and outcomes of critically ill patients with Middle East respiratory syndrome coronavirus infection. Ann Intern Med. 2014 Mar 18;160(6):389-97.
- Arabi YM, Balkhy HH, Hayden FG, Bouchama A, Luke T, Baillie JK, et al. Middle East Respiratory Syndrome. N Engl J Med. 2017 Feb 9: 376:584-94.
- Assiri A, Al-Tawfiq JA, Al-Rabeeah AA, Al-Rabiah FA, Al-Hajjar S, Al-Barrak A, et al. Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: a descriptive study. Lancet Infect Dis. 2013 Sep;13(9):752-61.
- Assiri A, McGeer A, Perl TM, Price CS, Al Rabeeah AA, Cummings DA, et al. Hospital outbreak of Middle East respiratory syndrome coronavirus. N Engl J Med. 2013 Aug 1;369(5):407-16.
- Bermingham A, Chand MA, Brown CS, Aarons E, Tong C, Langrish C, et al. Severe respiratory illness caused by a novel coronavirus, in a patient transferred to the United Kingdom from the Middle East, September 2012. Euro Surveill. 2012 Oct 4;17(40):20290.
- Drosten C, Seilmaier M, Corman VM, Hartmann W, Scheible G, Sack S, et al. Clinical features and virological analysis of a case of Middle East respiratory syndrome coronavirus infection. Lancet Infect Dis. 2013 Sep;13(9):745-51.
- Faure E, Poissy J, Goffard A, Fournier C, Kipnis E, Titecat M, et al. Distinct immune response in two MERS-CoV-infected patients: can we go from bench to bedside? PLoS One. 2014 Feb 14;9(2):e88716. doi: 10.1371/journal.pone.0088716. eCollection 2014.
- Guery B, Poissy J, el Mansouf L, Séjourné C, Ettahar N, Lemaire X, et al. Clinical features and viral diagnosis of two cases of infection with Middle East respiratory syndrome coronavirus: a report of nosocomial transmission. Lancet. 2013 Jun 29;381(9885):2265-72. doi: 10.1016/S0140-6736(13)60982-4. Erratum in: Lancet. 2013 Jun 29;381(9885):2254.
- Health Protection Agency (HPA) UK Novel Coronavirus Investigation team. Evidence of person-to-person transmission within a family cluster of novel coronavirus infections, United Kingdom, February 2013. Euro Surveill. 2013 Mar 14;18(11):20427.
- Hui DS, Memish ZA, Zumla A. Severe acute respiratory syndrome vs. the Middle East respiratory syndrome. Curr Opin Pulm Med. 2014 May;20(3):233-41.
- Memish ZA, Al-Tawfiq JA, Assiri A, Alrabiah FA, Hajjar SA, Albarrak A, et al. Middle East respiratory syndrome coronavirus disease in children. Pediatr Infect Dis J. 2014 Apr 23. [Epub ahead of print]
- Memish ZA, Al-Tawfiq JA, Makhdoom HQ, Assiri A, Alhakeem RF, Albarrak A, et al. Respiratory Tract Samples, Viral Load and Genome Fraction Yield in patients with Middle East Respiratory Syndrome. J Infect Dis. 2014 May 15. pii: jiu292. [Epub ahead of print]
- Memish ZA, Zumla AI, Al-Hakeem RF, Al-Rabeeah AA, Stephens GM. Family cluster of Middle East respiratory syndrome coronavirus infections. N Engl J Med. 2013 Jun 27;368(26):2487-94. doi: 10.1056/NEJMoa1303729. Erratum in: N Engl J Med. 2013 Aug 8;369(6):587.