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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection during pregnancy: Report of two cases & review of the literature</title><author><name sortKey="Alfaraj, Sarah H" sort="Alfaraj, Sarah H" uniqKey="Alfaraj S" first="Sarah H." last="Alfaraj">Sarah H. Alfaraj</name></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">29907538</idno><idno type="pmc">7128238</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7128238</idno><idno type="RBID">PMC:7128238</idno><idno type="doi">10.1016/j.jmii.2018.04.005</idno><date when="2018">2018</date><idno type="wicri:Area/Pmc/Corpus">000874</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000874</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection during pregnancy: Report of two cases & review of the literature</title><author><name sortKey="Alfaraj, Sarah H" sort="Alfaraj, Sarah H" uniqKey="Alfaraj S" first="Sarah H." last="Alfaraj">Sarah H. Alfaraj</name></author></analytic><series><title level="j">Journal of Microbiology, Immunology, and Infection</title><idno type="ISSN">1684-1182</idno><idno type="eISSN">1995-9133</idno><imprint><date when="2018">2018</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Who" uniqKey="Who">WHO</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Park, M H" uniqKey="Park M">M.H. Park</name></author><author><name sortKey="Kim, H R" uniqKey="Kim H">H.R. Kim</name></author><author><name sortKey="Choi, D H" uniqKey="Choi D">D.H. Choi</name></author><author><name sortKey="Sung, J H" uniqKey="Sung J">J.H. Sung</name></author><author><name sortKey="Kim, J H" uniqKey="Kim J">J.H. Kim</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Assiri, A" uniqKey="Assiri A">A. Assiri</name></author><author><name sortKey="Abedi, G R" uniqKey="Abedi G">G.R. Abedi</name></author><author><name sortKey="Al Masri, M" uniqKey="Al Masri M">M. Al Masri</name></author><author><name sortKey="Bin Saeed, A" uniqKey="Bin Saeed A">A. Bin Saeed</name></author><author><name sortKey="Gerber, S I" uniqKey="Gerber S">S.I. Gerber</name></author><author><name sortKey="Watson, J T" uniqKey="Watson J">J.T. Watson</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Alserehi, H" uniqKey="Alserehi H">H. Alserehi</name></author><author><name sortKey="Wali, G" uniqKey="Wali G">G. Wali</name></author><author><name sortKey="Alshukairi, A" uniqKey="Alshukairi A">A. Alshukairi</name></author><author><name sortKey="Alraddadi, B" uniqKey="Alraddadi B">B. Alraddadi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Malik, A" uniqKey="Malik A">A. Malik</name></author><author><name sortKey="El Masry, K M" uniqKey="El Masry K">K.M. El Masry</name></author><author><name sortKey="Ravi, M" uniqKey="Ravi M">M. Ravi</name></author><author><name sortKey="Sayed, F" uniqKey="Sayed F">F. Sayed</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Payne, D C" uniqKey="Payne D">D.C. Payne</name></author><author><name sortKey="Iblan, I" uniqKey="Iblan I">I. Iblan</name></author><author><name sortKey="Alqasrawi, S" uniqKey="Alqasrawi S">S. Alqasrawi</name></author><author><name sortKey="Al Nsour, M" uniqKey="Al Nsour M">M. Al Nsour</name></author><author><name sortKey="Rha, B" uniqKey="Rha B">B. Rha</name></author><author><name sortKey="Tohme, R A" uniqKey="Tohme R">R.A. Tohme</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Jeong, S" uniqKey="Jeong S">S. Jeong</name></author><author><name sortKey="Sung, S" uniqKey="Sung S">S. Sung</name></author><author><name sortKey="Sung, J" uniqKey="Sung J">J. Sung</name></author><author><name sortKey="Ahn, S" uniqKey="Ahn S">S. Ahn</name></author><author><name sortKey="Kang, E" uniqKey="Kang E">E. Kang</name></author><author><name sortKey="Chang, Y" uniqKey="Chang Y">Y. Chang</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="letter"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">J Microbiol Immunol Infect</journal-id><journal-id journal-id-type="iso-abbrev">J Microbiol Immunol Infect</journal-id><journal-title-group><journal-title>Journal of Microbiology, Immunology, and Infection</journal-title></journal-title-group><issn pub-type="ppub">1684-1182</issn><issn pub-type="epub">1995-9133</issn><publisher><publisher-name>Taiwan Society of Microbiology. Published by Elsevier Taiwan LLC.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">29907538</article-id><article-id pub-id-type="pmc">7128238</article-id><article-id pub-id-type="publisher-id">S1684-1182(18)30152-X</article-id><article-id pub-id-type="doi">10.1016/j.jmii.2018.04.005</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection during pregnancy: Report of two cases & review of the literature</article-title></title-group><contrib-group><contrib contrib-type="author" id="au1"><name><surname>Alfaraj</surname><given-names>Sarah H.</given-names></name><email>alfarajsa@pmah.med.sa</email></contrib></contrib-group><aff id="aff1">University of British Columbia, Vancouver, Canada</aff><aff id="aff2">Corona Center, Infectious Diseases Division, Department of Pediatric, Prince Mohamed Bin Abdulaziz Hospital (“PMAH”), Ministry of Health, Riyadh, Saudi Arabia</aff><contrib-group><contrib contrib-type="author" id="au2"><name><surname>Al-Tawfiq</surname><given-names>Jaffar A.</given-names></name><email>jaltawfi@yahoo.com</email></contrib></contrib-group><aff id="aff3">Indiana University School of Medicine, Indianapolis, IN, USA</aff><aff id="aff4">Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia</aff><contrib-group><contrib contrib-type="author" id="au3"><name><surname>Memish</surname><given-names>Ziad A.</given-names></name><email>zmemish@yahoo.com</email><xref rid="cor1" ref-type="corresp">∗</xref></contrib></contrib-group><aff id="aff5">College of Medicine, Alfaisal University, Riyadh, Saudi Arabia</aff><aff id="aff6">Infectious Diseases Division, Department of Medicine, Prince Mohamed Bin Abdulaziz Hospital (“PMAH”), Ministry of Health, Riyadh, Saudi Arabia</aff><aff id="aff7">Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA</aff><author-notes><corresp id="cor1"><label>∗</label>Corresponding author. P.O. Box 54146, Riyadh 11514, Saudi Arabia. <email>zmemish@yahoo.com</email></corresp></author-notes><pub-date pub-type="pmc-release"><day>2</day><month>6</month><year>2018</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="ppub"><month>6</month><year>2019</year></pub-date><pub-date pub-type="epub"><day>2</day><month>6</month><year>2018</year></pub-date><volume>52</volume><issue>3</issue><fpage>501</fpage><lpage>503</lpage><history><date date-type="received"><day>25</day><month>2</month><year>2018</year></date><date date-type="accepted"><day>10</day><month>4</month><year>2018</year></date></history><permissions><copyright-statement>© 2018 Taiwan Society of Microbiology. Published by Elsevier Taiwan LLC.</copyright-statement><copyright-year>2018</copyright-year><copyright-holder></copyright-holder><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions><kwd-group id="kwrds0010"><title>Keywords</title><kwd>MERS-CoV</kwd><kwd>Pregnancy</kwd><kwd>Saudi Arabia</kwd></kwd-group></article-meta></front><body><p content-type="salutation"><bold>Dear Editor</bold>,</p><p id="p0010">As of February, 2018 a total of 2143 cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) have been reported to the World Health Organization, including 750 deaths in 27 countries.<xref rid="bib1" ref-type="bibr"><sup>1</sup></xref> There were 10 reported cases of MERS-CoV in pregnancy.<xref rid="bib2" ref-type="bibr">2</xref>, <xref rid="bib3" ref-type="bibr">3</xref>, <xref rid="bib4" ref-type="bibr">4</xref>, <xref rid="bib5" ref-type="bibr">5</xref>, <xref rid="bib6" ref-type="bibr">6</xref>, <xref rid="bib7" ref-type="bibr">7</xref> Here, we present two cases form our hospital with MERS-CoV infections during pregnancy.</p><sec id="sec1"><title>Case 1</title><p id="p0015">The first patient was a 29-year-old female (gravida 2, para 1) at 6 weeks gestation and with no underlying medical conditions. She was asymptomatic and identified as part of the contact tracing of her mother, a positive MERS-CoV patient. On examination, she was afebrile, breathing normally and Lungs were clear to auscultation. The abdomen was gravid, soft, non-tender, non-distended, and normal bowel sounds. Nasopharyngeal swab testing by RT-PCR for MERS-CoV showed a positive result for ORF (Ct value 32). She had two repeated nasopharyngeal swab testing by RT-PCR for MERS-CoV and these showed probable results (Ct value 36) and the 4th swab was negative by PCR for MERS-CoV. The patient did not deliver during hospitalization and she was discharged on 24th August 2015, and subsequently delivered a healthy infant at term.</p></sec><sec id="sec2"><title>Case 2</title><p id="p0020">The second patient was a 39-year-old female (gravida 6, para 5) with history of end stage renal disease (ESRD) and hypertension on hemodialysis. She used to have hemodialysis at Wadi Aldawasir hospital during an active MERS-CoV outbreak there. She presented at 24 weeks of gestation after a contact with a positive MERS-CoV patient. Nasopharyngeal swab testing by RT-PCR was positive for MERS-CoV with E gene (Ct value 34) and OFR (Ct value 34). She was admitted to a regular ward. Subsequently, she had negative RT-PCR for MERS-CoV and she was discharged home.</p><p id="p0025a">Respiratory samples (Nasopharyngeal swabs or tracheal aspirates) were tested for MERS-CoV using real-time reverse-transcription polymerase chain reaction (RT-PCR) as described previously.</p><p id="p0025">The clinical presentation of MERS-CoV is variable and ranges from a mild disease or asymptomatic presentation to a more severe and fatal cases. There are sparse data on the effect and the likelihood of MERS-CoV during pregnancy.<xref rid="bib2" ref-type="bibr">2</xref>, <xref rid="bib3" ref-type="bibr">3</xref>, <xref rid="bib4" ref-type="bibr">4</xref>, <xref rid="bib5" ref-type="bibr">5</xref>, <xref rid="bib6" ref-type="bibr">6</xref>, <xref rid="bib7" ref-type="bibr">7</xref> We searched the MEDLINE database for articles published in English literature from January 2012 to July 2016. The references in the retrieved articles were further searched for any additional references. A summary of previous reports and the current two additional cases of pregnancy associated MERS-CoV is presented in <xref rid="tbl1" ref-type="table">Table 1</xref>. Of all the cases, the mean age ± SD was 33.7 ± 4.3 years and the gestation age was 26.3 ± 9 weeks, and there were four (36%) primi-gravida. The source of infection was not identified in 3 cases; contact with family members who had MERS-CoV was elucidated in two cases; four patients had health-care associated infection, two of them were healthcare workers. Six (54%) patients required ICU admission and three (27%) patients died during the hospital stay. Two of the deceased had an exposure during the third trimester and one acquired the infection during the second trimester. The infant death rate was 27%. The outcome was favorable in the majority of pregnancy-associated MERS-CoV cases. The exact prevalence of MERS-CoV antibodies and exposure of pregnant women to MERS-CoV is not known. All the reported cases were symptomatic. Among the 11 pregnancy-associated MERS-CoV infection, the case fatality rate was not statistically different when compared to the overall case fatality rate of 35%, P = 0.75. Regarding the infants, three (27%) infants had died.<table-wrap position="float" id="tbl1"><label>Table 1</label><caption><p>A summary of pregnancy associated MERS-CoV infection.</p></caption><alt-text id="alttext0010">Table 1</alt-text><table frame="hsides" rules="groups"><thead><tr><th></th><th>Age</th><th>Nationality</th><th>Gravida (G), Para (P)</th><th>Source of infection</th><th>Gestational age at illness onset (weeks)</th><th>ICU admission</th><th>Maternal comorbid conditions</th><th>Maternal outcome</th><th>Fetal outcome</th><th>Delivery details</th><th>Reference</th></tr></thead><tbody><tr><td>Patient 1 (PMAH)</td><td>29</td><td>Saudi</td><td>G2, P1</td><td>Household contact</td><td>6</td><td>NO</td><td>None</td><td>Survived</td><td>Survived</td><td>Delivery at term</td><td>Current report</td></tr><tr><td>Patient 2 (PMAH)</td><td>39</td><td>Saudi</td><td>G6, P5</td><td>Contact with MERS-CoV case in HD</td><td>24</td><td>NO</td><td>ESRD on hemodialysis, HTN</td><td>Survived</td><td>Survived</td><td>Delivery at term</td><td>Current report</td></tr><tr><td>Patient 3</td><td>34</td><td>Saudi</td><td>G7, P6</td><td>Unknown</td><td>34</td><td>YES</td><td>Preeclampsia</td><td>Survived</td><td>Died</td><td>Intrauterine Fetal death at 34 weeks</td><td><xref rid="bib3" ref-type="bibr">3</xref></td></tr><tr><td>Patient 4</td><td>32</td><td>Saudi</td><td>G2, P1</td><td>Unknown</td><td>38</td><td>YES</td><td>None</td><td>Died</td><td>Survived</td><td>Vaginal delivery at 38 weeks</td><td><xref rid="bib3" ref-type="bibr">3</xref></td></tr><tr><td>Patient 5</td><td>31</td><td>Saudi</td><td>Primigravida</td><td>HCW, occupational exposure</td><td>24</td><td>YES</td><td>Asthma, pulmonary fibrosis</td><td>Died</td><td>Died</td><td>Caesarean section at 24 weeks</td><td><xref rid="bib3" ref-type="bibr">3</xref></td></tr><tr><td>Patient 6</td><td>27</td><td>Saudi</td><td>Primigravida</td><td>Unknown</td><td>22</td><td>YES</td><td>None</td><td>Survived</td><td>Survived</td><td>Full term delivery</td><td><xref rid="bib3" ref-type="bibr">3</xref></td></tr><tr><td>Patient 7</td><td>30</td><td>Saudi</td><td>Primigravida</td><td>HCW, occupational exposure</td><td>23</td><td>YES</td><td>None</td><td>Survived</td><td>Survived</td><td>Full term delivery</td><td><xref rid="bib3" ref-type="bibr">3</xref></td></tr><tr><td>Patient 8</td><td>39</td><td>Jordanian</td><td>G7, P6</td><td>Household contact</td><td>20</td><td>NO</td><td>None</td><td>Survived</td><td>Still birth</td><td>Still birth at 5 months</td><td><xref rid="bib6" ref-type="bibr">6</xref></td></tr><tr><td>Patient 9</td><td>32</td><td>United Arab Emirates</td><td>G3, P2</td><td>Visited camel barn</td><td>32</td><td>YES</td><td>None</td><td>Died</td><td>Survived</td><td>Caesarean section at 32 weeks</td><td><xref rid="bib5" ref-type="bibr">5</xref></td></tr><tr><td>Patient 10</td><td>39</td><td>South Korean</td><td>G2, P1</td><td>Contact with MERS-CoV Patient in hospital</td><td>35 weeks and 4 days</td><td>NO</td><td>Gestational Diabetes</td><td>Survived</td><td>Survived</td><td>Caesarean section at 39 weeks</td><td><xref rid="bib2" ref-type="bibr">2</xref>, <xref rid="bib7" ref-type="bibr">7</xref></td></tr><tr><td>Patient 11</td><td>33</td><td>Saudi</td><td>Primigravida</td><td>Contact with MERS-CoV Patient</td><td>31</td><td>Yes</td><td>Hypothyroidism and primary infertility</td><td>Survived</td><td>Survived</td><td>Caesarean section at 32 weeks</td><td><xref rid="bib4" ref-type="bibr">4</xref></td></tr></tbody></table></table-wrap></p><p id="p0030">The overall case fatality rate remains high and is comparable to the overall case fatality rates. 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