Procalcitonin in severe acute respiratory syndrome (SARS)
Identifieur interne : 001180 ( Pmc/Corpus ); précédent : 001179; suivant : 001181Procalcitonin in severe acute respiratory syndrome (SARS)
Auteurs : Ai Ping Chua ; Kang Hoe LeeSource :
- The Journal of Infection [ 0163-4453 ] ; 2004.
Abstract
Url:
DOI: 10.1016/j.jinf.2004.01.015
PubMed: 15066330
PubMed Central: 7133698
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PMC:7133698Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Procalcitonin in severe acute respiratory syndrome (SARS)</title>
<author><name sortKey="Chua, Ai Ping" sort="Chua, Ai Ping" uniqKey="Chua A" first="Ai Ping" last="Chua">Ai Ping Chua</name>
</author>
<author><name sortKey="Lee, Kang Hoe" sort="Lee, Kang Hoe" uniqKey="Lee K" first="Kang Hoe" last="Lee">Kang Hoe Lee</name>
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<sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Procalcitonin in severe acute respiratory syndrome (SARS)</title>
<author><name sortKey="Chua, Ai Ping" sort="Chua, Ai Ping" uniqKey="Chua A" first="Ai Ping" last="Chua">Ai Ping Chua</name>
</author>
<author><name sortKey="Lee, Kang Hoe" sort="Lee, Kang Hoe" uniqKey="Lee K" first="Kang Hoe" last="Lee">Kang Hoe Lee</name>
</author>
</analytic>
<series><title level="j">The Journal of Infection</title>
<idno type="ISSN">0163-4453</idno>
<idno type="eISSN">1532-2742</idno>
<imprint><date when="2004">2004</date>
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<front><div type="abstract" xml:lang="en"><p><italic>Objective and methods.</italic>
The role of procalcitonin (PCT) in severe acute respiratory syndrome (SARS) has not been highlighted so far. We described retrospectively eight cases of sepsis from pneumonia of various microbiological aetiologies including two due to SARS, compared their PCT concentrations and provided further descriptors of SARS as a viral pneumonia.</p>
<p><italic>Results.</italic>
Like any viral pneumonia, patients with SARS had low PCT levels in contrast to bacterial or fungal pneumonia.</p>
<p><italic>Conclusions.</italic>
In the setting of pneumonia with a finding of low PCT, testing for SARS should be considered, especially if there is a positive travel or contact history. During a SARS epidemic, we also strongly advocate isolating all suspected community acquired pneumonia with a low PCT level.</p>
</div>
</front>
<back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Reinhart, K" uniqKey="Reinhart K">K Reinhart</name>
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<pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">J Infect</journal-id>
<journal-id journal-id-type="iso-abbrev">J. Infect</journal-id>
<journal-title-group><journal-title>The Journal of Infection</journal-title>
</journal-title-group>
<issn pub-type="ppub">0163-4453</issn>
<issn pub-type="epub">1532-2742</issn>
<publisher><publisher-name>Published by Elsevier Ltd.</publisher-name>
</publisher>
</journal-meta>
<article-meta><article-id pub-id-type="pmid">15066330</article-id>
<article-id pub-id-type="pmc">7133698</article-id>
<article-id pub-id-type="publisher-id">S0163-4453(04)00018-0</article-id>
<article-id pub-id-type="doi">10.1016/j.jinf.2004.01.015</article-id>
<article-categories><subj-group subj-group-type="heading"><subject>Article</subject>
</subj-group>
</article-categories>
<title-group><article-title>Procalcitonin in severe acute respiratory syndrome (SARS)</article-title>
</title-group>
<contrib-group><contrib contrib-type="author"><name><surname>Chua</surname>
<given-names>Ai Ping</given-names>
</name>
<email>chuaaiping@yahoo.com</email>
<xref rid="COR1" ref-type="corresp">∗</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Lee</surname>
<given-names>Kang Hoe</given-names>
</name>
</contrib>
</contrib-group>
<aff>Division of Respiratory and Critical Care Medicine, Department of General Medicine, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore</aff>
<author-notes><corresp id="COR1"><label>∗</label>
Corresponding author. Fax: +65-67794112 <email>chuaaiping@yahoo.com</email>
</corresp>
</author-notes>
<pub-date pub-type="pmc-release"><day>18</day>
<month>2</month>
<year>2004</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>5</month>
<year>2004</year>
</pub-date>
<pub-date pub-type="epub"><day>18</day>
<month>2</month>
<year>2004</year>
</pub-date>
<volume>48</volume>
<issue>4</issue>
<fpage>303</fpage>
<lpage>306</lpage>
<history><date date-type="accepted"><day>25</day>
<month>1</month>
<year>2004</year>
</date>
</history>
<permissions><copyright-statement>Copyright © 2004 Published by Elsevier Ltd.</copyright-statement>
<copyright-year>2004</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>
<abstract><p><italic>Objective and methods.</italic>
The role of procalcitonin (PCT) in severe acute respiratory syndrome (SARS) has not been highlighted so far. We described retrospectively eight cases of sepsis from pneumonia of various microbiological aetiologies including two due to SARS, compared their PCT concentrations and provided further descriptors of SARS as a viral pneumonia.</p>
<p><italic>Results.</italic>
Like any viral pneumonia, patients with SARS had low PCT levels in contrast to bacterial or fungal pneumonia.</p>
<p><italic>Conclusions.</italic>
In the setting of pneumonia with a finding of low PCT, testing for SARS should be considered, especially if there is a positive travel or contact history. During a SARS epidemic, we also strongly advocate isolating all suspected community acquired pneumonia with a low PCT level.</p>
</abstract>
<kwd-group><title>Keywords</title>
<kwd>Severe acute respiratory syndrome (SARS)</kwd>
<kwd>Procalcitonin (PCT)</kwd>
<kwd>Pneumonia</kwd>
</kwd-group>
</article-meta>
</front>
<body><sec><label>1</label>
<title>Introduction</title>
<p>Procalcitonin (PCT) is a recently described innovative marker of severe sepsis.<xref rid="BIB1" ref-type="bibr"><sup>1</sup>
</xref>
Concentration increases in bacterial infections but remains low in viral infections making it a useful marker for distinguishing between bacterial and viral infections.<xref rid="BIB2" ref-type="bibr">2.</xref>
, <xref rid="BIB3" ref-type="bibr">3.</xref>
Severe acute respiratory syndrome (SARS) had been documented to be due to a novel coronavirus which has caused a rapidly progressive pneumonia in all age sectors in an epidemic manner with high fatality rate.<xref rid="BIB4" ref-type="bibr">4.</xref>
, <xref rid="BIB5" ref-type="bibr">5.</xref>
Rapid and accurate diagnostic tools are critical in the management of this potentially fatal disease. There are limitations to the current existing diagnostic tools. A low PCT level may provide an additional useful case definition to this deadly viral pneumonia.</p>
</sec>
<sec><label>2</label>
<title>Method and materials</title>
<p>PCT concentrations were measured for patients on admission to our medical intensive care unit (MICU) for severe sepsis from community-acquired pneumonia according to the American College of Chest Physicians/Society of Critical Care Medicine criteria. These patients presented during the peak SARS outbreak period in our country from March to July this year. In vitro PCT levels were measured in serum samples by use of KRYPTOR immunoanalyser (DYAMED Biotech) available in a service laboratory at National University Hospital, Singapore. The upper limit of normal was 0.5 ng/ml.</p>
</sec>
<sec><label>3</label>
<title>Results</title>
<p>All patients with viral pneumonia including two patients with SARS had low PCT level of less than 1 ng/ml (<xref rid="TBL1" ref-type="table">Table 1</xref>
). In contrast, PCT concentrations were raised in bacterial and fungal neumonia with the exception of mycoplasma pneumonia.<table-wrap position="float" id="TBL1"><label>Table 1</label>
<caption><p>Summary of case series</p>
</caption>
<table frame="hsides" rules="groups"><thead><tr><th>Case no.</th>
<th>Age (yr)/gender</th>
<th>Comorbidities</th>
<th>Diagnosis</th>
<th>Radiological finding</th>
<th>Microbiology results</th>
<th>PCT level (ng/ml)</th>
<th>Mechanical ventilation<xref rid="TBLFN1" ref-type="table-fn">a</xref>
</th>
</tr>
</thead>
<tbody><tr><td>1</td>
<td>71/Female</td>
<td>Diabetes, autoimmune hypothyroidism</td>
<td>SARS</td>
<td>Bilateral lower lobe ground glass opacification</td>
<td>Nasopharyngeal aspirate SARS-CoV RT-PCR and anti-SARS-CoV Ig G titer positive</td>
<td>0.11</td>
<td>Yes</td>
</tr>
<tr><td>2</td>
<td>43/Female</td>
<td>Hypertension</td>
<td>SARS</td>
<td>Bilateral lower lobe consolidations</td>
<td>See<xref rid="TBLFN2" ref-type="table-fn">b</xref>
</td>
<td>0.74</td>
<td>Yes</td>
</tr>
<tr><td>3</td>
<td>65/Male</td>
<td>Gastric non-Hodgkin lymphoma 2001 with gastrectomy and chemotherapy</td>
<td><italic>Klebsiella pneumonia</italic>
</td>
<td>Airspace shadowing in right mid and upper zones</td>
<td>Sputum and blood cultures positivefor <italic>Klebsiella pneumoniae</italic>
</td>
<td>All >10, highest 27</td>
<td>Yes</td>
</tr>
<tr><td>4</td>
<td>76/Male</td>
<td>None</td>
<td>Pulmonary tuberculosis</td>
<td>Bilateral patchy fluffy infiltrate with cavitation</td>
<td>AFB smear positive</td>
<td>5.42</td>
<td>Yes</td>
</tr>
<tr><td>5</td>
<td>33/Male</td>
<td>Type 1 diabetes on insulin, melioidosis with meningitis and osteomyelitis 2002</td>
<td>Melioidosis</td>
<td>Multilobar consolidations</td>
<td>Blood and respiratory cultures positive for <italic>Burkholderia pseudomallei</italic>
</td>
<td>79.24</td>
<td>Yes</td>
</tr>
<tr><td>6</td>
<td>55/Male</td>
<td>Renal transplant 1988</td>
<td>PCP pneumonia<xref rid="TBLFN3" ref-type="table-fn">c</xref>
</td>
<td>Bilateral diffuse groundglass consolidation predominantly in the perihilar regions</td>
<td>Bronchoalveolar lavage cytology positive for PCP</td>
<td>2.58</td>
<td>Yes</td>
</tr>
<tr><td>7</td>
<td>47/Male</td>
<td>Bronchialasthma, newly diagnosed HIV positive</td>
<td>? CMV<xref rid="TBLFN4" ref-type="table-fn">d</xref>
pneumonia</td>
<td>Fine alveolar infiltrate in the perihilar regions bilaterally</td>
<td>Low grade CMV viraemia. Bronchoscopic lavage negative</td>
<td>0.07</td>
<td>No</td>
</tr>
<tr><td>8</td>
<td>45/Female</td>
<td>Migraine</td>
<td><italic>Mycoplasma pneumonia</italic>
</td>
<td>Infiltrate in left mid lung field obscuring left cardiac border</td>
<td>Significant rise in serum mycoplasma titre</td>
<td><0.06</td>
<td>No</td>
</tr>
</tbody>
</table>
<table-wrap-foot><fn id="TBLFN1"><label>a</label>
<p>Mechanical ventilation was indicated for severe type 1 respiratory failure from acute respiratory distress syndrome or severe pneumonia.</p>
</fn>
</table-wrap-foot>
<table-wrap-foot><fn id="TBLFN2"><label>b</label>
<p>All investigations were negative. Postmortem was not performed due to possible high infectious risk. Diagnostic kit for coronavirus was also not available in our hospital at that time. However, we think she likely had SARS as a healthcare worker who had performed a bronchoscopic lavage on her fell ill 3 days after the contact and was subsequently confirmed to have SARS serologically.</p>
</fn>
</table-wrap-foot>
<table-wrap-foot><fn id="TBLFN3"><label>c</label>
<p>Pneumocystis carinii pneumonia.</p>
</fn>
</table-wrap-foot>
<table-wrap-foot><fn id="TBLFN4"><label>d</label>
<p>Cytomegalovirus.</p>
</fn>
</table-wrap-foot>
</table-wrap>
</p>
</sec>
<sec><label>4</label>
<title>Discussion</title>
<p>Procalcitonin, a 14-kDa protein encoded by the Calc-1 gene along with calcitonin and kataclacin, is an innovative diagnostic parameter with kinetics different from other presently available indicators of the inflammatory response.<xref rid="BIB6" ref-type="bibr"><sup>6</sup>
</xref>
In the animal model, hyperprocalcitoninemia was an early systemic marker of sepsis which correlated closely with severity of acute illness and mortality.<xref rid="BIB7" ref-type="bibr"><sup>7</sup>
</xref>
Studies of its behavior in patients with bacterial sepsis have found it to be a useful marker of systemic bacterial infection, with greater specificity and sensitivity than acute phase proteins such as C-reactive protein, interleukin-6 and lactate levels even in a medical intensive care unit setting.<xref rid="BIB8" ref-type="bibr">8.</xref>
, <xref rid="BIB9" ref-type="bibr">9.</xref>
</p>
<p>The excellent specificity and negative predictive value at a cut-off point of 0.5 ng/ml suggests that this test might be a useful parameter in the management of infectious diseases.<xref rid="BIB10" ref-type="bibr"><sup>10</sup>
</xref>
PCT can help to identify an infectious cause or complication in patients with systemic inflammatory response syndrome (SIRS).<xref rid="BIB11" ref-type="bibr"><sup>11</sup>
</xref>
It has also been used to distinguish infectious from non-infectious causes of acute respiratory distress syndrome (ARDS).<xref rid="BIB12" ref-type="bibr"><sup>12</sup>
</xref>
It is moderately increased in local bacterial infection (pneumonia, pyelonephritis), parasitic and fungal infections and is unchanged or only slightly increased in even severe viral infections.<xref rid="BIB13" ref-type="bibr">13.</xref>
, <xref rid="BIB14" ref-type="bibr">14.</xref>
, <xref rid="BIB15" ref-type="bibr">15.</xref>
, <xref rid="BIB16" ref-type="bibr">16.</xref>
, <xref rid="BIB17" ref-type="bibr">17.</xref>
, <xref rid="BIB18" ref-type="bibr">18.</xref>
A serum PCT level of <0.4 ng/ml accurately rules out the diagnosis of bacteraemia.<xref rid="BIB19" ref-type="bibr"><sup>19</sup>
</xref>
Children with bacterial pneumonia had significantly higher PCT than those with sole viral aetiology.<xref rid="BIB20" ref-type="bibr"><sup>20</sup>
</xref>
PCT has also similarly high diagnostic value in both immunosuppressed and non-immunosuppressed patients with sepsis or severe infections.<xref rid="BIB21" ref-type="bibr">21.</xref>
, <xref rid="BIB22" ref-type="bibr">22.</xref>
, <xref rid="BIB23" ref-type="bibr">23.</xref>
</p>
<p>SARS is an emerging infectious disease by a novel coronavirus—SARS-CoV which is associated with pneumonia with global impact.<xref rid="BIB24" ref-type="bibr"><sup>24</sup>
</xref>
It is notable that nearly 40% of the patients developed respiratory failure that required assisted ventilation. In the ICU setting, SARS is essentially ARDS plus intensified respiratory isolation.<xref rid="BIB25" ref-type="bibr"><sup>25</sup>
</xref>
The clinical presentation and radiologic features of SARS bear some resemblance to the syndrome commonly referred to as ‘atypical pneumonia’. The high incidence of altered liver function, leucopenia, severe lymphopenia, thrombocytopenia, and subsequent evolution into adult respiratory distress syndrome suggest a severe systemic inflammatory damage induced by this human pneumonia-associated coronavirus.<xref rid="BIB26" ref-type="bibr"><sup>26</sup>
</xref>
The constellation of absence of upper respiratory symptoms, the presence of dry cough, and minimal auscultatory findings with consolidations on chest radiographs may alert the clinician to the possible diagnosis of SARS. However, the clinical and radiographic characteristics of atypical pneumonia are not useful in differentiating these pathogens from usual bacterial pathogens such as <italic>S. penumoniae</italic>
and <italic>H. influenzae.</italic>
Clinical diagnosis also becomes particularly problematic once the association with travel or case contact is lost. The difficulty of making a firm diagnosis until chest radiographic changes appear has important implications for healthcare personnel and for surveillance.</p>
<p>Early diagnosis by virus isolation or serological testing is essential to halt the spread of SARS. Rapid diagnosis of SARS for infection-control measures and potential treatment will require very sensitive and specific methods. There is still no reference standard (gold standard) test for SARS. Three diagnostic tests are currently available, but all with their limitations.<xref rid="BIB27" ref-type="bibr">27.</xref>
, <xref rid="BIB28" ref-type="bibr">28.</xref>
</p>
<p>We have reported two cases of patients with SARS and low PCT levels. This is consistent with the current evidence that SARS is just another viral pneumonia. High initial levels of PCT may be used to exclude SARS to a certain degree of accuracy whereas low PCT in relevant clinical context may prompt further testing for SARS. We recommend that PCT concentrations be determined for every patient presenting with community-acquired pneumonia.</p>
</sec>
<sec><label>5</label>
<title>Conclusions</title>
<p>In the setting of pneumonia with a finding of low PCT, with or without a positive contact history for SARS or relevant travel history, testing for SARS should be considered. This may be an additional screen to help narrow the number of patients that require specific SARS testing. However, the true validity of this test requires further prospective testing.</p>
</sec>
</body>
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