Clinical Virology / Lecture Six / Dr.

Batool Al-
Haidary

Severe Acute Respiratory Syndrome (SARS)

Introduction:
Since the recognition of the first case of severe acute respiratory
syndrome in November 2002, health care workers have done much work in
understanding the etiology, diagnosis treatment & progress in " The
proposed Criteria for Diagnosis of Infectious Atypical Pneumonia" and
the "Recommended Guidelines for Treatment of Infectious Atypical
Pneumonia" formulated by the Ministry of Public Health in April 2003
which, both played important roles in management the dz in China.
Severe Acute Respiratory Syndrome (SARS) is a new
infectious dz in human beings, caused by the SARS coronavirus (SARS-
CoV). It is a special pneumonia that is contagious and involved in multiple
organ disorders. The main clinical description of SARS includes fever,
hypodynamia, headaches, myalgia & arthalgia, and respiratory syndromes
such as dry cough, chest tightness and breathing difficulty. Chest X-rays
show pneumonic infiltration, while laboratory tests reveal normal or
increased WBCs counts in peripheral blood. Severe cases show significant
breathing difficulty and can lead rapidly to acute respiratory distress
syndrome (ARDS).

Etiology:
The identification of the virus was the result of the close
international collaboration of a network of 13 laboratories in nine countries.
The new coronavirus has been named SARS coronavirus (SARS-CoV).
Infections of classical corona viruses usually occur during the
seasons of winter and spring. These viruses spread word wild and have been
classified into three groups. Genetic studies suggest that the genotype of

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Haidary

SARS-CoV is not the same as the genotype of the three known types of
coronavirus, though serum infected with a group 1 coronavirus can cross
react with SARS-CoV but doesn't so for serum from SARS patients.
SARS-CoV is an enveloped virus with a diameter of 60-120 nm
surrounds the virus. There are petal-or cilia-like spikes on the envelope in a
form of radiation, each with a length of ≥20 nm and a narrow fundus. The
morphological development of SARS-CoV is slow and complicated. Mature
viruses are in the shape of spheres or ellipses. Many unusual virion shapes,
giving the appearance of kidney, drumsticks, horse-hooves or bells can be
found on tissue slides from autopsy samples.
It is temperature sensitive virus inactivated after 90 minutes at
56 0C or 30 minutes at 75 0C . The virus can also be killed after one-hour
exposure to ultraviolet radiation.
The virus genome is ss-RNA of positive sense type. It is
propagated in the cytoplasm.
The viral envelope is composed of a lipid bilayer membrane.
The outer coat proteins contain glycoprotein S, M and the small envelope
glycoprotein E. S protein is responsible for cell adherence, membrane fusion
and inducing of neutralizing antibodies. M & E proteins are believed to be
the smallest assembly units, with E protein playing a key role in viral
assembly. M protein serving to stabilize the viral nucleus.

Life cycle's steps of SARS virus:

1) The S protein on the surface of SARS virus binds to the receptor on

the surface of human cell; then the virus invades the cell by the
receptor-induced endocytosis.

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Haidary

2) The positive sense RNA genome translates RNA-dependent RNA

polymerase, which help in synthesis of the negative sense RNA (-).
With this template [(-) sense RNA] plenty of child genomic RNA (+)
are produced.
3) The three main structural proteins of SARS virus, the N proteins are
synthesized in the cytoplasm free ribosomes and combine the child
genomic RNA (+) to form neucleocapsid (NC) with relax helices, M
& S protein are translated on the ribosomes [RER] and then
transported into Golgi apparatus.
4) The N protein of NC will be bound by M protein in the RER or Golgi
apparatus, where protein also binds to S protein to bud as virions. The
budded virions will be transported from Golgi apparatus to SWV and
released by membrane fusion. This process requires M protein.
SARS
Adherence

SWV

Neucleus RER

Replication Life cycle of SARS Virus

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Haidary

Immunology of RARS Virus:

In most cases after the initiation of SARS-CoV infection,
humoral & cellular immunity are triggred in order to control the infection
and later clear the virus. Much evidence shows that SARS-CoV can invade
the immune system directly and cause a decrease in the No. of lymphocytes
and WBCs and pathological damage to peripheral lymphatic tissue. The No.
of CD3+, CD4+ and CD8+ T-lymphocytes decrease significantly as compared
to the normal controls. Usually the No. and Function of T cells return to
normal gradually during convalescence. SARS-CoV nucleic acids can be
detected in the nasopharngeal fluids of patients on the 5th after the onset of
the dz, and nucleic acid level reach a peak around day 10 and subsequantly
decreasing. The N protein induces a stronger IR, so it can be used for Ab
detection. Experimentally it is showed that IgM levels increase one wk after
the onset of the dz and remain high for at most three months. IgG levels go
up gradually from day 7-10 and the titer reaches its highest point about one
month. IgG is positively detected in all patients at that time. During
convalescence, antibody titers remain high for ~ 6 months. SARS is a new
dz to which the entire population is susceptible. Unfortunately, no
significant immune protection barriers have been formed in the general
population after the latest outbreak of SARS, which means that the general
population is still susceptible to the virus. The detection of serum specific
Ab to SARS-CoV is very helpful for clinical diagnosis.
Intimate contact and aerossol dropletes are the airborne
transmission route of the dz. No evidence for blood transmission, sexual
intercourse transmission and vertical transmission.

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Haidary
The dz susceptibility generally, is universal though the rate of
incidence in children is for unknown reason much lower than the adults.

Pathogenesis:
SARS-CoV infects the human body through the RT, and
replicates in epithelial cells of RT and pneumocytes. The virus then enters
blood circulation causing viremia. The target cells of SARS-CoV include
tracheobronchial epithelial cells, pneumocytes, endothelial cells of blood
vessels, macrophages, epithelial pneumocytes and epithilial cells of
intestinal tract , distal tubular & lymphocytes. The injuries to pneumocytes,
endothelial cells of blood vessels lead to the destruction of the integrality of
the blood-air exchange barrier, producing inflammatory edema and serious
exudates in addition to fibrinogen exudates. The exudated fibrinogen leads
to deposition, which , when mixed with cytoplasmic and lipid remnants of
necrotic epithelial cells contributes to the formation of an alveolar hyaline
membrane.
The host IR to the infection leads to lymphocyte production and
macrophage infiltration into alveolar septa and interstitial compartments.
These activated cells can release a variety of cytokines & oxygen radicals ,
which further increase the alveolar-walls capillarie's premeability and
fibroblast proliferation. Desquamation of damaged pneumocytes into
alveolar spaces and at the same time, there is a prominent proliferation of
type II pneumocytes. All togather in addition to some macrophages may fuse
to form giant cells. These changes represent the exudatative phase of diffuse
alveolar damage (DAD). In severe cases the exudative phase may progress
into proliferating, fibrosis phases. These changes may develop to collagen
III & I production.

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Haidary
Diffuse alveolar damage and diffuse consolidation of the lung
can lead to blood hypoxygenation and respiratory failure in SARS patients.

Clinical Features:
The incubation period is no more than 2wk usually 2-10 days.
The illness characterized by an acute onset and evolves over 2-3 wk. The
main clinical symptoms are:
1. Fever
2. Respiratory symptoms: Dry cough, chest discomfort, in severe cases
tachypenea, panting & respiratory distress. Dyspnoea & hypoxemia
are usually seen 6-12 days after dz onset.
3. Other symptoms: include diarrhea, nausea, vomiting and other GIT
symptoms.

Laboratory findings:
A. Peripheral Blood Features: WBCs count are generally normal
or below with decreased absolute lymphocyte count [lymphocyte count
of < 0.9x109 /L is highly suggestive of SARS]. Thrombocytopenia has
been found in some cases.
B. T lymphocyte subtype count: CD4+ & CD8+ t lymphocytes
count usually decrease in early stage of SARS, and the ratios of CD4+ /
CD8+ are normal or lower than normal.
C. Chest radiological examination: The typical imaging profile of
SARS is multiple patchy opacities with bilateral distribution. The
opacities are usually ground-glass in appearance. Chest radiographs
may be normal during the febrile prodrome and it may be difficult to

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Haidary
discern abnormalities when opacities are hazy or overlap with heart or
cardiovascular images. In this case chest radiograph must be repeated
every day.

D. Specific etiological testing:

 Serum specific SARS-CoV Ab which can be detected
in patient serum 10 days after dz onset using Immunofluorescence
assay (IF) and 21 days using Enzyme-linked Immunosrbent assay
(ELISA).
 Detection of SARS-CoV RNA is of significance for
early diagnosis using reverse transcriptase-polymerase chain reaction
(RT-PCR) method.
E. Clinical testing: According to dz stages [early, progressive &
recovery]. The early stage is defined at the first 1-7 days of
illness beginning with fever [>380C], headache, myalgia,
anthralgia, malaise & Fatigue. Progressive stage occurs 8-14
days after dz onset characterized by chest tightness, panting &
dyspnoea especially during exercise. Chest radiography shows
rapid evolvement of opacities distributed in multiple lobes.
Life-threatening condition such as respiratory distress can
involve in few cases. In the last stage the temperature
decreases gradually , clinical symptoms alleviated and lung
opacities disappear. Few patients may develop restrictive
pulmonary function & decreased diffusion capacity. They can
recover from these lung deficiencies 2-3 months later.

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Haidary
Laboratory Diagnosis:
1. Hematological test of peripheral blood: WBC counts are normal in
most cases, but are lower than normal in a few cases, accompanied by
cytomorphological changes. The normal WBC count is 4-10 x 109/ L.
The absolute lymphocyte count declines progressively in most cases.
2. Specific Ab test criteria: Detection of specific anti SARS CoVAb

Using ELISA or IFA techniques for double samples per each stage either
acute or convalescence . Serum tests performed in parallel during the
progression and recovery stages are very important .
3. PCR test: Samples are considered positive when they meet one of the
following conditions:
A. There are at least two different clinically positive samples [ e.g.
nasopharyngeal & stool specimens].
B. Positive results are obtained from the same clinical source
collected at an interval of two or more days [ 2 ≥
nasopharyngeal aspirates.]
C. Positive results are found in two different assays or after
repeated PCR using the same original clinical sample in all
tests.
The sensitivity of PCR test for SARS-CoV depends on the time of
sample collection & testing. False negative results are possible.
Sensitivity can be increased if multiple specimens / multiple body
site are tested.
The highest positive rate occurs 5-7 days after the onset of illness.
4. Differential diagnosis: Diagnosis of SARS during the early phase can
be aided by testing for the Influenza virus (A, B, C), Parainfluenza virus,

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Haidary
Respiratory Syncytial virus (RSV), Adenovirus, Legionella pneumon-
ophila , Mycoplasma pneumoniae, Chlamydia pneumoniae & respiratory
tract bacteria. Enzyme immunoassay (EIA) & indirect fluorescence
immunoassay (IIF) are used to detect specific Ag or Ab against specific
pathogen . Serological diagnosis depends on complement fixation reaction,
metabolic inhibition test , indirect hemagglutination test, indirect immuno-
fluorescence immunoassay. Increased Ab titer ≥ 4 fold are of diagnostic
significance.