A 30-year-old male (height: 175 cm, body weight: 105 kg) presented with fever for 6 days, and abdominal pain and diarrhea for 2 days. He was admitted to the gastroenterology department of an outside hospital. He did not have any history of underlying disease and had recently stopped smoking. He worked for 2 weeks at another hospital where a patient diagnosed with MERS. His initial vital signs and results of initial laboratory examination were unavailable to us, because he was admitted to an outside hospital. However, according to information from that hospital, physical examination on admission to that hospital revealed normal vital signs (except for fever) and initial laboratory examination showed mild elevation of liver enzymes. In that hospital, he firstly underwent chest and abdominal radiographs and abdominal CT for further evaluation of abdominal pain. The initial chest radiograph, which was taken 6 days after the onset of fever, showed a patchy increased opacity in the left lower lung zone, retrocardiac area (Fig. 1A). Abdominal CT showed no specific finding in abdominal and pelvic organs; however, a patchy area of consolidation with an air-bronchogram was detected in the left lower lobe of the lung, which was mainly peripherally located (Fig. 1B). Conservative treatment with intravenous fluid was used for abdominal pain. Although he did not initially have any respiratory symptoms, he began coughing 9 days after the onset of fever. Because of this new respiratory symptom, occupational history, and a recent MERS outbreak in Korea, he underwent laboratory examination for MERS. A follow-up chest radiograph, which was taken 10 days after the onset of fever, showed newly developed patchy areas of ill-defined increased opacity in the right upper lung zone and increased extent of the previously detected consolidation in the left lower lung zone (Fig. 1C). A chest CT scan performed on the same day showed multifocal patchy areas of nodular consolidations orgwith ground-glass opacity (GGO) halo and nodular GGO lesions in both upper lobes, which were mainly slightly peripherally located (Fig. 1D). Moreover, this scan also demonstrated increased extent of mixed consolidations and GGOs with air-bronchograms in both lower lobes, mainly in the dependent area (Fig. 1E). There was no pleural effusion or significant lymph node enlargement. Finally, he was diagnosed with MERS by testing the sputum by real-time reverse-transcriptase-polymerase chain reaction (rRT-PCR). For intensive care and management of MERS, he was transferred to a negative pressure room of our hospital on the day of diagnosis. Physical examination in our hospital showed fever (38.4C) and elevated blood pressure (154/106 mm Hg). His vital signs on admission are summarized in Table 1. Laboratory examination on admission of our hospital showed normal white blood cell counts (5640/microL), and elevated serum aspartate aminotransferase (AST, 155 international unit [IU]/L), alanine aminotransferase (ALT, 77 IU/L), lactate dehydrogenase (904 IU/L), and C-reactive protein (CRP, 9.39 mg/dL).
He was administered antiviral agents (ribavirin, kaletra [ritonavir + lopinavir], and interferon-alpha) and antibiotics (tabaxin [piperacillin + tazobactam] and cravit [levofloxacin]). Daily follow-up radiographs were taken to evaluate disease progression. Fever disappeared after 2 days of treatment; although radiologic abnormalities remained on early follow-up radiographs, then their extent decreased after 5 days of treatment. After a week of treatment, he showed no symptom. Follow-up laboratory examination showed normalization of CRP (0.14 mg/dL), slightly deceased but remained elevated AST (131 IU/L), whereas increased ALT (142 IU/L). Finally, follow-up sputum tests by rRT-PCR (conducted twice) showed negative results, and he was discharged after 13 days in our hospital.
On the day of discharge (23 days after the onset of fever) he underwent chest radiograph and chest CT scan. The chest radiograph depicted markedly decreased extent of previous increased opacities in the right upper and left lower lung zones (Fig. 1F). The chest CT scan showed markedly decreased extent of previously detected lesions with residual nodules or GGOs in both lungs, and developed traction bronchiectasis within retracted consolidation with volume loss in the left lower lobe, which suggested fibrosis (Fig. 1G, H).