in early march 2003 , a 26-year - old man was admitted to a general medical ward of the prince of wales hospital ; he had been ill for 1 week with fever , chills , and rigor .
his previous health had been good , and he had no history of recent travel .
physical examination showed a temperature of 40.2c and bronchial breath sounds at the right upper zone lung field .
chest x - ray confirmed right upper lobe consolidation ( figure , part a ) .
chest radiographs performed a , at admission , b , on day 4 , and c , on day 16 of hospitalization for index sars case - patient , prince of wales hospital .
a complete blood profile on admission showed a leukocyte count 3.1 x 10/l , absolute neutrophil count 2.0 x 10/l , lymphocyte count 0.7 x 10/l , platelet count 112 x 10/l , and hemoglobin 14.7 g / dl .
the patient had mild renal impairment , with a creatinine of 119 mol / l , urea and electrolytes within normal limits , and alanine transaminase mildly elevated at 90 iu / l ( normal < 58
a diagnosis of atypical or viral pneumonia was suspected because of the low leukocyte count and normal c - reactive protein .
other laboratory tests were performed , including blood , sputum , and urine cultures , nasopharyngeal aspirate for influenza and parainfluenza , indirect immunofluorescence for respiratory syncytial viral antigen detection , and atypical pneumonia titer ( for adenovirus , psittacosis , q fever , influenza a and b , and mycoplasma ) .
the patient was housed in a general medical ward with no specific isolation facility . after admission his high fever and productive cough , now with thick , yellowish sputum , persisted .
he also complained of progressive dyspnea , headache , dizziness , generalized malaise , and myalgia .
his pulse and blood pressure were normal , and his oxygen saturation was approximately 98% on room air . a sputum culture yielded normal oral flora , and sputum smears were negative for acid - fast bacilli .
nasopharyngeal aspiration was negative for influenza viruses a and b , respiratory syncytial virus , adenovirus , and parainfluenzavirus types 1 , 2 , and 3 , with the use of commercial immunofluorescence assay .
a chest radiograph on day 4 showed progression of pneumonia , with consolidation changes over the right upper and lower lobes ( figure , part b ) .
a repeat complete blood profile showed a leukocyte count of 5.4 x 10/l with persistent lymphopenia and a platelet count of 98 x 10/l .
amoxicillin - clavulanate was therefore changed to intravenous cefotaxime , 1 g every 8 h ; clarithromycin ( 500 mg twice a day ) was continued .
as the patient s condition deteriorated progressively and he had difficulty in expectorating sputum , salbutamol , 0.5 g four times a day , driven by a jet nebulizer at 6 l of oxygen per min , was given to assist mucociliary clearance .
starting from day 6 , the patient s fever and chest condition gradually improved . however , over the next 2 weeks , 138 persons ( mostly healthcare workers ) who had been in contact with him had onset of a similar illness with high fever and pneumonia .
the patient was subsequently confirmed to be the index case - patient in this hospital outbreak of sars ( 1 ) .
further history showed that he had visited a hotel in kowloon , hong kong , where a 64-year - old physician from southern china had stayed for 2 days ; this physician later died of severe atypical pneumonia 10 days after admission to a regional hospital in kowloon ( 2 ) .
the cause of the illness was not known at the time of the physician s death .
our patient was identified as the index case - patient 5 days after the onset of this large outbreak at the prince of wales hospital , as he was the first patient who had the characteristic clinical , radiologic , and laboratory features of sars and had epidemiologic links with other infected persons .
after 8 days , use of the nebulized bronchodilator was stopped because of the possibility of enhancing sars transmission , and the patient was isolated in a private room with negative - pressure ventilation .
after the patient completed a 7-day course of cefotaxime and a 10-day course of clarithromycin , his pneumonia recovered gradually , and serial chest radiographs confirmed resolution of his consolidation ( figure , part c ) .
an immunofluorescence test for antibody against sars - cov subsequently confirmed an elevated titer of 1:5,120 in convalescent - phase serum collected on day 21 of illness .
convalescent - phase serum was negative for other atypical pneumonia organisms , including adenovirus , psittacosis , q fever , influenza a and b , and mycoplasma .
repeat complete blood count showed that lymphocytes and thrombocytes had returned to normal , along with serum creatinine and alanine transaminase levels .
the patient was isolated in a private room until day 27 of his hospital stay , when his nasopharyngeal aspirate and urine samples were confirmed to be negative for sars - cov .
repeat chest radiograph at follow - up 2 weeks later showed no residual parenchymal opacity , and the patient remained asymptomatic .
this report describes the index patient responsible for the hospital outbreak in the prince of wales hospital ( 2 ) .
he was linked to spread of the virus to more than 100 persons ( 1 ) .
this outbreak , together with similar events in canada ( 3 ) , singapore ( 4 ) and other cities where the source of infection was also related to the chinese physician ( 5 ) , led to increased awareness of this emerging global infection caused by a novel coronavirus ( 6 ) .
the super - spread event in prince of wales hospital caused by this patient was related to failure to apply isolation precautions , as the disease had not been recognized during the early part of his admission .
the use of a nebulized bronchodilator may also have enhanced the spread of the virus in the ward , and this practice was stopped for patients with suspected sars after this incident ( 7 ) .
this case report illustrates the natural history of sars in a young , previously healthy patient who received no specific therapy .
his clinical features and laboratory parameters were similar to those of other patients with sars ( 25 ) .
his clinical course followed a typical pattern with progression of pneumonia during the 2nd week of his illness ( 8) .
he was treated presumptively for bacterial community - acquired pneumonia with conventional antimicrobials ( 9 ) , without antiviral agents or corticosteroids .
he started to improve by the 3rd week and subsequently recovered uneventfully . during the global outbreak in 2003 , treatment of sars was empiric .
several groups have reported the use of ribavirin ( 25,7,8 ) and corticosteroids ( 2,3,7,8,10,11 ) with generally favorable outcomes .
ribavirin has been associated with substantial adverse reactions , including hemolytic anemia , elevated transaminases , and bradycardia ( 4 ) , and has demonstrated no in vitro activity against sars - cov ( 12 ) .
further studies , preferably with a randomized , placebo - control design , are needed to address treatment of this disease , which has high attack rates and is frequently fatal .
 during the global outbreak of severe acute respiratory syndrome ( sars ) in 2003 , treatment was empiric . 
 we report the case history of the index patient in a hospital outbreak of sars in hong kong . 
 the patient recovered after conventional antimicrobial therapy . 
 further studies are needed to address treatment of sars , which has high attack and death rates . 
Case Report
Conclusions