Case Management

PPHSN Guidelines For the Preparedness, Surveillance And Response To Severe Acute Respiratory Syndrome (SARS) in Pacific Island Countries And Territories
CASE MANAGEMENT – the clinical response (Updated 30.04.2003)



  • Chest radiographs might be normal during the febrile prodrome and throughout the course of illness. However, in a substantial proportion of patients, the respiratory phase is characterized by early focal infiltrates progressing to more generalized, patchy, interstitial infiltrates. Some chest radiographs from patients in the late stages of SARS have also shown areas of consolidation. Samples of chest radiographs of SARS can be found at:

  • In typical severe cases, chest x-ray findings begin with a small unilateral patchy shadow, and progress over 24 – 48 hours to become bilateral, generalized, interstitial/confluent infiltrates. Patchy chest x-ray changes are sometimes noted in the absence of chest symptoms. Acute respiratory distress syndrome might be observed in the end stage. Post-mortem lung tissue shows generalized alveolar damage and lymphocytosis without obvious viral inclusion bodies. 


  • Initially the blood picture is often normal. However, by day 3 – 4 of the illness, lymphopenia is commonly observed (>70%), and less commonly, there might be thrombocytopenia. If SARS is complicated by secondary bacterial infection, neutrophilai may occur. 


  • Elevated hepatic transaminases, lactate dehydrogenase and creatine phosphokinase levels are seen early in the respiratory phase of the disease.


  • Sputum and blood culture are usually negative but should be performed to rule out other possible illnesses and secondary infection.

Management of suspect cases

In-flight care of suspected case of SARS 

  • If a passenger on a flight from an affected area becomes noticeably ill with a fever and respiratory symptoms, the following action is recommended for cabin crew: 

o   The passenger should be, as far as possible, isolated from other 

     passengers and crew 

o   The passenger should be asked to wear a protective mask and those 

     caring for the ill passenger should follow the infection control   

     measures recommended for cases of SARS 

o   A toilet should be identified and made available for the exclusive use  

     of the ill passenger 

o   The captain should radio ahead to alert the airport of destination so 

     that quarantine or health authorities are altered to the arrival of a 

     suspect case of SARS 

o   On arrival, the ill passenger should be placed in isolation and 

     assessed by port health authorities


General care of suspected case of SARS 

  • Patients with symptoms of SARS should be triaged immediately to designated examination rooms or wards to minimize exposure to other patients and staff. 

  • Patients with suspected SARS should be issued with surgical masks 

  • obtain and record detailed clinical, travel and contact history including occurrence of acute respiratory diseases in contact persons during the last 14 days 

  • obtain chest X-ray (CXR) and full blood count (FBC) 


if CXR is normal and:

Individual is a close contact of a case of SARS

(high risk of becoming a case of SARS): 

  • Admit to hospital using full isolation and barrier nursing procedures 

  • NURSE separately from probable cases of SARS 


Individual has a history of travel to an affected area

(Lower risk of becoming a case of SARS):

  • Provide advice on personal hygiene, avoidance of crowded areas and public transportation, remain at home until well [consider “home isolation” until incubation period over].

  • Discharge with CLEAR advice to seek medical care if respiratory symptoms worsen. 


if CXR demonstrates uni- or bi-lateral infiltrates with or without interstitial infiltration 


Management of probable cases

  • Hospitalise under isolation or cohorted with other SARS cases.

  • Cases need to be in the best isolation facility that can be arranged and MUST be nursed using strict barrier techniques including gown or preferably overalls, gloves, boots or over-shoes, HEPA or N95-100 mask (or at least a surgical mask if nothing else available) and goggles. Avoid interventions which may cause aerolisation of respiratory secretions, such as nebulisers, chest physiotherapy, bronchoscopy, and any intervention which may release respiratory secretions.

  • Samples for laboratory investigation (if possible) and exclusion of known causes of atypical pneumonia: 

o  throat and/or nasopharyngeal swabs1

o  blood for culture, FBC and serology (acute specimen and 

    convalescent specimen taken after 3 weeks) 

o  urine 

o  sputum Gram’s stain and culture 

o  bronchoalveolar lavage 

o  post mortem examination as appropriate 

Samples should be investigated in laboratories with proper containment facilities (BL2). 

  • CXR as clinically indicated 

  • Maintain oxygenation. Intubate and ventilate as required.

  • Samples should be stored or sent for testing when diagnostic tests become readily available.


  • Currently no validated specific diagnosis test for SARS is available and diagnosis should be based on clinical and epidemiological findings. Tests under validation include: molecular tests (PCR), antibody tests (ELISA and IFA) and cell culture. They are available through WHO laboratory network (see “Laboratory”). 

  • Other symptoms frequently observed are: chills, rigors, myalgia, headache and malaise. Gastrointestinal symptoms (diarrhea and vomiting) are observed in some cases. 

  • The other illnesses which should be considered as differential diagnosis are: influenza, parainfluenza (children), respiratory syncytial virus (children), respiratory adenoviruses (children), legionellosis, chlamydial, mycoplasmal or pneumococcal pneumonia etc.

Specific Treatment

  • Treatment regimens have included several antibiotics to presumptively treat known bacterial agents of atypical pneumonia. 

  • In several locations, therapy has included antiviral agents such as oseltamivir or ribavirin; the effectiveness of these treatments is uncertain.. 

  • Steroids have also been administered orally or intravenously to patients in combination with ribavirin and other antimicrobials, of which effectiveness is uncertain. 

  • At present, the most efficacious treatment regime, if any, is unknown.  

  • At the time of admission WHO recommends antibiotic therapy that will cover the common causative organisms in acquired pneumonia (including atypical pneumonia). Prophylactic antibiotics should also be used to prevent secondary bacterial infection.

Hospital discharge and follow-up

The period of communicability of the agent that causes SARS is unknown at this time. WHO advises that patients are fit for discharge if:

Clinical symptoms/findings: 

  • Afebrile for 48 hours 

  • Resolving cough

Laboratory tests: if done and previously abnormal 

  • White cell (lymphocyte) count returning to normal 

  • Platelet count returning to normal 

  • Creatinine phosphokinase returning to normal 

  • Liver function tests returning to normal

  • Plasma Sodium returning to normal

  • C reactive protein returning to normal 

Radiological findings: 

  • Improving chest x-ray changes


Follow-up for convalescent cases

  • Discharged convalescent patients should be asked to return to hospital if they have an elevated temperature of 38 degrees and above on two consecutive occasions they should report to the health care facility from which they were discharged. 

  • Follow up is recommended at one week (or before if decided so by the clinician) at which time they should have a repeat chest x-ray, full blood count and any other blood tests that were previously abnormal. 

  • The patient should be followed up by the health care facility from which they were discharged. If possible they should not return to their home island. 

  • Subsequent follow-ups are recommended until the chest x-ray and patient’s health returns to normal. 

  • As part of the follow-up convalescent serology should be taken at 3 weeks (if an acute serum specimen was taken) after the date of the presenting symptoms and provided to the health care facility from which they were discharged. 

  • Until more is known about the aetiological agent, and the potential for continued carriage (and hence the risk of continuing transmission) a cautious approach is warranted. 

  • WHO advises that following discharge from hospital convalescent cases should be advised to wait for a minimum of 14 days, before considering returning to work/school/college. This is twice the known maximum incubation period. During this period they should stay indoors, keeping contact with others to a minimum. Clear instructions should be given to convalescent cases to return to the health care facility from which they were discharged [see above] if their condition deteriorates and any further symptoms develop.