key: cord-0040093-8dfbds8f
authors: Sridhar, Shruti; Lagier, Jean-Christophe; Gautret, Philippe
title: Respiratory Tract Infection in a Traveler Returning from the Hajj
date: 2016-08-12
journal: Infectious Diseases
DOI: 10.1016/b978-0-7020-6285-8.00228-8
sha: c240d920b29ce38dab7b3be099e599bd2abaee83
doc_id: 40093
cord_uid: 8dfbds8f

nan

SHRUTI SRIDHAR | JEAN-CHRISTOPHE LAGIER | PHILIPPE GAUTRET 34 respiratory symptoms may be up to 90%, as observed in a French cohort survey during the 2012 Hajj season, with cough as the most frequently reported complaint (83% of respondents) followed by sore throat (78%) and rhinorrhea (69%). Respiratory diseases are by far the main reason for consultation at primary healthcare centers during the Hajj and major causes of hospitalization in tertiary care hospitals among pilgrims during their stay in Saudi Arabia. Recent studies demonstrated a rapid acquisition of respiratory viruses and bacteria nasal carriage among pilgrims during their stay in Saudi Arabia, most notably coronaviruses, rhinovirus, influenza virus and Streptococcus pneumoniae. According to a survey in 2012, out of the pilgrims who presented with fever and cough or sore throat (influenza-like illness), 7% were associated with Strep. pneumoniae nasal carriage and 37.5% with virus carriage. The majority of viral cases were associated with human rhinovirus, followed by influenza H3N2 virus. The differentiation between bacterial and viral infection is imperative in deciding the course of treatment. Also, this implies that antibiotics would be rendered ineffective in almost 40% of cases presenting with fever and cough.

According to the World Health Organization, there has also been an ongoing outbreak of MERS-CoV in Saudi Arabia since April 2012 with over 1060 laboratory confirmed cases as of August 2015 and a case fatality rate of approximately 38%. The majority of human cases of MERS-CoV infections are secondary cases and attributable to human-to-human transmission, primarily among healthcare workers. Cases have been acquired or reported in Saudi Arabia (>85%), Qatar, Jordan, Oman, Kuwait, United Arab Emirates and Yemen. Some cases have been exported from the Arabian Peninsula in Europe, the USA, North Africa, Asia and the Middle East. In addition, there has been a significant cluster of 186 cases in South Korea, associated with 36 deaths. This was traced to a traveler returning from the Middle East. There is evidence suggesting that camels may act as a reservoir. In the case presented here, we considered that the patient may have been infected by MERS-CoV and she was managed in a BSL3 environment until a diagnosis of influenza H1N1 was made. It is not always possible to identify patients with MERS-CoV early because some have mild or unusual symptoms. For this reason, it is important that healthcare workers apply standard precautions consistently with all patients, regardless of their diagnosis, in all work practices all the time. Droplet precautions should be added to the standard precautions when providing care to any patient with symptoms of acute respiratory infection. Contact precautions and eye protection should be added when caring for probable or confirmed cases of MERS-CoV infection. Airborne precautions should be applied when performing aerosol-generating procedures.

Hajj pilgrims should be up to date with routine immunizations and must have had the tetravalent meningococcal vaccine ≤3 years and ≥10 days before arriving in Saudi Arabia. Seasonal influenza vaccine is

A 71-year-old woman returned from Saudi Arabia complaining of cough and fever for 10 days. The complaints started during the Hajj pilgrimage in Mecca. The initial episode started abruptly with dry cough, fatigue and subjective fever which were followed by diarrhea a few days later. Many pilgrims from her group presented with similar symptoms. On her arrival from Saudi Arabia, she immediately presented to the emergency ward and was subsequently transferred to the infectious disease ward in biologic safety level 3 (BSL3) conditions. She complained of fatigue, cough, dyspnea, diarrhea (five stools per day) and nausea.

She had a history of hypertension, chronic hypertensive heart disease, atrial fibrillation, hypothyroidism, gastritis, depression and allergy to penicillin. On admission, she was treated with furosemide, bisoprolol, ramipril, eplerone, rivaroxaban, L-thyroxine, esomeprazole and fluoxetine. She was vaccinated against meningitis before the pilgrimage but was not vaccinated against influenza in that year and never against invasive pneumococcal disease. She used face masks from time to time during the pilgrimage and practiced hand hygiene more often than usual. Physical examination in the emergency room revealed a body temperature of 39 °C, dry cough, respiratory rate of 30 breaths per minute, bilateral diffused rhonchi and sibilants, without crepitant rales or decreased breathing sounds, blood pressure 130/70 mmHg, heart rate of 74 beats per minute (irregular). Oxygen saturation was 95% on ambient air. Chest radiography showed increased interstitial bilateral diffuse markings and moderate cardiomegaly. The laboratory results on admission were: white blood cell count 4.34 × 10 9 /L (59% neutrophils, 34% lymphocytes); C-reactive protein 24 mg/L; serum sodium 141 mmol/L; serum phosphorus 85 IU/L; serum creatinine 11.5 mg/L; serum glutamate pyruvate transaminase 22 IU/L; serum oxaloacetate transaminase 41 IU/L; gamma glutamyl transferase 36 IU/L. Nasal swab polymerase chain reaction (PCR) detection of influenza H1N1 virus was positive. Nasal swab PCR detection of influenza A3N2, influenza B, parainfluenza viruses 1, 2, 3 and 4, rhinovirus, human metapneumovirus, human respiratory syncytial virus and Middle East Respiratory Syndrome coronavirus (MERS-CoV), E229 coronavirus, HKU1 coronavirus, NL63 coronavirus and OC 43 coronavirus were negative. Legionella antigens were negative in urine samples. Sputum bacterial cultures were negative. Blood cultures were negative. Atrial fibrillation was confirmed by the electrocardiogram. Oral levofloxacin and oseltamivir were administered. She was apyrexial on the second day and was discharged on day 6.

The pilgrimage to Mecca, also known as the Hajj, is the fifth pillar of Islam and is mandatory for all adult Muslims who are physically and financially capable to undertake at least once during their lifetime. Therefore, about 2-3 million Muslims from more than 180 countries gather each year in the Kingdom of Saudi Arabia to perform the Hajj pilgrimage. As a result of overcrowding during the stay, acute respiratory infections are very common among pilgrims. Incidence rate of recommended for all pilgrims and pneumococcal vaccine for pilgrims aged ≥65 years and for younger pilgrims with co-morbidities. Behavioral interventions such as hand hygiene, wearing a face mask, cough etiquette, social distancing and contact avoidance can be effective at mitigating respiratory illness among Hajj pilgrims. Additionally, pilgrims should take precautions when visiting farms and markets where camels are present. These precautions include: avoiding contact with camels; not drinking raw camel milk or camel urine; and not eating meat that has not been thoroughly cooked.

Further reading available online at expertconsult.com.

Global perspectives for prevention of infectious diseases associated with mass gatherings

Health risks at the Hajj

Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: a descriptive study

Circulation of respiratory viruses among pilgrims during the 2012 Hajj pilgrimage

Lack of MERS coronavirus but prevalence of influenza virus in French pilgrims after