Correspondence

The Use of Corticosteroids in SARS

N Engl J Med 2003; 348:2034-2035May 15, 2003

Article

To the Editor:

The use of systemic corticosteroids in patients with the severe acute respiratory syndrome (SARS) is of serious concern. Lee and colleagues report anecdotal success in their article on SARS elsewhere in this issue.1 And in the recent Web broadcast on SARS by the CDC, Dr. Sung, one of the coauthors, states, “High-dose steroid should be given early to stop the progression of the disease.”2 The pathogenesis of SARS is diffuse alveolar damage with the acute respiratory distress syndrome (ARDS), not bronchiolitis obliterans with organizing pneumonia. And SARS is most likely due to coronavirus pneumonitis. Early treatment with corticosteroids in patients with ARDS is highly controversial and is not a standard of care, at least in North America. Although ribavirin has activity against coronaviruses and human metapneumoviruses in vitro, there are no antimicrobial agents with proven effectiveness for the treatment of SARS at this point. And the use of corticosteroids with possibly ineffective antiviral agents in patients with viral-induced pneumonitis or ARDS can be hazardous. I believe systemic corticosteroids should not be used at least until the etiologic agent of SARS has been confirmed and effective antiviral agents have been established.

Yuji Oba, M.D.
University of Missouri—Kansas City, Kansas City, MO 64108

2 References

1. 1

   Lee N, Hui D, Wu A, et al. A major outbreak of severe acute respiratory syndrome in Hong Kong. N Engl J Med 2003;348:1986-1994
   Full Text | Web of Science | Medline

2. 2

   Preventing the spread of severe acute respiratory syndrome (SARS). Atlanta: Centers for Disease Control and Prevention, 2003 (broadcast).(Accessed April 25, 2003, at http://www.cdc.gov/ncidod/sars/webcast/broadcast040403.htm.)
   

Author/Editor Response

We agree with Dr. Oba that the efficicacy of antiviral agents is not certain and that the use of corticosteroids in patients with infectious disease is potentially hazardous. But SARS is a serious disease with a rapid downhill course. In the Canadian report, 5 of 10 patients required mechanical ventilation, and 3 died.1 Of the three patients who received board-spectrum antibiotics, 2 died and 1 remained in the intensive care unit. According to another report on SARS elsewhere in this issue, antibiotics alone did not have any clinical benefit in patients.2

The combination of ribavirin and corticosteroid is an empirical therapy but not without basis. Ribavirin is a antiviral agent previously shown to be effective for respiratory syncytial virus infection, influenza virus A and B infections, measles, parainfluenza, and Lassa fever. It was chosen in this case because of its board-spectrum coverage. It is also known that in acute viral respiratory infections, early-response cytokines such as interferon-tumor nocrosis factor, interleukin-1 and interleukin-6 mediate lung injury. We used corticosteroid treatment to suppress the cytokine storm, hoping that would stop the progression of pulmonary disease. And, in fact, in many cases, it did. Lung shadows started to resolve, and oxygenation improved after corticosteroid treatment. We must emphasize that corticosteroids were not used to treat ARDS. We are in the process of analyzing the clinical responses to these treatments and will make that information available as soon as possible.

Nelson Lee, M.B.,B.S., M.B.,B.S.
Joseph Sung, M.D.
Chinese University of Hong Kong, Hong Kong, China

2 References

1. 1

   Poutanen SM, Low DE, Henry B, et al. Identification of severe acute respiratory syndrome in Canada. N Engl J Med 2003;348:1995-2005
   Full Text | Web of Science | Medline

2. 2

   Tsang KW, Ho PL, Ooi GC, et al. A cluster of cases of severe acute respiratory syndrome in Hong Kong. N Engl J Med 2003;348:1977-1985
   Full Text | Web of Science | Medline

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