Al-Tawfiq, Jaffar A.

Alfaraj, Sarah H.

Memish, Ziad A.

Journal of Microbiology Immunology and Infection

English

ScholarWorks  IU Indianapolis

Journal of Microbiology, Immunology and Infection (2019) 52, 501e503Available online at www.sciencedirect.comScienceDirectjournal homepage: www.e- jmii .comCorrespondenceMiddle East Respiratory SyndromeCoronavirus (MERS-CoV) infection duringpregnancy: Report of two cases & review ofthe literatureht16BYKEYWORDSMERS-CoV;Pregnancy;Saudi Arabiatps://doi.org/10.1016/j.jmii.2018.084-1182/Copyright ª 2018, Taiwan S-NC-ND license (http://creativecomDear Editor,As of February, 2018 a total of 2143 cases of Middle EastRespiratory Syndrome Coronavirus (MERS-CoV) have beenreported to the World Health Organization, including 750deaths in 27 countries.1 There were 10 reported cases ofMERS-CoV in pregnancy.2e7 Here, we present two casesform our hospital with MERS-CoV infections duringpregnancy.Case 1The first patient was a 29-year-old female (gravida 2, para1) at 6 weeks gestation and with no underlying medicalconditions. She was asymptomatic and identified as part ofthe contact tracing of her mother, a positive MERS-CoVpatient. On examination, she was afebrile, breathing nor-mally and Lungs were clear to auscultation. The abdomenwas gravid, soft, non-tender, non-distended, and normalbowel sounds. Nasopharyngeal swab testing by RT-PCR forMERS-CoV showed a positive result for ORF (Ct value 32).She had two repeated nasopharyngeal swab testing by RT-PCR for MERS-CoV and these showed probable results (Ctvalue 36) and the 4th swab was negative by PCR for MERS-CoV. The patient did not deliver during hospitalization and4.005ociety of Microbiology. Publishedmons.org/licenses/by-nc-nd/4.0/she was discharged on 24th August 2015, and subsequentlydelivered a healthy infant at term.Case 2The second patient was a 39-year-old female (gravida 6,para 5) with history of end stage renal disease (ESRD) andhypertension on hemodialysis. She used to have hemodial-ysis at Wadi Aldawasir hospital during an active MERS-CoVoutbreak there. She presented at 24 weeks of gestationafter a contact with a positive MERS-CoV patient. Naso-pharyngeal swab testing by RT-PCR was positive for MERS-CoV with E gene (Ct value 34) and OFR (Ct value 34). Shewas admitted to a regular ward. Subsequently, she hadnegative RT-PCR for MERS-CoV and she was dischargedhome.Respiratory samples (Nasopharyngeal swabs or trachealaspirates) were tested for MERS-CoV using real-timereverse-transcription polymerase chain reaction (RT-PCR)as described previously.The clinical presentation of MERS-CoV is variable andranges from a mild disease or asymptomatic presentation toa more severe and fatal cases. There are sparse data on theeffect and the likelihood of MERS-CoV during pregnancy.2e7We searched the MEDLINE database for articles published inEnglish literature from January 2012 to July 2016. Thereferences in the retrieved articles were further searchedfor any additional references. A summary of previous re-ports and the current two additional cases of pregnancyassociated MERS-CoV is presented in Table 1. Of all thecases, the mean age  SD was 33.7  4.3 years and thegestation age was 26.3  9 weeks, and there were four(36%) primi-gravida. The source of infection was not iden-tified in 3 cases; contact with family members who hadMERS-CoV was elucidated in two cases; four patients hadby Elsevier Taiwan LLC. This is an open access article under the CC).Table 1 A summary of pregnancy associated MERS-CoV infection.Age Nationality Gravida (G),Para (P)Source of infection Gestationalage at illnessonset (weeks)ICUadmissionMaternalcomorbidconditionsMaternaloutcomeFetaloutcomeDelivery details ReferencePatient 1(PMAH)29 Saudi G2, P1 Household contact 6 NO None Survived Survived Delivery at term CurrentreportPatient 2(PMAH)39 Saudi G6, P5 Contact withMERS-CoV case in HD24 NO ESRD onhemodialysis,HTNSurvived Survived Delivery at term CurrentreportPatient 3 34 Saudi G7, P6 Unknown 34 YES Preeclampsia Survived Died Intrauterine Fetaldeath at 34 weeks3Patient 4 32 Saudi G2, P1 Unknown 38 YES None Died Survived Vaginal delivery at38 weeks3Patient 5 31 Saudi Primigravida HCW, occupationalexposure24 YES Asthma,pulmonaryfibrosisDied Died Caesarean sectionat 24 weeks3Patient 6 27 Saudi Primigravida Unknown 22 YES None Survived Survived Full term delivery 3Patient 7 30 Saudi Primigravida HCW, occupationalexposure23 YES None Survived Survived Full term delivery 3Patient 8 39 Jordanian G7, P6 Household contact 20 NO None Survived Still birth Still birth at 5months6Patient 9 32 United ArabEmiratesG3, P2 Visited camel barn 32 YES None Died Survived Caesarean sectionat 32 weeks5Patient 10 39 South Korean G2, P1 Contact withMERS-CoV Patient inhospital35 weeks and 4 days NO GestationalDiabetesSurvived Survived Caesarean sectionat 39 weeks2,7Patient 11 33 Saudi Primigravida Contact withMERS-CoV Patient31 Yes Hypothyroidismand primaryinfertilitySurvived Survived Caesarean sectionat 32 weeks4502CorrespondenceCorrespondence 503health-care associated infection, two of them werehealthcare workers. Six (54%) patients required ICUadmission and three (27%) patients died during the hospitalstay. Two of the deceased had an exposure during the thirdtrimester and one acquired the infection during the secondtrimester. The infant death rate was 27%. The outcome wasfavorable in the majority of pregnancy-associated MERS-CoV cases. The exact prevalence of MERS-CoV antibodiesand exposure of pregnant women to MERS-CoV is notknown. All the reported cases were symptomatic. Amongthe 11 pregnancy-associated MERS-CoV infection, the casefatality rate was not statistically different when comparedto the overall case fatality rate of 35%, P Z 0.75. Regardingthe infants, three (27%) infants had died.The overall case fatality rate remains high and is com-parable to the overall case fatality rates. The disease hadalso resulted in fetal demise in 27% of cases.References1. WHO. Middle East respiratory syndrome coronavirus (MERS-CoV) e update. February 2018. http://www.who.int/csr/don/2018_12_02/en/.2. Park MH, Kim HR, Choi DH, Sung JH, Kim JH. Emergency cesar-ean section in an epidemic of the Middle East respiratory syn-drome: a case report. Korean J Anesthesiol 2016;69:287e91.https://doi.org/10.4097/kjae.2016.69.3.287.3. Assiri A, Abedi GR, Al Masri M, Bin Saeed A, Gerber SI, Watson JT.Middle East respiratory syndrome coronavirus infection duringpregnancy: a report of 5 cases from Saudi Arabia. Clin Infect Dis2016;63:951e3.4. Alserehi H, Wali G, Alshukairi A, Alraddadi B. Impact of MiddleEast respiratory syndrome coronavirus (MERS-CoV) on pregnancyand perinatal outcome. BMC Infect Dis 2016;16:105. https://doi.org/10.1186/s12879-016-1437-y.5. Malik A, El Masry KM, Ravi M, Sayed F. Middle East respiratorysyndrome coronavirus during pregnancy, Abu Dhabi, United ArabEmirates, 2013. Emerg Infect Dis 2016;22. https://doi.org/10.3201/eid2203.151049.6. Payne DC, Iblan I, Alqasrawi S, Al Nsour M, Rha B, Tohme RA,et al. Stillbirth during infection with Middle East respiratorysyndrome coronavirus. J Infect Dis 2014;209:1870e2.7. Jeong S, Sung S, Sung J, Ahn S, Kang E, Chang Y, et al. MERS-CoVinfection in a pregnant woman in Korea. J Korean Med Sci 2017;32:1717e20.Sarah H. AlfarajUniversity of British Columbia, Vancouver, CanadaCorona Center, Infectious Diseases Division, Department ofPediatric, Prince Mohamed Bin Abdulaziz Hospital(“PMAH”), Ministry of Health, Riyadh, Saudi ArabiaE-mail address: alfarajsa@pmah.med.saJaffar A. Al-TawfiqIndiana University School of Medicine, Indianapolis, IN, USAJohns Hopkins Aramco Healthcare, Dhahran, Saudi ArabiaE-mail address: jaltawfi@yahoo.comZiad A. Memish*College of Medicine, Alfaisal University, Riyadh, SaudiArabiaInfectious Diseases Division, Department of Medicine,Prince Mohamed Bin Abdulaziz Hospital (“PMAH”), Ministryof Health, Riyadh, Saudi ArabiaHubert Department of Global Health, Rollins School ofPublic Health, Emory University, Atlanta, GA, USA*Corresponding author. P.O. Box 54146, Riyadh 11514, SaudiArabia.E-mail address: zmemish@yahoo.com (Z.A. Memish)25 February 2018Available online 2 June 2018

Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection during pregnancy: Report of two cases & review of the literature

IUPUIScholarWorks

Journal of Microbiology, Immunology and Infection (2019) 52, 501e503Available online at www.sciencedirect.comScienceDirectjournal homepage: www.e- jmii .comCorrespondenceMiddle East Respiratory SyndromeCoronavirus (MERS-CoV) infection duringpregnancy: Report of two cases & review ofthe literatureht16BYKEYWORDSMERS-CoV;Pregnancy;Saudi Arabiatps://doi.org/10.1016/j.jmii.2018.084-1182/Copyright ª 2018, Taiwan S-NC-ND license (http://creativecomDear Editor,As of February, 2018 a total of 2143 cases of Middle EastRespiratory Syndrome Coronavirus (MERS-CoV) have beenreported to the World Health Organization, including 750deaths in 27 countries.1 There were 10 reported cases ofMERS-CoV in pregnancy.2e7 Here, we present two casesform our hospital with MERS-CoV infections duringpregnancy.Case 1The first patient was a 29-year-old female (gravida 2, para1) at 6 weeks gestation and with no underlying medicalconditions. She was asymptomatic and identified as part ofthe contact tracing of her mother, a positive MERS-CoVpatient. On examination, she was afebrile, breathing nor-mally and Lungs were clear to auscultation. The abdomenwas gravid, soft, non-tender, non-distended, and normalbowel sounds. Nasopharyngeal swab testing by RT-PCR forMERS-CoV showed a positive result for ORF (Ct value 32).She had two repeated nasopharyngeal swab testing by RT-PCR for MERS-CoV and these showed probable results (Ctvalue 36) and the 4th swab was negative by PCR for MERS-CoV. The patient did not deliver during hospitalization and4.005ociety of Microbiology. Publishedmons.org/licenses/by-nc-nd/4.0/she was discharged on 24th August 2015, and subsequentlydelivered a healthy infant at term.Case 2The second patient was a 39-year-old female (gravida 6,para 5) with history of end stage renal disease (ESRD) andhypertension on hemodialysis. She used to have hemodial-ysis at Wadi Aldawasir hospital during an active MERS-CoVoutbreak there. She presented at 24 weeks of gestationafter a contact with a positive MERS-CoV patient. Naso-pharyngeal swab testing by RT-PCR was positive for MERS-CoV with E gene (Ct value 34) and OFR (Ct value 34). Shewas admitted to a regular ward. Subsequently, she hadnegative RT-PCR for MERS-CoV and she was dischargedhome.Respiratory samples (Nasopharyngeal swabs or trachealaspirates) were tested for MERS-CoV using real-timereverse-transcription polymerase chain reaction (RT-PCR)as described previously.The clinical presentation of MERS-CoV is variable andranges from a mild disease or asymptomatic presentation toa more severe and fatal cases. There are sparse data on theeffect and the likelihood of MERS-CoV during pregnancy.2e7We searched the MEDLINE database for articles published inEnglish literature from January 2012 to July 2016. Thereferences in the retrieved articles were further searchedfor any additional references. A summary of previous re-ports and the current two additional cases of pregnancyassociated MERS-CoV is presented in Table 1. Of all thecases, the mean age  SD was 33.7  4.3 years and thegestation age was 26.3  9 weeks, and there were four(36%) primi-gravida. The source of infection was not iden-tified in 3 cases; contact with family members who hadMERS-CoV was elucidated in two cases; four patients hadby Elsevier Taiwan LLC. This is an open access article under the CC).Table 1 A summary of pregnancy associated MERS-CoV infection.Age Nationality Gravida (G),Para (P)Source of infection Gestationalage at illnessonset (weeks)ICUadmissionMaternalcomorbidconditionsMaternaloutcomeFetaloutcomeDelivery details ReferencePatient 1(PMAH)29 Saudi G2, P1 Household contact 6 NO None Survived Survived Delivery at term CurrentreportPatient 2(PMAH)39 Saudi G6, P5 Contact withMERS-CoV case in HD24 NO ESRD onhemodialysis,HTNSurvived Survived Delivery at term CurrentreportPatient 3 34 Saudi G7, P6 Unknown 34 YES Preeclampsia Survived Died Intrauterine Fetaldeath at 34 weeks3Patient 4 32 Saudi G2, P1 Unknown 38 YES None Died Survived Vaginal delivery at38 weeks3Patient 5 31 Saudi Primigravida HCW, occupationalexposure24 YES Asthma,pulmonaryfibrosisDied Died Caesarean sectionat 24 weeks3Patient 6 27 Saudi Primigravida Unknown 22 YES None Survived Survived Full term delivery 3Patient 7 30 Saudi Primigravida HCW, occupationalexposure23 YES None Survived Survived Full term delivery 3Patient 8 39 Jordanian G7, P6 Household contact 20 NO None Survived Still birth Still birth at 5months6Patient 9 32 United ArabEmiratesG3, P2 Visited camel barn 32 YES None Died Survived Caesarean sectionat 32 weeks5Patient 10 39 South Korean G2, P1 Contact withMERS-CoV Patient inhospital35 weeks and 4 days NO GestationalDiabetesSurvived Survived Caesarean sectionat 39 weeks2,7Patient 11 33 Saudi Primigravida Contact withMERS-CoV Patient31 Yes Hypothyroidismand primaryinfertilitySurvived Survived Caesarean sectionat 32 weeks4502CorrespondenceCorrespondence 503health-care associated infection, two of them werehealthcare workers. Six (54%) patients required ICUadmission and three (27%) patients died during the hospitalstay. Two of the deceased had an exposure during the thirdtrimester and one acquired the infection during the secondtrimester. The infant death rate was 27%. The outcome wasfavorable in the majority of pregnancy-associated MERS-CoV cases. The exact prevalence of MERS-CoV antibodiesand exposure of pregnant women to MERS-CoV is notknown. All the reported cases were symptomatic. Amongthe 11 pregnancy-associated MERS-CoV infection, the casefatality rate was not statistically different when comparedto the overall case fatality rate of 35%, PZ 0.75. Regardingthe infants, three (27%) infants had died.The overall case fatality rate remains high and is com-parable to the overall case fatality rates. The disease hadalso resulted in fetal demise in 27% of cases.References1. WHO. Middle East respiratory syndrome coronavirus (MERS-CoV) e update. February 2018. http://www.who.int/csr/don/2018_12_02/en/.2. Park MH, Kim HR, Choi DH, Sung JH, Kim JH. Emergency cesar-ean section in an epidemic of the Middle East respiratory syn-drome: a case report. Korean J Anesthesiol 2016;69:287e91.https://doi.org/10.4097/kjae.2016.69.3.287.3. Assiri A, Abedi GR, Al Masri M, Bin Saeed A, Gerber SI, Watson JT.Middle East respiratory syndrome coronavirus infection duringpregnancy: a report of 5 cases from Saudi Arabia. Clin Infect Dis2016;63:951e3.4. Alserehi H, Wali G, Alshukairi A, Alraddadi B. Impact of MiddleEast respiratory syndrome coronavirus (MERS-CoV) on pregnancyand perinatal outcome. BMC Infect Dis 2016;16:105. https://doi.org/10.1186/s12879-016-1437-y.5. Malik A, El Masry KM, Ravi M, Sayed F. Middle East respiratorysyndrome coronavirus during pregnancy, Abu Dhabi, United ArabEmirates, 2013. Emerg Infect Dis 2016;22. https://doi.org/10.3201/eid2203.151049.6. Payne DC, Iblan I, Alqasrawi S, Al Nsour M, Rha B, Tohme RA,et al. Stillbirth during infection with Middle East respiratorysyndrome coronavirus. J Infect Dis 2014;209:1870e2.7. Jeong S, Sung S, Sung J, Ahn S, Kang E, Chang Y, et al. MERS-CoVinfection in a pregnant woman in Korea. J Korean Med Sci 2017;32:1717e20.Sarah H. AlfarajUniversity of British Columbia, Vancouver, CanadaCorona Center, Infectious Diseases Division, Department ofPediatric, Prince Mohamed Bin Abdulaziz Hospital(“PMAH”), Ministry of Health, Riyadh, Saudi ArabiaE-mail address: alfarajsa@pmah.med.saJaffar A. Al-TawfiqIndiana University School of Medicine, Indianapolis, IN, USAJohns Hopkins Aramco Healthcare, Dhahran, Saudi ArabiaE-mail address: jaltawfi@yahoo.comZiad A. Memish*College of Medicine, Alfaisal University, Riyadh, SaudiArabiaInfectious Diseases Division, Department of Medicine,Prince Mohamed Bin Abdulaziz Hospital (“PMAH”), Ministryof Health, Riyadh, Saudi ArabiaHubert Department of Global Health, Rollins School ofPublic Health, Emory University, Atlanta, GA, USA*Corresponding author. P.O. Box 54146, Riyadh 11514, SaudiArabia.E-mail address: zmemish@yahoo.com (Z.A. Memish)25 February 2018Available online 2 June 2018

Sarah H. Alfaraj

Jaffar A. Al-Tawfiq

Ziad A. Memish

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Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection during pregnancy: Report of two cases &amp; review of the literature

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Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection during pregnancy: Report of two cases & review of the literature

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