Middle East respiratory syndrome coronavirus infection laboratory findings: Difference between revisions

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==Overview==
==Overview==
[[MERS|Middle East Respiratory Syndrome]] ([[MERS]]) is a [[viral]] [[respiratory disease|respiratory illness]]. It is caused by an emerging [[coronavirus]], specifically a ''betacoronavirus'' called [[Middle east respiratory syndrome coronavirus|MERS-CoV]] ([[Middle east respiratory syndrome coronavirus|Middle East Respiratory Syndrome Coronavirus]]), first discovered in 2012. Being a relatively novel [[virus]], there is no [[virus]]-specific [[prevention]] or treatment options for [[MERS]] patients. Attending to the fact that a [[vaccine]] hasn't been developed yet, enhancing [[infection]] prevention and control measures is critical to prevent the possible spread of [[MERS-CoV]] in hospitals and communities. Persons with [[symptoms]] suspicious of [[MERS-CoV]] [[infection]] need medical evaluation. According to the [[CDC]], a certified case of [[MERS-CoV]] [[infection]] is considered an individual who shows [[laboratory test|laboratory]] confirmation of [[infection]] by [[MERS-CoV]]. This last one is given by a positive [[PCR]] test on ≥2 specific genomic targets or, a single positive target followed by successful sequencing of a second.
Laboratory findings of MERS-CoV may include [[leukopenia]], [[lymphopenia]], [[thrombocytopenia]], elevated inflammatory markers, and elevated [[lactate dehydrogenase]] ([[LDH]]) levels.<ref name=CDC>{{cite web | title = MERS Clinical Features| url = http://www.cdc.gov/coronavirus/mers/clinical-features.html }}</ref> Lab findings are not diagnostic of MERS-CoV but are useful to monitor for the development of MERS-CoV infection.


Lab tests, such as [[PCR]] for MERS-CoV are available at state health departments, [[CDC]] and some international labs. Otherwise, [[MERS-CoV]] tests are not routinely available. There are also a limited number of commercial tests available, however, these are not [[FDA]]-approved.<ref name="pmid24841273">{{cite journal| author=Dyall J, Coleman CM, Hart BJ, Venkataraman T, Holbrook MR, Kindrachuk J et al.| title=Repurposing of clinically developed drugs for treatment of Middle East Respiratory Coronavirus Infection. | journal=Antimicrob Agents Chemother | year= 2014 | volume= | issue= | pages= | pmid=24841273 | doi=10.1128/AAC.03036-14 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24841273 }} </ref><ref name=WHO>{{cite web | title = Clinical management of severe acute respiratory infections when novel coronavirus is suspected: What to do and what not to do | url = http://www.who.int/csr/disease/coronavirus_infections/InterimGuidance_ClinicalManagement_NovelCoronavirus_11Feb13u.pdf }}</ref><ref name=CDC>{{cite web | title = MERS Prevention and Treatment | url = http://www.cdc.gov/coronavirus/MERS/about/prevention.html }}</ref>
==Laboratory Findings==
*Laboratory confirmation of [[MERS-CoV]] infection requires a positive [[PCR]] test of ≥2 specific genomic targets or, a single positive target followed by successful sequencing of a second.
*Blood testing among hospitalized patients is useful. Lab findings may include non-specific findings of viral infections. In addition, lab findings may be useful to monitor for the development of MERS-CoV infection. Laboratory abnormalities may include:<ref name="AjlanAhyad2014">{{cite journal|last1=Ajlan|first1=Amr M.|last2=Ahyad|first2=Rayan A.|last3=Jamjoom|first3=Lamia Ghazi|last4=Alharthy|first4=Ahmed|last5=Madani|first5=Tariq A.|title=Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Infection: Chest CT Findings|journal=American Journal of Roentgenology|year=2014|pages=1–6|issn=0361-803X|doi=10.2214/AJR.14.13021}}</ref><ref name="pmid23891402">{{cite journal| author=Assiri A, Al-Tawfiq JA, Al-Rabeeah AA, Al-Rabiah FA, Al-Hajjar S, Al-Barrak A et al.| title=Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: a descriptive study. | journal=Lancet Infect Dis | year= 2013 | volume= 13 | issue= 9 | pages= 752-61 | pmid=23891402 | doi=10.1016/S1473-3099(13)70204-4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23891402 }} </ref><ref name="MemishZumla2013">{{cite journal|last1=Memish|first1=Ziad A.|last2=Zumla|first2=Alimuddin I.|last3=Al-Hakeem|first3=Rafat F.|last4=Al-Rabeeah|first4=Abdullah A.|last5=Stephens|first5=Gwen M.|title=Family Cluster of Middle East Respiratory Syndrome Coronavirus Infections|journal=New England Journal of Medicine|volume=368|issue=26|year=2013|pages=2487–2494|issn=0028-4793|doi=10.1056/NEJMoa1303729}}</ref><ref name="AssiriMcGeer2013">{{cite journal|last1=Assiri|first1=Abdullah|last2=McGeer|first2=Allison|last3=Perl|first3=Trish M.|last4=Price|first4=Connie S.|last5=Al Rabeeah|first5=Abdullah A.|last6=Cummings|first6=Derek A.T.|last7=Alabdullatif|first7=Zaki N.|last8=Assad|first8=Maher|last9=Almulhim|first9=Abdulmohsen|last10=Makhdoom|first10=Hatem|last11=Madani|first11=Hossam|last12=Alhakeem|first12=Rafat|last13=Al-Tawfiq|first13=Jaffar A.|last14=Cotten|first14=Matthew|last15=Watson|first15=Simon J.|last16=Kellam|first16=Paul|last17=Zumla|first17=Alimuddin I.|last18=Memish|first18=Ziad A.|title=Hospital Outbreak of Middle East Respiratory Syndrome Coronavirus|journal=New England Journal of Medicine|volume=369|issue=5|year=2013|pages=407–416|issn=0028-4793|doi=10.1056/NEJMoa1306742}}</ref><ref name="Abdel-Moneim2014">{{cite journal|last1=Abdel-Moneim|first1=Ahmed S.|title=Middle East respiratory syndrome coronavirus (MERS-CoV): evidence and speculations|journal=Archives of Virology|year=2014|issn=0304-8608|doi=10.1007/s00705-014-1995-5}}</ref>
*[[Lymphopenia]]
*[[Thrombocytopenia]]
*[[Leukopenia]]
*Elevated [[CRP]] and [[ESR]] concentrations
*Elevated [[serum]] [[LDH]] concentration
*Elevated [[AST]] and [[ALT]] concentration
*Elevated [[serum creatinine]] concentration


==Laboratory Tests==
==Specimen Collection==
* CDC has changed its guidance to indicate that testing for MERS-CoV and other respiratory pathogens can be conducted simultaneously and that positive results for another respiratory pathogen should not necessarily preclude testing for MERS-CoV. Health-care providers in the United States should continue to evaluate patients for MERS-CoV infection if they develop fever and pneumonia or acute respiratory distress syndrome (ARDS) within 14 days after traveling from countries in or near the Arabian Peninsula. Providers also should evaluate patients for MERS-CoV infection if they have ARDS or fever and pneumonia, and have had close contact§ with a recent traveler from this area who has fever and acute respiratory illness.
*The [[CDC]] recommends that priority for collection and real-time [[RT-PCR]] testing should be given to [[lower respiratory tract]] [[Laboratory specimen|specimens]]. [[Lower respiratory]] [[Laboratory specimen|specimen]] testing appears to be more [[sensitivity|sensitive]] in the detection of [[MERS-CoV]], when compared to [[Laboratory specimen|specimens]] from the [[upper respiratory tract]].<ref name=WHO>{{cite web | title =
Interim surveillance recommendations for human infection with Middle East respiratory syndrome coronavirus | url = http://www.who.int/csr/disease/coronavirus_infections/InterimRevisedSurveillanceRecommendations_nCoVinfection_27Jun13.pdf }}</ref><ref name=CDC3>{{cite web | title =
Laboratory Testing for Middle East Respiratory Syndrome Coronavirus | url = http://www.who.int/csr/disease/coronavirus_infections/MERS_Lab_recos_16_Sept_2013.pdf }}</ref><ref name="pmid23760190">{{cite journal| author=Centers for Disease Control and Prevention (CDC)| title=Update: Severe respiratory illness associated with Middle East Respiratory Syndrome Coronavirus (MERS-CoV)--worldwide, 2012-2013. | journal=MMWR Morb Mortal Wkly Rep | year= 2013 | volume= 62 | issue= 23 | pages= 480-3 | pmid=23760190 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23760190  }} </ref><ref name=CDC4>{{cite web | title =
Interim Guidelines for Collection, Processing and Transport of Clinical Specimens from Patients Under Investigation for Middle East Respiratory Syndrome (MERS) | url = http://www.cdc.gov/coronavirus/mers/downloads/Interim-Guidelines-MERS-Collection-Processing-Transport.pdf }}</ref><ref name="pmid24837403">{{cite journal| author=Memish ZA, Al-Tawfiq JA, Makhdoom HQ, Assiri A, Alhakeem RF, Albarrak A et al.| title=Respiratory Tract Samples, Viral Load and Genome Fraction Yield in patients with Middle East Respiratory Syndrome. | journal=J Infect Dis | year= 2014 | volume=  | issue=  | pages=  | pmid=24837403 | doi=10.1093/infdis/jiu292 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24837403  }} </ref>
*It is recommended the collection of '''''multiple''''' [[Laboratory specimen|specimens]] from '''''different locations''''' and in '''''different times''''', in order to increase the probability of collecting and detecting the [[pathogen]], by virtue of the potential impact of the [[infection]] by [[MERS-CoV]], the risk of [[transmission]] and how little is known about the [[sensitivity]] of the [[diagnostic test]]s for this [[virus]].<ref name=CDC3>{{cite web | title = Laboratory Testing for Middle East Respiratory Syndrome Coronavirus | url = http://www.who.int/csr/disease/coronavirus_infections/MERS_Lab_recos_16_Sept_2013.pdf }}</ref><ref name=CDC6.>{{cite web | title = Morbidity and Mortality Weekly Report (MMWR) | url = http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6319a4.htm?s_cid=mm6319a4_w }}</ref>
*It is recommended that, in all cases of severe disease, priority is given to [[respiratory]] samples, particularly [[lower respiratory tract]] [[Laboratory specimen|specimens]]
**In the case of mild disease, [[upper respiratory tract|upper tract]] [[Laboratory specimen|specimen]] should be collected
**In the case of [[lower respiratory tract|lower tract]] [[Laboratory specimen|specimens]] cannot be obtained.
*[[Serum]] samples should be collected for [[serologic]] testing, as well as a stool sample or a rectal swab. However, contrariwise to [[SARS-CoV]], stool samples have a very low [[concentration]] of [[MERS-CoV]].<ref name=CDC7>{{cite web | title = Morbidity and Mortality Weekly Report (MMWR) | url = http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6319a4.htm?s_cid=mm6319a4_w }}</ref>
*In the presence of a negative test result in an highly suspicious patient, for [[infection]] by [[MERS-CoV]], further samples should be collected for testing. A [[false-negative]] result is commonly due to any of the following:<ref name=CDC3>{{cite web | title = Laboratory Testing for Middle East Respiratory Syndrome Coronavirus | url = http://www.who.int/csr/disease/coronavirus_infections/MERS_Lab_recos_16_Sept_2013.pdf }}</ref>
**Poor [[Laboratory specimen|specimen]] quality
**Wrong timing of collection
**Mishandled/shipped sample
**Technical problem during testing


* CDC continues to recommend that clusters of patients with severe acute respiratory illness (e.g., fever and pneumonia requiring hospitalization) be evaluated for common respiratory pathogens and reported to local and state public health departments. If the illnesses remain unexplained, particularly if the cluster includes health-care providers, testing for MERS-CoV should be considered, in consultation with state and local health departments. In this situation, testing should be considered even for patients without travel-related exposure.
===Collection of Respiratory Specimens===
 
====Lower respiratory tract broncheoalveolar lavage, tracheal aspirate and pleural fluid====
* Confirmatory laboratory testing now requires a positive [[polymerase chain reaction]] (PCR) of at least two, instead of one, specific genomic targets or a single positive target with sequencing of a second.
Collect 2-3 mL into a [[sterile]], leak-proof, screw-cap [[sputum]] collection cup or [[sterile]] dry container. Refrigerate [[Laboratory specimen|specimen]] at 2-8°C up to 72 hours; if exceeding 72 hours, freeze at -70°C and ship on dry ice.<ref name=CDC2>{{cite web | title = Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Patients Under Investigation (PUIs) for Middle East Respiratory Syndrome Coronavirus (MERS-CoV) – Version 2
 
| url = http://www.cdc.gov/coronavirus/mers/guidelines-clinical-specimens.html }}</ref>
* Lab tests (PCR) for MERS-CoV are available at state health departments, CDC, and some international labs. Otherwise, MERS-CoV tests are not routinely available. There are a limited number of commercial tests available, but these are not FDA-approved.
 
===Confirmed Case===
A confirmed case is a person with laboratory confirmation of MERS-CoV infection.
 
===Probable Case===
A probable case is a PUI with absent or inconclusive laboratory results for MERS-CoV infection who is a close contact of a laboratory-confirmed MERS-CoV case.
 
==Collecting, Handling, and Testing Clinical Specimens==
===Respiratory Specimens===
 
====Lower respiratory tract Broncheoalveolar lavage, tracheal aspirate, pleural fluid====
 
Collect 2-3 mL into a sterile, leak-proof, screw-cap sputum collection cup or sterile dry container. Refrigerate specimen at 2-8°C up to 72 hours; if exceeding 72 hours, freeze at -70°C and ship on dry ice.


====Sputum====
====Sputum====
 
Have the patient rinse the [[mouth]] with [[water]] and then [[expectorate]] deep [[cough]] [[sputum]] directly into a [[sterile]], leak-proof, screw-cap [[sputum]] collection cup or [[sterile]] dry container. Refrigerate specimen at 2-8°C up to 72 hours; if exceeding 72 hours, freeze at -70°C and ship on dry ice.<ref name=CDC2>{{cite web | title = Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Patients Under Investigation (PUIs) for Middle East Respiratory Syndrome Coronavirus (MERS-CoV) – Version 2
Have the patient rinse the mouth with water and then expectorate deep cough sputum directly into a sterile, leak-proof, screw-cap sputum collection cup or sterile dry container. Refrigerate specimen at 2-8°C up to 72 hours; if exceeding 72 hours, freeze at -70°C and ship on dry ice.
| url = http://www.cdc.gov/coronavirus/mers/guidelines-clinical-specimens.html }}</ref>


===Upper respiratory tract===
===Upper respiratory tract===
 
====Nasopharyngeal and oropharyngeal swabs (NP/OP swabs)====
====Nasopharyngeal AND oropharyngeal swabs (NP/OP swabs)====
Use only synthetic fiber swabs with plastic shafts. Do not use [[calcium]] alginate swabs or swabs with wooden shafts, as they may contain substances that inactivate some [[viruses]] and inhibit [[PCR|PCR testing]]. Place swabs immediately into [[sterile]] tubes containing 2-3 ml of [[viral]] transport media. NP/OP [[Laboratory specimen|specimens]] can be combined, placing both swabs in the same vial. Refrigerate [[Laboratory specimen|specimen]] at 2-8°C up to 72 hours; if exceeding 72 hours, freeze at -70°C and ship on dry ice.<ref name=CDC2>{{cite web | title = Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Patients Under Investigation (PUIs) for Middle East Respiratory Syndrome Coronavirus (MERS-CoV) – Version 2
 
| url = http://www.cdc.gov/coronavirus/mers/guidelines-clinical-specimens.html }}</ref>
Use only synthetic fiber swabs with plastic shafts. Do not use calcium alginate swabs or swabs with wooden shafts, as they may contain substances that inactivate some viruses and inhibit PCR testing. Place swabs immediately into sterile tubes containing 2-3 ml of viral transport media. NP/OP specimens can be combined, placing both swabs in the same vial. Refrigerate specimen at 2-8°C up to 72 hours; if exceeding 72 hours, freeze at -70°C and ship on dry ice.


====Nasopharyngeal swabs====
====Nasopharyngeal swabs====
Insert a swab into the nostril parallel to the palate. Leave the swab in place for a few seconds to absorb secretions. Swab both nasopharyngeal areas.
Insert a swab into the [[nostril]] parallel to the [[palate]]. Leave the swab in place for a few seconds to absorb secretions. Swab both [[nasopharyngeal]] areas.<ref name=CDC2>{{cite web | title = Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Patients Under Investigation (PUIs) for Middle East Respiratory Syndrome Coronavirus (MERS-CoV) – Version 2
| url = http://www.cdc.gov/coronavirus/mers/guidelines-clinical-specimens.html }}</ref>
====Oropharyngeal swabs====
====Oropharyngeal swabs====
Swab the posterior pharynx, avoiding the tongue.
Swab the [[pharynx|posterior pharynx]], avoiding the [[tongue]].<ref name=CDC2>{{cite web | title = Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Patients Under Investigation (PUIs) for Middle East Respiratory Syndrome Coronavirus (MERS-CoV) – Version 2
| url = http://www.cdc.gov/coronavirus/mers/guidelines-clinical-specimens.html }}</ref>


====Nasopharyngeal wash/aspirate or nasal aspirates====
====Nasopharyngeal wash/aspirate or nasal aspirates====
 
Collect 2-3 mL into a [[sterile]], leak-proof, screw-cap [[sputum]] collection cup or [[sterile]] dry container. Refrigerate [[Laboratory specimen|specimen]] at 2-8°C up to 72 hours; if exceeding 72 hours, freeze at -70°C and ship on dry ice.<ref name=CDC2>{{cite web | title = Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Patients Under Investigation (PUIs) for Middle East Respiratory Syndrome Coronavirus (MERS-CoV) – Version 2
Collect 2-3 mL into a sterile, leak-proof, screw-cap sputum collection cup or sterile dry container. Refrigerate specimen at 2-8°C up to 72 hours; if exceeding 72 hours, freeze at -70°C and ship on dry ice.
| url = http://www.cdc.gov/coronavirus/mers/guidelines-clinical-specimens.html }}</ref>


===Blood Components===
===Blood Components===
====Serum (for serologic testing)====
====Serum (for serologic testing)====
For [[serum]] [[antibody]] testing: [[serum]] [[Laboratory specimen|specimens]] should be collected during the acute stage of the [[disease]], preferably during the first week after onset of illness, and again during [[convalescence]], ≥3 weeks after the acute sample was collected. However, since we do not want to delay detection at this time, a single [[serum]] sample collected 14 or more days after [[symptom]] onset may be beneficial. [[Serologic]] testing is currently available at [[CDC]] upon request and approval. Please be aware that the [[MERS-CoV]] [[serologic]] test is for [[research]]/surveillance purposes and not for [[diagnostic]] purposes - it is a tool developed in response to the [[MERS-CoV]] outbreak. Contact [[CDC]]’s Emergency Operations Center (EOC) (770-488-7100) for consultation and approval if [[serologic]] testing is being considered.<ref name=CDC2>{{cite web | title = Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Patients Under Investigation (PUIs) for Middle East Respiratory Syndrome Coronavirus (MERS-CoV) – Version 2
| url = http://www.cdc.gov/coronavirus/mers/guidelines-clinical-specimens.html }}</ref>


For serum antibody testing:  Serum specimens should be collected during the acute stage of the disease, preferably during the first week after onset of illness, and again during convalescence, ≥ 3 weeks after the acute sample was collected.  However, since we do not want to delay detection at this time, a single serum sample collected 14 or more days after symptom onset may be beneficial.  Serologic testing is currently available at CDC upon request and approval.  Please be aware that the MERS-CoV serologic test is for research/surveillance purposes and not for diagnostic purposes - it is a tool developed in response to the MERS-CoV outbreak.  Contact CDC’s Emergency Operations Center (EOC) (770-488-7100) for consultation and approval if serologic testing is being considered.
====EDTA blood (plasma)====
 
Collect 1 tube (10 mL) of [[heparin|heparinized]] (green-top) or [[EDTA]] (purple-top) [[blood]]. Refrigerate [[Laboratory specimen|specimen]] at 2-8°C and ship on ice-pack; do not freeze.<ref name=CDC2>{{cite web | title = Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Patients Under Investigation (PUIs) for Middle East Respiratory Syndrome Coronavirus (MERS-CoV) – Version 2
===Serum (for rRT-PCR testing)===
| url = http://www.cdc.gov/coronavirus/mers/guidelines-clinical-specimens.html }}</ref>
 
* For rRT-PCR testing (i.e., detection of the virus and not antibodies), a single serum specimen collected optimally during the first week after symptom onset, preferably within 3-4 days, after symptom onset, may be also be beneficial.
 
* Children and adults: Collect 1 tube (5-10 mL) of whole blood in a serum separator tube.  Allow the blood to clot, centrifuge briefly, and separate sera into sterile tube container. The minimum amount of serum required for testing is 200 µL. Refrigerate the specimen at 2-8°C and ship on ice- pack; freezing and shipment on dry ice is permissible.
 
* Infants: A minimum of 1 mL of whole blood is needed for testing of pediatric patients. If possible, collect 1 mL in an EDTA tube and in a serum separator tube. If only 1 mL can be obtained, use a serum separator tube.
 
===EDTA blood (plasma)===
 
Collect 1 tube (10 mL) of heparinized (green-top) or EDTA (purple-top) blood. Refrigerate specimen at 2-8°C and ship on ice-pack; do not freeze.


===Stool===
===Stool===
Collect 2-5 grams of stool specimen (formed or liquid) in sterile, leak-proof, screw-cap sputum collection cup or sterile dry container. Refrigerate specimen at 2-8°C up to 72 hours; if exceeding 72 hours, freeze at -70°C and ship on dry ice.
Collect 2-5 grams of [[stool]] [[Laboratory specimen|specimen]] (formed or liquid) in [[sterile]], leak-proof, screw-cap [[sputum]] collection cup or [[sterile]] dry container. Refrigerate [[Laboratory specimen|specimen]] at 2-8°C up to 72 hours; if exceeding 72 hours, freeze at -70°C and ship on dry ice.<ref name=CDC2>{{cite web | title = Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Patients Under Investigation (PUIs) for Middle East Respiratory Syndrome Coronavirus (MERS-CoV) – Version 2
| url = http://www.cdc.gov/coronavirus/mers/guidelines-clinical-specimens.html }}</ref>


==References==
==References==
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]

Overview

Laboratory findings of MERS-CoV may include leukopenia, lymphopenia, thrombocytopenia, elevated inflammatory markers, and elevated lactate dehydrogenase (LDH) levels.[1] Lab findings are not diagnostic of MERS-CoV but are useful to monitor for the development of MERS-CoV infection.

Laboratory Findings

  • Laboratory confirmation of MERS-CoV infection requires a positive PCR test of ≥2 specific genomic targets or, a single positive target followed by successful sequencing of a second.
  • Blood testing among hospitalized patients is useful. Lab findings may include non-specific findings of viral infections. In addition, lab findings may be useful to monitor for the development of MERS-CoV infection. Laboratory abnormalities may include:[2][3][4][5][6]
  • Lymphopenia
  • Thrombocytopenia
  • Leukopenia
  • Elevated CRP and ESR concentrations
  • Elevated serum LDH concentration
  • Elevated AST and ALT concentration
  • Elevated serum creatinine concentration

Specimen Collection

Collection of Respiratory Specimens

Lower respiratory tract broncheoalveolar lavage, tracheal aspirate and pleural fluid

Collect 2-3 mL into a sterile, leak-proof, screw-cap sputum collection cup or sterile dry container. Refrigerate specimen at 2-8°C up to 72 hours; if exceeding 72 hours, freeze at -70°C and ship on dry ice.[14]

Sputum

Have the patient rinse the mouth with water and then expectorate deep cough sputum directly into a sterile, leak-proof, screw-cap sputum collection cup or sterile dry container. Refrigerate specimen at 2-8°C up to 72 hours; if exceeding 72 hours, freeze at -70°C and ship on dry ice.[14]

Upper respiratory tract

Nasopharyngeal and oropharyngeal swabs (NP/OP swabs)

Use only synthetic fiber swabs with plastic shafts. Do not use calcium alginate swabs or swabs with wooden shafts, as they may contain substances that inactivate some viruses and inhibit PCR testing. Place swabs immediately into sterile tubes containing 2-3 ml of viral transport media. NP/OP specimens can be combined, placing both swabs in the same vial. Refrigerate specimen at 2-8°C up to 72 hours; if exceeding 72 hours, freeze at -70°C and ship on dry ice.[14]

Nasopharyngeal swabs

Insert a swab into the nostril parallel to the palate. Leave the swab in place for a few seconds to absorb secretions. Swab both nasopharyngeal areas.[14]

Oropharyngeal swabs

Swab the posterior pharynx, avoiding the tongue.[14]

Nasopharyngeal wash/aspirate or nasal aspirates

Collect 2-3 mL into a sterile, leak-proof, screw-cap sputum collection cup or sterile dry container. Refrigerate specimen at 2-8°C up to 72 hours; if exceeding 72 hours, freeze at -70°C and ship on dry ice.[14]

Blood Components

Serum (for serologic testing)

For serum antibody testing: serum specimens should be collected during the acute stage of the disease, preferably during the first week after onset of illness, and again during convalescence, ≥3 weeks after the acute sample was collected. However, since we do not want to delay detection at this time, a single serum sample collected 14 or more days after symptom onset may be beneficial. Serologic testing is currently available at CDC upon request and approval. Please be aware that the MERS-CoV serologic test is for research/surveillance purposes and not for diagnostic purposes - it is a tool developed in response to the MERS-CoV outbreak. Contact CDC’s Emergency Operations Center (EOC) (770-488-7100) for consultation and approval if serologic testing is being considered.[14]

EDTA blood (plasma)

Collect 1 tube (10 mL) of heparinized (green-top) or EDTA (purple-top) blood. Refrigerate specimen at 2-8°C and ship on ice-pack; do not freeze.[14]

Stool

Collect 2-5 grams of stool specimen (formed or liquid) in sterile, leak-proof, screw-cap sputum collection cup or sterile dry container. Refrigerate specimen at 2-8°C up to 72 hours; if exceeding 72 hours, freeze at -70°C and ship on dry ice.[14]

References

  1. ↑ "MERS Clinical Features".
  2. ↑ Ajlan, Amr M.; Ahyad, Rayan A.; Jamjoom, Lamia Ghazi; Alharthy, Ahmed; Madani, Tariq A. (2014). "Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Infection: Chest CT Findings". American Journal of Roentgenology: 1–6. doi:10.2214/AJR.14.13021. ISSN 0361-803X.
  3. ↑ Assiri A, Al-Tawfiq JA, Al-Rabeeah AA, Al-Rabiah FA, Al-Hajjar S, Al-Barrak A; et al. (2013). "Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: a descriptive study". Lancet Infect Dis. 13 (9): 752–61. doi:10.1016/S1473-3099(13)70204-4. PMID 23891402.
  4. ↑ Memish, Ziad A.; Zumla, Alimuddin I.; Al-Hakeem, Rafat F.; Al-Rabeeah, Abdullah A.; Stephens, Gwen M. (2013). "Family Cluster of Middle East Respiratory Syndrome Coronavirus Infections". New England Journal of Medicine. 368 (26): 2487–2494. doi:10.1056/NEJMoa1303729. ISSN 0028-4793.
  5. ↑ Assiri, Abdullah; McGeer, Allison; Perl, Trish M.; Price, Connie S.; Al Rabeeah, Abdullah A.; Cummings, Derek A.T.; Alabdullatif, Zaki N.; Assad, Maher; Almulhim, Abdulmohsen; Makhdoom, Hatem; Madani, Hossam; Alhakeem, Rafat; Al-Tawfiq, Jaffar A.; Cotten, Matthew; Watson, Simon J.; Kellam, Paul; Zumla, Alimuddin I.; Memish, Ziad A. (2013). "Hospital Outbreak of Middle East Respiratory Syndrome Coronavirus". New England Journal of Medicine. 369 (5): 407–416. doi:10.1056/NEJMoa1306742. ISSN 0028-4793.
  6. ↑ Abdel-Moneim, Ahmed S. (2014). "Middle East respiratory syndrome coronavirus (MERS-CoV): evidence and speculations". Archives of Virology. doi:10.1007/s00705-014-1995-5. ISSN 0304-8608.
  7. ↑ "Interim surveillance recommendations for human infection with Middle East respiratory syndrome coronavirus" (PDF).
  8. ↑ 8.0 8.1 8.2 "Laboratory Testing for Middle East Respiratory Syndrome Coronavirus" (PDF).
  9. ↑ Centers for Disease Control and Prevention (CDC) (2013). "Update: Severe respiratory illness associated with Middle East Respiratory Syndrome Coronavirus (MERS-CoV)--worldwide, 2012-2013". MMWR Morb Mortal Wkly Rep. 62 (23): 480–3. PMID 23760190.
  10. ↑ "Interim Guidelines for Collection, Processing and Transport of Clinical Specimens from Patients Under Investigation for Middle East Respiratory Syndrome (MERS)" (PDF).
  11. ↑ Memish ZA, Al-Tawfiq JA, Makhdoom HQ, Assiri A, Alhakeem RF, Albarrak A; et al. (2014). "Respiratory Tract Samples, Viral Load and Genome Fraction Yield in patients with Middle East Respiratory Syndrome". J Infect Dis. doi:10.1093/infdis/jiu292. PMID 24837403.
  12. ↑ "Morbidity and Mortality Weekly Report (MMWR)".
  13. ↑ "Morbidity and Mortality Weekly Report (MMWR)".
  14. ↑ 14.0 14.1 14.2 14.3 14.4 14.5 14.6 14.7 14.8 "Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Patients Under Investigation (PUIs) for Middle East Respiratory Syndrome Coronavirus (MERS-CoV) – Version 2".

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