Numerous coronaviruses, first discovered in domestic poultry in the 1930s, cause respiratory, gastrointestinal, liver, and neurologic diseases in animals. Only 7 coronaviruses are known to cause disease in humans.
Four of the 7 coronaviruses most frequently cause symptoms of the common cold Common Cold The common cold is an acute, usually afebrile, self-limited viral infection causing upper respiratory symptoms, such as rhinorrhea, cough, and sore throat. Diagnosis is clinical. Handwashing... read more . Coronaviruses 229E, OC43, NL63, and HKU1 cause about 15 to 30% of cases of the common cold. Rarely, severe lower respiratory tract infections, including bronchiolitis and pneumonia, can occur, primarily in infants, older people, and the immunocompromised.
Three of the 7 coronaviruses cause much more severe, and sometimes fatal, respiratory infections in humans than other coronaviruses and have caused major outbreaks of deadly pneumonia in the 21st century:
SARS-CoV-2 COVID-19 COVID-19 is a respiratory illness caused by the novel coronavirus SARS-CoV-2. Infection may be asymptomatic or have symptoms ranging from mild upper respiratory symptoms to acute respiratory... read more is a novel coronavirus identified as the cause of coronavirus disease 2019 (COVID-19) that began in Wuhan, China in late 2019 and spread worldwide.
MERS-CoV Middle East Respiratory Syndrome (MERS) Coronaviruses are enveloped RNA viruses that cause respiratory illnesses of varying severity from the common cold to fatal pneumonia. Numerous coronaviruses, first discovered in domestic poultry... read more was identified in 2012 as the cause of Middle East respiratory syndrome (MERS).
SARS-CoV Severe Acute Respiratory Syndrome (SARS) Coronaviruses are enveloped RNA viruses that cause respiratory illnesses of varying severity from the common cold to fatal pneumonia. Numerous coronaviruses, first discovered in domestic poultry... read more was identified in 2003 as the cause of an outbreak of severe acute respiratory syndrome (SARS) that began in China near the end of 2002.
These coronaviruses that cause severe respiratory infections are zoonotic pathogens, which begin in infected animals and are transmitted from animals to people. SARS-CoV-2 has significant person-to-person transmission.
Middle East Respiratory Syndrome (MERS)
MERS-CoV infection was first reported in September 2012 in Saudi Arabia, but an outbreak in April 2012 in Jordan was confirmed retrospectively. Through 2021, worldwide, over 2500 cases of MERS-CoV infection (with at least 850 related deaths) have been reported from 27 countries; all cases of MERS have been linked through travel to or residence in countries in and near the Arabian Peninsula, with > 80% involving Saudi Arabia. The largest known outbreak of MERS outside the Arabian Peninsula occurred in the Republic of Korea in 2015. The outbreak was associated with a traveler returning from the Arabian Peninsula. Cases have also been confirmed in countries throughout Europe, Asia, North Africa, the Middle East, and the United States in patients who were either transferred there for care or became ill after returning from the Middle East. Only a handful of cases have been reported since 2019 (1 Reference Coronaviruses are enveloped RNA viruses that cause respiratory illnesses of varying severity from the common cold to fatal pneumonia. Numerous coronaviruses, first discovered in domestic poultry... read more ).
Preliminary seroprevalence studies indicate that the infection is not widespread in Saudi Arabia.
The World Health Organization considers the risk of contracting MERS-CoV infection to be very low for pilgrims traveling to Saudi Arabia for Umrah and Hajj.
Median age of patients with MERS-CoV is about 50 years, and patients are predominantly male. Infection tends to be more severe in older patients and in patients with a preexisting disorder such as diabetes, a chronic heart disorder, or a chronic renal disorder.
Transmission of MERS-CoV
MERS-CoV may be transmitted from person to person via direct contact, respiratory droplets (particles > 5 micrometers), or aerosols (particles < 5 micrometers). Person-to-person transmission has been established by the development of infection in people whose only risk was close contact with people who had MERS.
The reservoir of MERS-CoV is thought to be dromedary camels, but the mechanism of transmission from camels to humans is unknown. Most reported cases involved direct human-to-human transmission in health care settings. If MERS is suspected in a patient, infection control measures must be initiated promptly to prevent transmission in health care settings.
Symptoms and Signs of MERS
The incubation period for MERS-CoV is about 5 days.
Most reported cases have involved severe respiratory illness requiring hospitalization, with a case fatality rate of about 35%; however, about 21% of patients had mild or no symptoms (1 Symptoms and signs reference Coronaviruses are enveloped RNA viruses that cause respiratory illnesses of varying severity from the common cold to fatal pneumonia. Numerous coronaviruses, first discovered in domestic poultry... read more ). Fever, chills, myalgia, and cough are common. Gastrointestinal symptoms (eg, diarrhea, vomiting, abdominal pain) occur in about one third of patients. Manifestations may be severe enough to require treatment in an intensive care unit, but the proportion of such cases has declined sharply over time.
Symptoms and signs reference
Diagnosis of MERS
Real-time reverse transcriptase-polymerase chain reaction (RT-PCR) testing of upper and lower respiratory secretions and serum
MERS should be suspected in patients who have an unexplained acute febrile lower respiratory infection and who have had any of the following within 14 days of symptom onset:
Travel to or residence in an area where MERS has recently been reported or where transmission could have occurred
Contact with a health care facility where MERS has been transmitted
Close contact with a patient who was ill with suspected MERS
MERS should also be suspected in patients who have had close contact with a patient with suspected MERS and who have a fever whether they have respiratory symptoms or not.
The most recent recommendations are available from the Centers for Disease Control and Prevention (CDC) (MERS: Interim Guidance for Healthcare Professionals).
Testing should include real-time RT-PCR testing of upper and lower respiratory secretions, ideally taken from different sites and at different times. Serum should be obtained from patients and from all, even asymptomatic close contacts, including health care workers (to help identify mild or asymptomatic MERS). Serum is obtained immediately after MERS is suspected or after contacts are exposed (acute serum) and 3 to 4 weeks later (convalescent serum). Testing is done at state health departments or the CDC.
In all patients, chest imaging detects abnormalities, which may be subtle or extensive, unilateral or bilateral. In some patients, levels of LDH and AST are elevated and/or levels of platelets and lymphocytes are low. A few patients have acute kidney injury Acute Kidney Injury (AKI) Acute kidney injury is a rapid decrease in renal function over days to weeks, causing an accumulation of nitrogenous products in the blood (azotemia) with or without reduction in amount of urine... read more . Disseminated intravascular coagulation Disseminated Intravascular Coagulation (DIC) Disseminated intravascular coagulation (DIC) involves abnormal, excessive generation of thrombin and fibrin in the circulating blood. During the process, increased platelet aggregation and coagulation... read more and hemolysis may develop.
Treatment of MERS
Treatment of MERS is supportive. To help prevent spread from suspected cases, health care practitioners should use standard, contact, and airborne precautions.
There is no vaccine.
The following are English-language resources that may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Severe Acute Respiratory Syndrome (SARS)
SARS is much more severe than other coronavirus infections. SARS is an influenza-like illness that occasionally leads to progressively severe respiratory insufficiency.
SARS-CoV was first detected in the Guangdong province of China in November 2002 and subsequently spread to 28 additional countries. In this outbreak, > 8000 cases were reported worldwide, with 774 deaths (about a 10% case fatality rate, increased significantly with age, with a mortality rate > 50% in those > 65 years-old) (1, 2 SARS references Coronaviruses are enveloped RNA viruses that cause respiratory illnesses of varying severity from the common cold to fatal pneumonia. Numerous coronaviruses, first discovered in domestic poultry... read more ). The SARS-CoV outbreak was the first time that the Centers for Disease Control and Prevention (CDC) advised against travel to a region. This outbreak subsided, and no new cases have been identified since 2004. The immediate source was presumed to be civet cats, that were being sold for food in a live-animal market and had likely been infected through contact with a bat before they were captured for sale. Bats are frequent hosts of coronaviruses.
SARS-CoV is transmitted from person to person by close personal contact. It is thought to be transmitted most readily by respiratory droplets produced when an infected person coughs or sneezes.
Diagnosis of SARS is made clinically, and treatment is supportive. Coordination of prompt and rigid infection control practices helped control the 2002 outbreak rapidly.
Although no new cases have been reported since 2004, SARS should not be considered eliminated because the causative virus has an animal reservoir from which it conceivably could reemerge.
CDC Morbidity and Mortality Weekly Report: Revised U.S. Surveillance Case Definition for Severe Acute Respiratory Syndrome (SARS) and Update on SARS Cases --- United States and Worldwide, 52(49);1202-1206, 2003
Peiris JS, Yuen KY, Osterhaus AD, et al: The severe acute respiratory syndrome. N Engl J Med 349(25):2431-41, 2003. doi: 10.1056/NEJMra032498. PMID: 14681510