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Systemic corticosteroid therapy may delay viral clearance in patients with Middle East Respiratory Syndrome Coronavirus infection David S Hui MD Dept of Medicine IQR 5 to 8 days 12 The interesting study by Arabi et al5 has been the first publication to shed some light that systemic corticosteroid might delay viral clearance in patients with MERS CoV infection From the infection control and prevention point of view it would be of great interest to see in future studies if systemic corticosteroid therapy would increase the infectivity of patients hospitalized with MERS CoV infection through prolongation of viral shedding In addition Arabi et al5 did not examine other outcome measures such as opportunistic infections neuro myopathy and hyperglycemia but these are important complications to watch out for with corticosteroid therapy in future studies Currently the main treatment of MER CoV infection remains supportive therapy 1 13 Based on Page 4 of 8 AJRCCM Articles in Press Published on 11 December 2017 as 10 1164 rccm 201712 2371ED Copyright 2017 by the American Thoracic Society data from the marmoset model interferon and lopinavir appear to have good inhibitory effects against MERS CoV 14 Monoclonal and polyclonal antibodies which inhibit the spike protein of MERS CoV are potentially useful treatment modalities that are undergoing clinical trials in the Middle East 13 Retrieval of convalescent plasma from patients who have recovered from MERS CoV infection as passive immunotherapy is difficult as the antibody responses in survivors who had severe disease lasted for less than 1 year whereas those with milder disease could not maintain antibody response soon after recovery from the acute illness 15 The results of the current observational study 5 together with data from treatment of SARS CoV infection 6 seasonal and avian influenza 7 12 suggest that the risk of systemic corticosteroid would likely exceed any benefit for treatment of MERS CoV infection 13 More clinical studies preferably with a RCT design with a standardized treatment and serial viral sampling protocol are needed to evaluate more scientifically the role of interferon lopinavir passive immunotherapy such as monoclonal polyclonal antibodies and systemic corticosteroid in the clinical management of MERS CoV infection Page 5 of 8 AJRCCM Articles in Press Published on 11 December 2017 as 10 1164 rccm 201712 2371ED Copyright 2017 by the American Thoracic Society References 1 Zumla A Hui DS Perlman S Middle East respiratory syndrome Lancet 2015 386 995 1007 2 Zhou J Chu H Li C Wong BH Cheng ZS Poon VK Sun T Lau CC Wong KK Chan JY et al Active replication of Middle East respiratory syndrome coronavirus and aberrant induction of inflammatory cytokines and chemokines in human macrophages implications for pathogenesis J Infect Dis 2014 209 1331 1342 3 Alsaad KO Hajeer AH Al Balwi M Al Moaiqel M Al Oudah N Al Ajlan A AlJohani S Alsolamy S Gmati GE Balkhy H et al Histopathology of Middle East respiratory syndrome coronovirus MERS CoV infection clinicopathological and ultrastructural study Histopathology 2017 Aug 31 doi 10 1111 his 13379 Epub ahead of print 4 Arabi YM Al Omari A Mandourah Y Al Hameed F Sindi AA Alraddadi B Shalhoub S Almotairi A Al Khatib K Abdulmomen A et al Critically Ill Patients With the Middle East Respiratory Syndrome A Multicenter Retrospective Cohort Study Crit Care Med 2017 45 1683 1695 5 Arabi YM Mandourah Y Al Hameed F Sindi AA Al Mekhlafi GA Hussein MA Jose J Pinto R Al Omari A Kharaba A et al Saudi Critical Care Trial group Corticosteroid Therapy for Critically Ill Patients with the Middle East Respiratory Syndrome Am J Respir Crit Care Med online ahead of print 21 Nov 2017 www atsjournals org doi abs 10 1164 rccm 201706 1172OC 6 Lee N Allen Chan KC Hui DS Ng EK Wu A Chiu RW Wong VW Chan PK Wong KT Wong E et al Effects of early corticosteroid treatment on plasma SARS associated Page 6 of 8 AJRCCM Articles in Press Published on 11 December 2017 as 10 1164 rccm 201712 2371ED Copyright 2017 by the American Thoracic Society Coronavirus RNA concentrations in adult patients J Clin Virol 2004 31 304 309 7 Rodrigo C Leonardi Bee J Nguyen Van Tam J Lim WS Corticosteroids as adjunctive therapy in the treatment of influenza Cochrane Database Syst Rev 2016 3 CD010406 8 Cao B Gao H Zhou B Deng X Hu C Deng C Lu H Li Y Gan J Liu J et al Adjuvant Corticosteroid Treatment in Adults With Influenza A H7N9 Viral Pneumonia Crit Care Med 2016 44 e318 328 9 Li H Yang SG Gu L Zhang Y Yan XX Liang ZA Zhang W Jia HY Chen W Liu M et al National Influenza A H1N1 pdm09 Clinical Investigation Group of China Effect of low to moderate dose corticosteroids on mortality of hospitalized adolescents and adults with influenza A H1N1 pdm09 viral pneumonia Influenza Other Respir Viruses 2017 11 345 354 10 Lee N Leo YS Cao B Chan PK Kyaw WM Uyeki TM Tam WW Cheung CS Yung IM Li H et al Neuraminidase inhibitors superinfection and corticosteroids affect survival of influenza patients Eur Respir J 2015 45 1642 1652 11 Oh MD Park WB Choe PG Choi SJ Kim JI Chae J Park SS Kim EC Oh HS Kim EJ et al Viral Load Kinetics of MERS Coronavirus Infection N Engl J Med 2016 375 1303 1305 12 Kang CK Song KH Choe PG Park WB Bang JH Kim ES Park SW Kim HB Kim NJ Cho SI et al Clinical and Epidemiologic Characteristics of Spreaders of Middle East Respiratory Syndrome Coronavirus during the 2015 Outbreak in Korea J Korean Med Sci 2017 32 744 749 13 International Severe Acute Respiratory and Emerging Infection Consortium and Public Health England Treatment of MERS CoV Information for Clinicians Clinical decision Page 7 of 8 AJRCCM Articles in Press Published on 11 December 2017 as 10 1164 rccm 201712 2371ED Copyright 2017 by the American Thoracic Society making support for treatment of MERS CoV patients 16 August 2017 version 4 0 Accessed on 17 August 2017 Available at https www gov uk government uploads system uploads attachment data file 6386 28 MERS CoV guidance for clinicians pdf 14 Chan JF Yao Y Yeung ML Deng W Bao L Jia L Li F Xiao C Gao H Yu P et al Treatment With Lopinavir Ritonavir or Interferon 1b Improves Outcome of MERS CoV Infection in a Nonhuman Primate Model of Common Marmoset J Infect Dis 2015 212 1904 1913 15 Choe PG Perera RA Park WB Song KH Bang JH Kim ES Kim HB Ko LWR Park SW Kim NJ et al MERS CoV Antibody Responses 1 Year after Symptom Onset South Korea 2015 Emerg Infect Dis 2017 23 1079 1084 Page 8 of 8 AJRCCM Articles in Press Published on 11 December 2017 as 10 1164 rccm 201712 2371ED Copyright 2017 by the American Thoracic Society