Discharge and Follow-up 137

supports the contention that cytokine dysregulation may account, at least partly, for the severity of the clinical disease (Nicholls).

Examination of the liver revealed microvesicular fatty change, focal hemorrhages, and hepatocyte necrosis with scattered acidophilic bodies. The spleen showed large areas of probable ischemic necrosis and some atypical lymphocytes in the periarteriolar sheaths (Poutanen).

In one series, autopsy of hemato-lymphoid organs from four patients showed neither enlarged lymph nodes in the peripheral soft tissues or other body parts, nor reactive lymphoid hyperplasia or T zone reaction. The splenic white pulps appeared atrophic with lymphoid depletion, and the red pulp was congested. Bone marrow appeared active with the presence of three lineages. No features of hypoplastic marrow or reactive hemophagocytic syndrome were noted (Wong R).

Discharge and Follow-up

The duration of shedding of the SARS virus from respiratory secretions of SARS patients appears to be variable. Some animals can shed infectious coronavirus persistently from the enteric tract for weeks or months without signs of disease, transmitting the infectious virus to neonates and other susceptible animals (Holmes). Studies are being done to learn whether the SARS virus is shed persistently from the respiratory and/or enteric tracts of some humans without signs of disease (Holmes). In the meantime, all SARS patients should limit interactions outside the home and should not go to work, school, out- of-home childcare, or other public areas until 10 to 14 days after the fever and respiratory symptoms have resolved. During this time, the infection control precautions for SARS patients should be followed. In a small study of 14 patients, none reported secondary cases in their household following their discharge home (Avendano).

At a follow-up visit one week after discharge, all 14 patients in one series still felt weak and complained of dyspnea on exertion. They all reported significant weight loss during their acute illness (mean 7 kg). Two patients had had a low grade fever (up to 37.5°C) for 2–3 days following discharge. Only 2 patients had persistence of a slight dry cough. The chest radiograph was clear for 7 patients and, although

Kamps and Hoffmann (eds.)