Chong Pek Yoon, Chui Paul, Ling Ai E, Franks Teri J, Tai Dessmon Y H, Leo Yee Sin, Kaw Gregory J L, Wansaicheong Gervais, Chan Kwai Peng, Ean Oon Lynette Lin, Teo Eng Swee, Tan Kong Bing, Nakajima Noriko, Sata Tetsutaro, Travis William D
Arch Pathol Lab Med. 2004 Feb;128(2):195-204. doi: 10.5858/2004-128-195-AODDTS.
An outbreak of severe acute respiratory syndrome (SARS), an infectious disease attributed to a novel coronavirus, occurred in Singapore during the first quarter of 2003 and led to 204 patients with diagnosed illnesses and 26 deaths by May 2, 2003. Twenty-one percent of these patients required admission to the medical intensive care unit. During this period, the Center for Forensic Medicine, Health Sciences Authority, Singapore, performed a total of 14 postmortem examinations for probable and suspected SARS. Of these, a total of 8 were later confirmed as SARS infections.
Our series documents the difficulties encountered at autopsy during the initial phases of the SARS epidemic, when the pattern of infection and definitive diagnostic laboratory criteria were yet to be established.
Autopsies were performed by pathologists affiliated with the Center for Forensic Medicine, Health Sciences Authority, Singapore. Tissue was accessed and read at the Tan Tock Seng Hospital, Singapore, and at the Armed Forces Institute of Pathology, Washington, DC. Autopsy tissue was submitted to the Virology Department, Singapore General Hospital, for analysis, and in situ hybridization for the SARS coronavirus was carried out at the National Institute of Infectious Diseases, Tokyo, Japan.
Thirteen of 14 patients showed features of diffuse alveolar damage. In 8 patients, no precipitating etiology was identified, and in all of these patients, we now have laboratory confirmation of coronavirus infection. Two of the 8 patients presented at autopsy as sudden unexpected deaths, while the remaining 6 patients had been hospitalized with varying lengths of stay in the intensive care unit. In 3 patients, including the 2 sudden unexpected deaths, in situ hybridization showed the presence of virally infected cells within the lung. In 4 of the 8 SARS patients, pulmonary thromboemboli were also recognized on gross examination, while one patient had marantic cardiac valvular vegetations.
It is unfortunate that the term atypical pneumonia has been used in conjunction with SARS. Although nonspecific by itself, the term does not accurately reflect the underlying dangers of viral pneumonia, which may progress rapidly to acute respiratory distress syndrome. We observed that the clinical spectrum of disease as seen in our autopsy series included sudden deaths. This is a worrisome finding that illustrates that viral diseases will have a spectrum of clinical presentations and that the diagnoses made for such patients must incorporate laboratory as well as clinical data.
2003年第一季度，新加坡爆发了严重急性呼吸综合征（SARS），这是一种由新型冠状病毒引起的传染病。截至2003年5月2日，共有204例确诊病例，26人死亡。其中21%的患者需要入住医疗重症监护病房。在此期间，新加坡卫生科学局法医中心共对14例可能和疑似SARS病例进行了尸检。其中，共有8例后来被确认为SARS感染。
我们的系列报道记录了SARS疫情初期尸检过程中遇到的困难，当时感染模式和明确的诊断实验室标准尚未确立。
尸检由新加坡卫生科学局法医中心的病理学家进行。组织在新加坡丹戎巴葛医院和华盛顿特区武装部队病理研究所进行取材和阅片。尸检组织提交给新加坡总医院病毒学部门进行分析，并在日本东京国立传染病研究所进行SARS冠状病毒原位杂交。
14例患者中有13例表现为弥漫性肺泡损伤特征。8例患者未发现明确病因，目前所有这些患者均经实验室确诊为冠状病毒感染。8例患者中有2例尸检时表现为猝死，其余6例患者曾住院治疗，在重症监护病房的住院时间各不相同。3例患者，包括2例猝死患者，原位杂交显示肺内存在病毒感染细胞。8例SARS患者中有4例在大体检查时也发现了肺血栓栓塞，1例患者有消耗性心瓣膜赘生物。
很遗憾，“非典型肺炎”一词一直与SARS一起使用。虽然这个词本身不具有特异性，但它并不能准确反映病毒性肺炎的潜在危险这种肺炎可能迅速发展为急性呼吸窘迫综合征。我们观察到，在我们的尸检系列中看到的疾病临床谱包括猝死。这是一个令人担忧的发现，说明病毒性疾病会有一系列临床表现，对这类患者的诊断必须结合实验室和临床数据。
