Severe acute respiratory syndrome (SARS) is an emerging
infectious disease and by 31 December 2003, SARS
had been described in 29 countries, involving 8096
individuals and causing 774 deaths.1 Severe pneumonia
causing respiratory failure was the major cause of death
in these patients. Fever and influenza-like symptoms
were the predominant presenting features but diarrhea,
nausea and vomiting were frequently observed.2–6 Diarrhea
was an important problem because SARS coronavirus
could be identified in stool in up to 100% of
cases on day 10 in one study,5 and up to 70 days after
onset of symptoms in another study.7 Although stool
culture for SARS coronavirus failed,7 the possibility of
oral–fecal transmission became imminent.8 Amoy Gardens
was one of the most densely populated private
housing estates in Hong Kong and in March 2003, 321
residents from 15 blocks had contracted the disease.
The source was traced to a 33-year-old patient with
watery diarrhea and it was postulated that the virus was
spread via a faulty sewage system.8 Recently, coronavirus
protein was identified in the esophagus, stomach
and small intestines by immunohistochemical staining9
and in colon by culture and electron microscopy,7 suggesting
a high intestinal tropism of the SARS coronavirus.
Recently coronavirus-related proteins or toxins
were postulated to be the cause of diarrhea.7 In Hong
1 World Health Organization. Cumulative number of
reported probable cases of severe acute respiratory syndrome
(SARS). Weekly Epidemiol. Rec. 2004; 79: 1–12.
2 Booth CM, Matukas LM, Tomlinson GA et al. Clinical
features and short term outcomes of 144 patients with
SARS in the Greater Toronto area. JAMA 2003; 289:
3 Lee N, Hui D, Wu A et al. A major outbreak of severe
acute respiratory syndrome in Hong Kong. N. Engl. J.
Med. 2003; 348: 1986–94.
4 Hsu LY, Lee CC, Green JA et al. Severe acute respiratory
syndrome (SARS) in Singapore; clinical features of index
Figure 3 Correlation of peak frequency of diarrhea with
chest X-ray scores. n = 49; correlation coefficient = -0.09;
P = 0.5.
610 AC-P Kwan et al.
patient and initial contacts. Emerg. Infect. Dis. 2003; 9: