DISPATCH CLINICAL STUDIES Atypical SARS and Escherichia coli Bacteremia Thuan Tong Tan,* Ban Hock Tan,* Asok Kurup,* Lynette Lin Ean Oon,* Derrick Heng,* Su Yun Se Thoe,* Xin Lai Bai,* Kwai Peng Chan,* and Ai Ee Ling* We describe a patient with severe acute respiratory syndrome (SARS) whose clinical symptoms were masked by Escherichia coli bacteremia. SARS developed in a clus- ter of healthcare workers who had contact with this patient. SARS was diagnosed when a chest infiltrate developed and when the patient’s brother was hospitalized with acute respiratory failure. We highlight problems in atypical cases and offer infection control suggestions. Srecognized condition. In early March 2003, the World evere acute respiratory syndrome (SARS) is a newly Health Organization (WHO) issued case definitions for SARS (1). In most studies, the clinical syndrome includes fever in 100% of patients (2–4). Other common clinical features include chills and rigors (73%), myalgia (60%), and cough (>50%). Some patients initially thought to have SARS have been excluded when tests showed other caus- es (5). We report a patient whose coexisting conditions masked the diagnosis of SARS, leading to a cluster of sus- pect and probable cases. Case Report A 59-year-old Chinese man was admitted on March 24, 2003, to the Singapore General Hospital. He had previous- ly been hospitalized in Tan Tock Seng Hospital, the hospi- tal in which the first SARS outbreak in Singapore occurred (6), from March 5 to March 20 for diabetic nephropathy. The patient had multiple coexisting conditions includ- ing ischemic heart disease with atrial fibrillation, previous stroke with scar epilepsy, diabetes mellitus with nephropa- thy (creatinine 242 µ mol/L), and peripheral vascular dis- ease. He was not on steroids or traditional medications. Clinical signs and symptoms were melena and dizzi- ness. He was pale, temperature was 36.5°C, blood pressure was 126/70 mm Hg, and pulse rate was 110/min. Chest examination was normal, and the abdomen was soft. Rectal examination showed melena. The patient also had a sloughy right heel ulcer. Laboratory values are shown in the Table. Antral gastritis was diagnosed on gastroscopy. *Singapore General Hospital, Singapore Colonoscopy and barium enema were unsuccessful because of excessive fecal residue. The patient had a temperature spike (38.4°C) on March 26, and intravenous (IV) amoxicillin/clavulanic acid was started. His temperature spiked again (38.8°C) on March 28. The source of sepsis was thought to be the necrotic heel ulcer; wound débridement was performed on March 30. The fever persisted from March 28 until April 2. Blood cultures drawn on March 28 isolated E. coli of intermedi- ate sensitivity to amoxicillin/clavulanic acid. Further eval- uation for the source of bacteremia included urinalysis, which indicated a leukocyte count of 4 and erythrocyte count of 165. Ultrasonography showed a 2.8-cm abscess at the midpole of the right kidney. Urine culture yielded mixed bacteria growth. The patient’s medication was changed to IV ceftriaxone (to which the organism was sus- ceptible) on April 1. Tissue cultures from the necrotic heel yielded Pseudomonas aeruginosa sensitive only to imipenem. Although fever was lower after 1 day of ceftri- axone, the patient’s medication was switched to IV imipenem on April 2. He remained afebrile thereafter. On April 1 (6 days after the patient’s first spike of tem- perature), three healthcare workers from the ward into which he had first been admitted became febrile. At this time, physicians were notified that the patient was on a surveillance program for SARS. He was transferred from the general surgical ward to an isolation room, and health- care workers used a combination of airborne, contact, and droplet precautions. His clinical course was scrutinized for evidence of SARS. Despite the positive contact history, he did not have any respiratory symptoms. Three chest x-rays performed on days 1, 5, and 7 of hospitalization were nor- mal (Figure 1A, B, and C). The fever could have been attributed to the E. coli bacteremia because it subsided after the patient’s antimicrobial drug was changed to an appropriate one. Over the subsequent days, 16 healthcare workers from the two wards where this patient was treated became febrile. On day 11 of hospitalization (April 3, 14 days after the patient’s last day in Tan Tock Seng Hospital), an ill- defined air space shadow was noted in the right lower zone Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 10, No. 2, February 2004 349