On January 16, 2020, a 57 year old woman came to Emergency Department of the First Hospital of Changsha City, China. After 10 minutes, She was taken into the examination room and evaluated by the emergency physician. According to the chief complaint of this patient, she developed cough and fever with general weakness and muscle aches after returning from Wuhan to Changsha 7 days ago. Given her symptoms and recent travel history, she decided to see a health care provider. The patient has a history of hypertension, carotid plaque, hypothyroidism, and chronic gastritis without the habit of smoking or drinking. The physical examination indicated a body temperature of 38.0℃, blood pressure: 143/76 mmHg, pulse: 78 beats per minute, respiratory rate: 13 breaths per minute, and oxygen saturation: 96%. She had congestion in throat and thick breath sounds in the lungs. Considering abnormal breath sounds in lung, we performed examination of chest CT, which revealed pneumonia in both side of the lung (Fig. 1A). Both of nucleic acid amplification test (NAAT) for influenza A and B were negative. Given the patient’s travel history and CT finding, the Hunan province and Chinese Center for Disease Control and Prevention (CCDC) were immediately notified. CCDC staff required us to test the patient for 2019-nCoV even though the patient reported that she had never been to the Huanan seafood market and reported no known contact with ill persons in the past one month. Specimens were collected following CCDC guidance. After specimen collection, she was admitted to the isolation ward of the First Hospital of Changsha City. On admission, the patient reported persistent dry cough, fatigue, headache, sore throat and chest pain for a week. On physical examination, the patient was found to have congestion in throat without other remarkable finding.
On hospital days 2 - 4 (illness days 8 - 10), the patient’s vital signs remained largely stable. She reported cough and sore throat were worse than before, accompanied by chest pain and a small amount of sputum. Intermittent fevers and sore throat were still reported (Table 2). Supportive treatment was performed in this stage and methylprednisolone sodium succinate 40mg QD intravenously guttae was given to inhibit inflammation in lung. During this period, we found that the patient developed melena in the morning so that we should be aware of the possibility of upper gastrointestinal bleeding. Patients were treated with pantoprazole for acid suppression. Ambroxol (30mg BID intravenously guttae) and limonene and pinene enteric soft capsules (0.3g TID peros) were used to expel sputum. Laboratory results on hospital days 1 - 3 (illness days 7 - 9) reflected leukopenia, neutropenia, lymphopenia and reduced hematocrit. Additionally, elevated levels of lactate dehydrogenase and C-reactive protein were found (Table 1).
On hospital day 4 (illness day 10), re-examination of lung CT shows progress in lung inflammation (Fig. 1B). The usage for methylprednisolone sodium succinate changed to 40mg Q12H intravenously guttae and human immunoglobulin (PH4) 5g BID was added via intravenously guttae to inhibit inflammation in lung. Given the clinical presentation, treatment with piperacillin sodium and tazobactam sodium (4.5g Q8H intravenously guttae) and moxifloxacin hydrochloride and sodium chloride injection (0.4g QD intravenously guttae) was initiated.
On hospital day 5 (illness day 11), the CCDC confirmed that the oropharyngeal swabs of this patient tested positive for 2019-nCoV by real-time reverse transcriptase-polymerase chain reaction (rRT-PCR) assay. According to the suggestion of The Diagnosis and Treatment of Pneumonitis with 2019-nCoV Infection (DTPI) published by National Health Commission of the PRC, lopinavir and ritonavir tablets (2 pills BID peros), which were used for HIV infection in the past, as well as interferon alfa-2b injection (5 million IU add into 2ml of sterile water, inhalation BID) were given into the treatment for this patient. On hospital day 8 (illness day 14), the temperature of this patient dropped to 36.4℃. Moreover, her appetite improved and she was asymptomatic apart from fatigue and chest pain. CT scans showed that the patchy lesions in bilateral lung are absorbed compared to the CT imagine obtained previously (Fig. 1C). Methylprednisolone sodium succinate was discontinued. On hospital day 9 (illness day 15), blood pressure of this patient dropped to 85/55mmHg. Therefore, Shenmai injection 50mg QD intravenously guttae was used and the patient’s blood pressure rose to 113/70mmHg. On hospital day 10 (illness day 16), negative result was obtained for 2019-nCoV assay. This patient reported that she stopped cough and fever with clinical condition improved. Lopinavir and ritonavir tablets were discontinued on hospital day 10 (illness day 16). Interferon alfa-2b injection and antibiotics were discontinued on hospital day 11 (illness day 17). On hospital day 14 (illness day 20), this patient retested negative for 2019-nCoV by rRT-PCR assay and was discharged on January 30, 2020 (hospital day 15, illness day 21).
