A 45-year-old male was admitted for fever over one week on 5 Jan, 2020. The vital signs from a general physical examination were 38.3 degree for body temperature, 110 times/min for pulse, 24 times/min for breathing rate and 125/72 mmHg for blood pressure. The patient reported no history of hypertension, diabetes, hyperlipidemia, heart disease and no history of smoking and drinking. His neurological examination on admission was normal. The clinical serum laboratory examination showed an increased serum amyloid protein (SAA) of 288.42 mg/L (normal range 0-10mg/L), C reactive protein (CRP) of 25.17 mg/L (normal range 0-10 mg/L), D-dimer of 15.21 mg/L (normal range 0-0.5 mg/L) and fibrinogen (FIB) of 4.87 G/L (normal range 2-4 G/L). The levels of serum cytokines are also increased extremely, including IL-8 of 438.20 pg/ml (normal range 0-62 pg/ml), IL-10 of 836.50 pg/ml (normal range 0-9.1 pg/ml) and IL-6 of 962.70 pg/ml (normal range 0-7 pg/ml). The white blood cell was normal together with lymphocytopenia (0.64 G/L, normal range 0.8-4 G/L). The levels of glucose, lipid and homocysteine are normal. The chest computed tomography (CT) scans showed typical bilateral patchy shadowing (Figure 1). The real-time RT-PCR assay for 2019-nCoV test is positive.
The patient was treated with oxygen therapy, ribavirin (0.5g, i.v. drip, Q12h), and venous rehydration solution. At 9 a.m. on Jan 6th, the patient found to have stroke symptoms, such as speak unclearly, weakness of left limb (4/5 muscle strength throughout), shallow of left nasolabial groove and tongue toward to left. The muscle strength declined to 1/5 of upper limb and 2/5 of lower limbs at 5 p.m in the afternoon. The NIHSS score was 9 points. The laboratory examination displayed increased levels of D-dimer (32mg/L) and decreased level of FIB (1.06 G/L), together with longer prothrombin time (PT, 14.7s, normal range 11-14s) and thrombin time (TT, 22.7s, normal range 9-20s). But the head CT (Figure 2A) and neck arterial CTA (Figure 2C, 2D) didn't show any obvious abnormalities at that time. The patient was treated with atorvastatin (20mg, p.o., q.d.), tirofiban (0.1ug/kg.min, continuous intravenous pumping for 48 hours), following by daily aspirin (100mg, p.o.) and clopidogrel (75mg, p.o.). On 8 Jan, neurological function defects about dysarthria and left limb weakness of the patient got recovery gradually. Repeat head CT re-examination 2 days later showed right corona radiata infarction (Figure 2B). The patient didn't have fever in the later of hospitalization and his lung symptoms was significantly improved. The patient discharged from hospital on 3 Feb with mild dysarthria. His left limb muscle strength score gets to 5. The NIHSS score declined to 2 points from 9 and MRS score was 1 point on the discharge day.
A 50-year-old male was admitted for fever over 9 days with sudden left limb weakness for 28 hours on 10 Feb. The patient reported smoking history for 20 years, without other histories of hypertension, diabetes, hyperlipidemia and heart disease. The patient has left thyroid cancer removal surgery on 19 Jan in our hospital and discharged after recovery. The routine surgical evaluation on 17 Jan didn't found any other abnormalities from colour-doppler ultrasound test and CT angiography examination except for basilar artery fenestration (Figure 3A). The general physical examination at admission on 10 Feb were 37.8 degree for body temperature, 78 times/min for pulse, 18 times/min for breathing rate and 132/76 mmHg for blood pressure. The neurological examinations showed shallow of left nasolabial groove, tongue toward to left and dysarthria, with left upper limb muscle strength score 3 and positive reflex of Babinski's sign. The NIHSS score was 7 points. The laboratory examination displayed increased levels of SAA (>300mg/L), CRP (93.15 mg/L), D-dimer (19.86 mg/L), longer PT (15.4 s) and lymphocytopenia (0.39 G/L). The levels of serum cytokines, such as IL-8 of 84.90 pg/ml (normal range 0-62 pg/ml), IL-1b of 36.60 pg/ml (normal range 0-5 pg/ml) and IL-10 of 26.70 pg/ml (normal range 0-9.1 pg/ml) are increased. The levels of glucose, lipid and homocysteine are normal. The COVID-19 were diagnosed with typical bilateral patchy shadowing from chest CT (Figure 4) and positive RT-PCR assay test. The head CT on 10 Feb presented right basal ganglia infarction (Figure 3B). The patient was treated with oxygen therapy, ribavirin (0.5g, i.v. drip, Q12h), and venous rehydration solution, following by daily aspirin (100mg, p.o.), clopidogrel (75mg, p.o.) and atorvastatin (20mg, p.o.). During hospitalization, the patient didn't have a fever again and the lung symptoms get relieved obviously. But the neurological function defects get recovery gradually. The patient discharged on 1 Mar with mild dysarthria. The left limb muscle strength score is 4, NIHSS score is 5 and MRS score was 3.