A 51-year-old Chinese woman with no significant past medical history presented to our institution with a one-day history of fevers, chills, sweats, nonproductive cough from a Southern California quarantine facility. She had worked as a nurse in an outpatient medicine clinic in Wuhan, China, where she cared for patients with upper respiratory symptoms but without confirmed diagnoses of COVID-19. While caring for these patients, she reported wearing a standard surgical mask and gloves. Three weeks prior to hospital admission, upon becoming aware of a rapidly spreading pulmonary infection within her community, the patient took leave from work and self-isolated herself in her apartment with her husband and grandson, neither of whom had signs of infection. She had no direct exposure to the Huanan seafood market.
Four days prior to hospital admission, she and her grandson were evacuated on a flight from the Wuhan International Airport. Late the next day, she arrived at a Southern California government facility for an intended fourteen-day quarantine. One day prior to admission, the patient developed nonproductive cough, fevers, chills and sweats. The same day, nasopharyngeal (NP) and oropharyngeal (OP) swabs for COVID-19 using reverse transcription polymerase chain reaction (RT-PCR) were sent from the quarantine facility to the US Centers for Disease Control and Prevention (CDC) laboratory per recommended guidelines. * (see appendix)
The following day, she was admitted to our institution and was placed in contact, droplet, and airborne isolation precautions per CDC recommendations. At admission, her temperature was 38.4⁰C, blood pressure was 101/69 mm Hg, heart rate was 84 beats per minute, respiratory rate was 17 breaths per minute, and oxygen saturation was 96% on room air. Physical examination including cardiopulmonary evaluation was unremarkable. Laboratory studies were notable for WBC 3600 per mm3 (range 4100-10,400/mm3), absolute neutrophil count (ANC) 2100 per mm3, ALC 1000 per mm3, and platelet count 121,000 per mm3. Other tests including liver function tests, coagulation studies, procalcitonin, and urinalysis were unremarkable. A NP swab using RT-PCR was negative for usual viral pathogens, including influenza A/B, respiratory syncytial virus, human rhinovirus/enterovirus, human metapneumovirus, parainfluenza, and four common coronavirus strains previously known to cause human illness (229E, HKU1, NL63, and OC43). Chest x-ray demonstrated clear lung fields bilaterally without consolidation or effusion (Figure 2A). Serial NP and OP swabs were tested every other day per CDC guidance to evaluate clearance of infection. No antibiotics were given to the patient. NP and OP swabs from the day prior to admission returned positive for COVID-19, and the patient became the fourteenth confirmed case in the United States.
During days 1-6 of hospitalization, she experienced daily fevers, chills, drenching night sweats, and a nonproductive cough. By day 3, she had dyspnea with minimal exertion, exacerbated by coughing fits. She also had diminished appetite with occasional nausea. She denied abdominal pain, diarrhea or dysuria. Between days 3 and 6, maximum temperature (Tmax) ranged from 39.0⁰C to 39.7⁰C (Figure 1). Blood pressure remained in low normal range. Pulmonary exam demonstrated bibasilar crackles without labored breathing. On hospital day 3, her chest x-ray demonstrated new findings of bilateral lower lobe reticular opacities (Figure 2B). Platelets reached a nadir of 101,000 per mm3 on day 4, before improving. WBC improved to 5100 per mm3 on hospital day 5, however, ALC decreased to 600 per mm3 on day 6, before recovering (Figure 1). Liver enzymes remained normal until day 6 when aspartate aminotransferase (AST) rose to 50 U/L (Figure 3). Transthoracic echocardiogram was unremarkable. Chest X ray on day 6 showed worsened bibasilar reticular opacification (Figure 2C). Blood cultures remained negative during hospitalization. TB Quantiferon resulted negative. Treatment was largely supportive during this time comprising of intravenous hydration and antipyretic therapy (acetaminophen <4g daily, ibuprofen, and axillary ice packs).
On day 6 of hospitalization, due to persistent high fevers, relative hypoxemia, evolving chest x-ray findings, and mildly abnormal liver function, patient was initiated on compassionate use remdesivir 200 mg intravenous on day 1 followed by 100 mg daily. Remdesivir, an investigational antiviral for COVID-19, was previously used in Ebola virus disease, severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV).  Her fever curve improved on day 8 (Figure 1). The patient continued to have mild dyspnea, nausea, poor appetite, and fatigue. Her cough became productive of scant white sputum. Alanine aminotransferase (ALT) peaked at 84 U/L on day 10, before trending down (Figure 3). As of hospital day 11, she remained afebrile off antipyretics. Oxygen saturations improved to 97% on ambient air. Her dyspnea and auscultatory rales resolved, however a mild productive cough persisted.
On hospital day 9, the CDC reported serial NP and OP swabs from her entire hospitalization to be negative (Figure 4). This included samples at the height of illness severity (days 1 to 7). Due to concerns with the adequacy of negative OP and NP testing in defining infection clearance, sputum PCR for COVID-19 on days 10 and 11 were obtained. Surprisingly, both sputum samples returned positive (Figure 4). Given the possibility that her productive cough harbored transmissible live virus, the patient was discharged on day 15 to a government medical facility for continued isolation until the resolution of all symptoms. At the time of transfer, she remained afebrile and asymptomatic apart from a mild productive cough. Patient returned home after 19 days at the government isolation facility after resolution of her cough. She remained non-symptomatic at home when last followed up.