The first 2019-nCoV infection case report from Iran CURRENT STATUS: POSTED

Background: The total mortality rate of COVID-19 is estimated almost at 2 % based on a wide range of publications. To avoid negative global impact of this new emergency, the entailment of control measures for prevention is highly recommended. Unfortunately, Iran has been the manifestation of attention as one of the countries is struggling with this pandemic. Here we intend to report a unique case of 2019-nCoV infected patient with underlying diseases and one of the rare pulmonary manifestations of 2019-nCoV infection (pleural effusion) who has recovered and discharged. Case presentation: The current case report from Iran showed a positive COVID-19 case accompanied by pleural effusion and severe pneumonia and even underlying diseases. She received twelve days of treatment and recovered with good oxygen saturation and without associated factors including fever and cough. In this report, presentations, diagnoses and management of novel 2019 coronavirus patient has been described in details. Conclusions: The pleural effusion in 2019-nCoV is not a dominant feature and can be considered as one of the diagnostic features in the disease. Even with underlying diseases, 2019-nCoV symptoms are not supposed to be severed.


Background
Since the end of December 2019, Wuhan City, has discovered multiple cases of novel coronavirus pneumonia, caused by a new beta coronavirus infection named 2019 novel coronavirus (2019-nCoV) (1). 2019-nCoV is a new coronavirus strain which have never been found in human populations before (2). The emergence of 2019-nCoV and its rapid national and international spread pose a global health emergency (3). Previous studies have showed clinical characteristics of patients with 2019-nCoV and the evidence of person-to-person transmission (4). There have been reported around 938205 cases, 47781 deaths, and 190943 recovered among 172 countries until date (02/04/2020) (5).
China could overcome transmission, by applying strict infection control measures, quarantine cases, update the treatment process and educate people (6). Unfortunately, this pandemic entered in Iran and until 02/04/2020 around 47593 cases and 3036 deaths have been reported (5).
Here we intend to describe a 61 years old woman with nasopharynx and oropharynx swabs tested 3 2019-nCoV positive using qRT-PCR. This case showed pleural effusion unlike most of other 2019-nCoV infection patients while also is suffering from underlying diseases.

Case Presentation
In 8 March 2020; a 61 years old woman, citizen of Tehran city, who is married, 60 Kg weight, temperature at admission 38° C, RR 18 per min, PR 82 per min and blood pressure 130/80 mmHg.
The main complaint at admission was coughing and fever. She has a history of diabetes, hypothyroidism, osteoarthrosis and hypertension and went under angiography with implanted stent in her heart. It worth to mention that she is not allergic to any drugs nor food. Echocardiography and ECG had no pathological evidence.
On the first day of admission, she had discomfort in chest wall and she mentioned she had white The FBS assessment during our treatment procedure (Table 1) and the clinical symptom report during our treatment procedure (Table 2) are shown in tables 1 and 2.
The results of pleural fluid tests in comparison to serum LDH and serum protein amounts, showed that the pleural fluid nature was exudative with lymphocyte preference, this result rules out the possibility of appearance of pleural effusion due to other heart problems. The tapped pleural fluid had no empyema properties, therefore there was no need for fluid discharge by chest tube.

2-1. PCR test for corona COVID-19 came positive
The duration of drug admission is twelve days, and her fever fade away on the day 4. It should be mentioned that her previous drugs for diabetes, hypertension and heart problems continued as before. She received metformin and zipmet for diabetes and metoral, losartan and atorvastatin for cardiovascular disease. After endocrinology consultation, diabetes medicine was changed to melijent.
Fortunately, in spite of multiple underlying diseases and the first report of pleural effusion in our entire patients, she had good appetite without fever in 11 th day of admission. Finally she discharged on 19 March with good general condition and O2 sat of 95%. The patient was advised to quarantine herself at home for two weeks.

Discussion And Conclusion
WHO has shifted its attention to wide range outbreak of 2019-nCoV as an international pandemic concern (6). Furthermore, epidemiological data for situational awareness in order to take an intervention strategy undeniably is crucial (7). There have been several studies concerning vertical transmission potential of 2019-nCoV (8); therefore, it seems that isolation is proper choice (9). Our patient never been in Wuhan, China.
The severity of viral pneumonia in older ages susceptible people with underlying disease have been reported high (10). Older ages and underlying diseases are risk factors for severe illness and death. Cardiovascular disease 10.5%, diabetes 7.3%, and for chronic respiratory disease, hypertension, and cancer approximately 6% each. Underlying diseases including hypertension, heart disease, prior stroke, chronic lung disease diabetes, and chronic kidney disease are associated with more severe illness and worse outcomes (11). However, the patient we reported in this article presented an inconsistent situation. We speculate the reasons for the recovery of our patient; the combination of drugs and the treatment plan was effective, the interactions of drugs checked and some medicines replaced successfully.
We indicate the first case report study from Iran, who was confirmed with 2019-nCoV. According to the clinical manifestations, healing was unpredictable due to the underlying diseases. Previous studies showed that the presence of pleural effusion in patients infected with MERS-CoV or avian influenza H5N1 is a poor prognostic indicator (12). Unlike the previous studies, our patient healed from 2019-nCoV.
In summary, our patient showed common pulmonary manifestations of 2019-nCoV (ground glass and consolidation infiltration), as well as non-common pleural effusion pulmonary manifestation. Due to the characteristics of the pleural fluid and its exudation, the incidence of pleural effusion as a result of cardiac causes is ruled out.
Compared to RT-PCR, chest CT imaging may be a more reliable, practical, and rapid method to diagnose and assess 2019-nCoV, especially in epidemic area (13). However, our current limitation in 2019-nCoV management is the inability to test patients more than one time for each patient. Our patient discharged based on clinical manifestations and O2 sat percentage, with home-based quarantine recommendation for 2 weeks. She must follow up to determine when CT will return 6 normal.

5-1. Ethics approval and consent to participate
Informed consent was obtained from the patient for publication of this case report.

5-2. Consent for publication
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

5-3. Availability of data and materials
The data and medical reports and documents during the current study are available from the corresponding author on reasonable request.

5-4. Competing interests
The authors declare that they have no competing interests.

5-5. Funding
This study was not received any related grant.

5-6. Authors' contribution.
MM (first author) did the study design, literature review, writing the article and did the data interpretation. SV did the literature review, writing the article. ZM did the scientific edition and helped in writing the article. MM (correspondence author) did the study design, data collection, provided figures, scientific edition and helped in writing the article. All authors have read and approved the manuscript. 6. Acknowledgments