The first case of the emerging coronavirus 2019 in the United States

On January 19, 2020, a 35-year-old man presented to an urgent care clinic in Snohomish County, Washington, with a 4-day history of cough and autoimmune fever. Upon arrival at the clinic, the patient wore a mask in the waiting room. After waiting for approximately 20 minutes, he was taken to the examination room and evaluated by a provider. He revealed that he returned to Washington state on January 15 after traveling to visit his family in Wuhan, China. The patient stated that he saw a health alert from the US Centers for Disease Control and Prevention (CDC) regarding the outbreak of the novel coronavirus in China, and due to his symptoms and recent travel, decided to visit a healthcare provider.

Posterior and lateral chest radiography, January 19, 2020 (4th sickness day).

No chest abnormalities were observed.

Regardless of history of hypertriglyceridemia, the patient was a healthy non-smoker. Physical examination revealed body temperature of 37.2 °C, blood pressure of 134/87 mm Hg, pulse of 110 beats per minute, respiratory rate of 16 breaths per minute, and oxygen saturation of 96% as the patient breathed ambient air. Pulmonary auscultation revealed rhonchi, chest radiograph was performed, no abnormalities were reported (shape 1). The rapid nucleic acid amplification test (NAAT) for influenza A and B was negative. Oropharyngeal swab sample was obtained and sent for detection of viral respiratory pathogens by NAAT; This was reported again within 48 hours as negative for all pathogens tested, including influenza A and B, influenza, respiratory syncytial virus, rhinoviruses, adenoviruses, and four common strains of coronavirus known to cause disease. for humans (HKU1, NL63, 229E, and OC43).

Given the patient’s travel history, the local and state health departments were immediately notified. Along with an urgent care physician, the Washington Department of Health notified the Centers for Disease Control and Prevention’s Emergency Operations Center. Although the patient reported that he did not spend time at the Huanan seafood market and did not report any known contact with sick people while traveling to China, CDC staff agreed on the need to test the patient for 2019-nCoV based on the current CDC “Persons under investigation” case definitions.8 Samples were collected according to CDC guidelines and included serum, nasopharyngeal, and oropharyngeal samples. After specimen collection, the patient was discharged to home isolation with active monitoring by the local health department.

On January 20, 2020, the CDC confirmed that the patient’s nasopharyngeal and nasopharyngeal swabs were positive for 2019-nCoV by real-time reverse transcriptase-polymerase chain reaction (rRT-PCR) assay. In coordination with expert CDC experts, state and local health officials, emergency medical services, and hospital leadership and staff, the patient was admitted to an airborne isolation unit at Providence Regional Medical Center for clinical monitoring, with health care workers affiliated with the CDC. Recommendations for contact, droplet, and airborne precautions with eye protection.9

On admission, the patient reported a persistent dry cough and a 2-day history of nausea and vomiting. He stated that he had no shortness of breath or chest pain. Vital signs were within the normal range. On physical examination, the patient was found to have dry mucous membranes. The remainder of the examination was generally unremarkable. After admission, the patient received supportive care, including 2 liters of normal saline and ondansetron for nausea.

Symptoms and maximum body temperatures by day of illness and day of hospitalization, from January 16 to January 30, 2020.

On days 2 to 5 of hospitalization (days 6 to 9 of illness), the patient’s vital signs remained largely stable, apart from the development of intermittent fever accompanied by periods of tachycardia (Figure 2). The patient continued to report a nonproductive cough and appeared tired. On the afternoon of the second hospital day, the patient had a loose bowel movement and reported abdominal pain. A second episode of overnight loose stools has been reported; A sample of this stool was collected for rRT-PCR testing, along with additional respiratory samples (nasopharyngeal and oropharyngeal) and serum. Stool and respiratory samples subsequently tested positive by rRT-PCR for 2019-nCoV, while serum remained negative.

Treatment during this time has been largely supportive. For symptom management, the patient received, as needed, antipyretic treatment consisting of 650 mg of acetaminophen every 4 hours and 600 mg of ibuprofen every 6 hours. He also received 600 mg of guaifenesin for a persistent cough and about 6 liters of normal saline during the first six days of hospitalization.

Clinical laboratory results.

The nature of the patient isolation unit allowed point-of-care laboratory testing to be performed only initially; Complete blood count and blood chemical studies were available starting on hospital day 3. Laboratory results on hospital days 3 and 5 (disease days 7 and 9) reflect leukopenia, mild thrombocytopenia, and elevated creatine kinase levels (Table 1). In addition, there were changes in measures of liver function: levels of alkaline phosphatase (68 units per liter), alanine aminotransferase (105 units per liter), aspartate aminotransferase (77 units per liter), and lactate dehydrogenase (465 units per liter) were All elevated on the fifth day of hospitalization. Given the patient’s recurrent fever, blood cultures were obtained on the fourth day. These have not shown any growth yet.

Posterior and lateral chest radiography, January 22, 2020 (illness day 7, hospital day 3).

No severe intrathoracic abnormality was observed.

Posterior chest radiograph, January 24, 2020 (illness day 9, hospital day 5).

An increased left basal opacity was visible, which raised concern about pneumonia.

A chest radiograph taken on hospital day 3 (illness day 7) was reported to show no evidence of infiltration or abnormalities (Figure 3). However, the second chest radiography from the night of the fifth hospital day (illness day 9) showed evidence of pneumonia in the lower lobe of the left lung (Figure 4). These radiographic findings coincided with a change in respiratory status starting on the evening of the fifth hospital day, when the patient’s oxygen saturation values ​​as measured by pulse oximetry decreased to 90% while he was breathing ambient air. On the sixth day, the patient started supplemental oxygen, via a nasal cannula at a rate of 2 liters per minute. Given the changing clinical presentation and concern about hospital-acquired pneumonia, treatment was started with vancomycin (1750 mg loading dose followed by 1 g intravenously every 8 hours) and cefepime (administered intravenously every 8 hours).

Anterior and posterior chest radiographs, 26 January 2020 (illness day 10, hospital day 6).

Stable striated opacities at the lung bases were visible, indicating the possible presence of atypical pneumonia; The opacity intensity has steadily increased over time.

On hospital day 6 (illness day 10), a fourth chest radiograph showed striated basal opacities in both lungs, a finding consistent with atypical pneumonia (Figure 5), and rales were observed in both lungs upon auscultation. Considering radiographic findings, decision to administer oxygen supplementation, patient persistent fever, persistent positive 2019-nCoV RNA at multiple sites, and published reports of acute pneumonia progression.3,4 In a period corresponding to the development of actinic pneumonia in this patient, clinicians sought the compassionate use of experimental antiviral therapy. Treatment with intravenous remdesivir (a new nucleotide adjuvant drug in development10,11) on the evening of the seventh day, and no adverse effects associated with the infusion were observed. Vancomycin was discontinued evening 7, and cefepime discontinued the next day, after serial negative procalcitonin levels and negative nasal PCR test for methicillin resistance. Staphylococcus aureus.

On the eighth hospital day (illness day 12), the patient’s clinical condition improved. The supplemental oxygen stopped, and his oxygen saturation values ​​improved to 94 to 96% as he breathed ambient air. The former bilateral lower lobe marsupials are no longer present. His appetite improved, and he was asymptomatic apart from a dry, intermittent cough and runny nose. As of January 30, 2020, the patient is still hospitalized. He has a fever, all the symptoms are gone except for his cough which is decreasing in intensity.

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