March 13, 2020


Estimating Clinical Severity of COVID-19 from the Transmission Dynamics in Wuhan, China 


As of February 13, 2020, there have been 59,863 laboratory-confirmed cases of COVID-19 infections in mainland China, including 1,367 deaths. A key public health priority during the emergence of a novel pathogen is estimating clinical severity. Here we estimated the symptomatic case-fatality risk (sCFR; the probability of dying from the infection after developing symptoms) of COVID-19 in Wuhan using public and published information. We estimated that sCFR was 0.5% (0.1%-1.3%), 0.5% (0.2%-1.1%) and 2.7% (1.5%-4.7%) for those aged 15-44, 45-64 and >64 years. The overall sCFR among those aged ≥15 years was 1.4% (0.8%-2.0%).
 



March 13, 2020


Clinical Management of Severe Acute Respiratory Infection (SARI) when COVID-19 Disease is Suspected 


This review is intended for clinicians involved in the care of adult, pregnant, and pediatric patients with or at risk for severe acute respiratory infection (SARI) when infection with the COVID-19 virus is suspected. Considerations for pediatric patients and pregnant women are highlighted throughout the text. It is not meant to replace clinical judgment or specialist consultation but rather to strengthen clinical management of these patients and to provide up-to-date guidance. Best practices for infection prevention and control (IPC), triage and optimized supportive care are included. 

March 13, 2020


Chest CT Could Be Used to Diagnose 2019 Novel Coronavirus Pneumonia Clinically in Hubei Province 


In December 2019, novel coronavirus pneumonia-19 (COVID-19) was discovered in the viral pneumonia cases that occurred in Wuhan, Hubei Province, China; and then quickly spread inside and outside of Wuhan and even other countries. This report describes the clinical course of two patients who had COVID-19.  The first case was a typical COVID-19 case. A 66-year-old female presented to our hospital with a 3-day history of fever with coughing, white sputum, runny nose and dizziness. She had contacted with a COVID-19 patient, her daughter-in-law who was diagnosed with COVID-19 two days before. Chest CT showed typical COVID-19 CT imaging. She was diagnosed with COVID-19 by positive nucleic acid test. The second case was a 50-year-old male with a 2-day history of fever and dry coughing. He denied having been to Wuhan. Chest CT also showed typical COVID-19 CT imaging. He accepted COVID- 19 nucleic acid test using reverse-transcription polymerase chain reaction of his throat swab sampling 7 times and the test results remained controversial. Eventually, he was diagnosed with COVID-19 after 5 days.  Chest CT examination has high sensitivity for diagnosis of COVID-19 clinically, particularly when nucleic acid test is negative. Chest CT should be considered for the COVID-19 screening, comprehensive evaluation and following-up and patients could benefit from effective treatment in time.

March 13, 2020


COVID-19: Consider Cytokine Storm Syndromes and Immunosuppression 


As of March 12, 2020, coronavirus disease 2019 (COVID-19) has been confirmed in 125 048 people worldwide, carrying a mortality of approximately 3·7%,1 compared with a mortality rate of less than 1% from influenza. There is an urgent need for effective treatment. Current focus has been on the development of novel therapeutics, including antivirals and vaccines. Accumulating evidence suggests that a subgroup of patients with severe COVID-19 might have a cytokine storm syndrome. We recommend identification and treatment of hyper-inflammation using existing, approved therapies with proven safety profiles to address the immediate need to reduce the rising mortality. 

March 13, 2020

     

Difficulties in False Negative Diagnosis of Coronavirus Disease 2019: A Case Report 


     

In December 2019, a novel coronavirus emerging in china and spread rapidly globally. Early identification and effective quarantine are essential to reduce the spread of the disease. However, the presence of false-negative makes the diagnosis difficult, especially in the early stages of the disease. A 34-year-old man who had an epidemiological link to Wuhan, presenting with intermittent fever and cough, with chest computed tomography showing ground-glass opacity, and repeated detection of negative 2019 novel coronavirus(2019- nCoV) nucleic acid by real-time reverse transcription-polymerase chain reaction assay, which was eventually diagnosed as coronavirus disease 2019(COVID-19).    This case highlights that a single negative result of the test, particularly if it is based on an upper respiratory tract specimen, in highly suspected cases, does not exclude COVID-19. Repeat and multiple-site sampling and testing in combination with dynamic imaging changes in the chest are strongly recommended in progressive disease. 

March 13, 2020


Re-evaluation of Nucleic Acid Retested Positive Cases in the Recovered COVID-19 Patients: Report from a Designated Transfer Hospital in Chongqing, China 


Since the outbreak of coronavirus disease 2019 (COVID-19) in Wuhan, Hubei province, China, the epidemic has spread rapidly in Hubei province and other regions in China. A total of 80,552 patients confirmed with COVID-19 have been reported in the main land China up to March 5th, 2020. They included a huge number of patients discharged from hospital. A total of 53726 cases have met the discharge criteria (one of the criteria includes two continued negative result of nucleic acid test with repeated interval period of at least 1day or 24 hours.) in mainland China up to March 5th, 2020. Previous studies have paid more attention to the epidemic situation of COVID-19 and patient's diagnosis and treatment. Closely attention should be paid to the discharged patients. Surprising, previous follow-up reported that some patients nucleic acid retest result was positive again after discharge. Impact factors should be further investigated. Since the first confirmed case was diagnosed in our hospital (Chongqing Emergency Medical Center, the designated transfer hospital) on February 4th, we have confirmed a total of 17 cases. All the patients infected with the novel coronavirus have been transferred to a designated hospital in Southwest China's Chongqing by ambulance with an inbuilt negative-pressure chamber. In the follow-up of these patients, all patients accepted RT-PCR tests again after having discharged from designated hospital 3 days later. Four of them showed recurrence of positive results after few days of discharge. Thus, we reported these cases aiming to provide information on policy formulation and modification of discharge plans. 


March 12, 2020


CT Manifestations of the Coronavirus Disease 2019 in Patients Outside Wuhan: with a History of Exposure to Wuhan vs. with Second-Generation Infection 


     

To explore discrepancy in CT manifestations of coronavirus disease 2019 (COVID-19) in patients outside Wuhan between cases with a history of exposure to Wuhan and with the second-generation infection. Twenty-two patients with confirmed COVID-19 from two hospitals in Nanchong outside Wuhan were enrolled. All patients underwent initial and follow-up computed tomography after admission, and were divided into two groups. Group A and B were composed of 15 patients with a history of exposure to Wuhan and 7 with the second- generation infection in Nanchong, respectively. Initial CT features including extent score and density score between groups were statistically compared. All patients in group A had abnormal CT findings while 3 of 7 patients in group B had. Patients with abnormal CT findings were more frequent in group A than in group B (P < 0.05). On initial CT, pure ground glass opacity (GGO), and GGO with consolidation and/or other abnormalities were found in 20% (3/15) and 80% (12/15) patients in group A, respectively, while 1 (14.3%), 2 (28.6%) and 4 (57.1%) had pure GGO, GGO with focal consolidation, and normal CT appearances in Group B, respectively. Patients with extent and density scores of ≥5 were more frequent in group A than in group B (Ps < 0.01). Additionally, 3 of 4 (75%) patients with normal initial CT findings had focal pure GGO lesions on follow-up CT. The COVID-19 in patients with a history of exposure to Wuhan can be severer than with the second-generation infection on CT.
 

March 12, 2020

     

CT Imaging Changes of Corona Virus Disease 2019 (COVID-19): A Multi-Center study in Southwest China 


Since the first case of a coronavirus disease 2019 (COVID-19) infection pneumonia was detected in Wuhan, China, a series of confirmed cases of the COVID-19 were found in Southwest China. The aim of this study was to describe the imaging manifestations of hospitalized patients with confirmed COVID-19 infection in southwest China. In this retrospective study, data were collected from 131 patients with confirmed coronavirus disease 2019 (COVID-19) from 3 Chinese hospitals. Their common clinical manifestations, as well as characteristics and evolvement features of chest CT images, were analyzed. A total of 100 (76%) patients had a history of close contact with people living in Wuhan , Hubei. The clinical manifestations of COVID-19 included cough, fever. Most of the lesions identified in chest CT images were multiple lesions of bilateral lungs, lesions were more localized in the peripheral lung, 109 (83%) patients had more than two lobes involved, 20 (15%) patients presented with patchy ground glass opacities, patchy ground glass opacities and consolidation of lesions co-existing in 61 (47%) cases. Complications such as pleural thickening, hydrothorax, pericardial effusion, and enlarged mediastinal lymph nodes were detected but only in rare cases. For the follow-up chest CT examinations (91 cases), We found 66 (73%) cases changed very quickly, with an average of 3.5 days, 25 cases (27%) presented absorbed lesions, progression was observed in 41 cases (46%), 25 (27%) cases showed no significant changes. Chest CT plays an important role in diagnosing COVID-19. The imaging pattern of multifocal peripheral ground glass or mixed consolidation is highly suspicious of COVID- 19, that can quickly change over a short period of time. 

March 12, 2020


Clinical and Radiographic Characteristics, Management and Short-term Outcomes of Patients with COVID-19 in Wenzhou, China 


  Coronavirus disease 2019 (COVID-19) is an emerging viral disease. Here, we reported the clinical features, management, and short-term outcomes of COVID-19 patients in Wenzhou, an area outside Wuhan. Patients admitted to the Infectious Diseases Department of Ruian People's Hospital in Wenzhou, from January 21 to February 7, 2020, were recruited. Medical data on epidemiological history, demographics, clinical characteristics, laboratory tests, computerized tomography (CT) examination, treatment, and short-term outcomes were retrospectively reviewed. Blood biochemistry and routine tests were examined using standard methods and automatic machines. CT examination was performed again for several times during the hospitalization as necessary. A total of 67 confirmed COVID-19 cases were diagnosed; 64 (95.4%) were common cases and three (4.5%) severe cases. The most common symptoms at admission were fever (86.6%), cough (77.6%), productive cough (52.2%), chest distress (17.9%), and sore throat (11.9%), followed by diarrhea (7.4%), headache (7.4%), shortness of breath (6.0%), dizziness (4.5%), muscular soreness (4.5%), and running nose (4.5%). Thirty patients (47.8%) had increased C-reactive protein levels. The CT radiographs at admission showed abnormal findings in 54 (80.6%) patients. The patients were treated mainly by oxygen therapy and antiviral drugs. By February 17, 2020, none of the 67 patients died and no infection occurred among medical staff in the department. Fifty-four (80.6%) patients were completely recovered and all others were improving. Cases in Wenzhou are mild, with good prognosis. Timely and appropriate screening, diagnosis, and treatment are the key to achieve the good outcomes. 

March 12, 2020

     

A Family Cluster of Severe Acute Respiratory Syndrome Coronavirus 2 Infections 


In December 2019, the outbreak of 2019 novel coronavirus disease (COVID- 19) began in Wuhan, Hubei Province, China. The disease has rapidly spread from Wuhan to other provinces and other countries. Clinical and epidemiological knowledge is limited. We aimed to describe the clinical and epidemiological characteristics of a family cluster of COVID-19 in Beijing. We reported a family cluster of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases in Beijing, China. We obtained and analyzed clinical and epidemiological data from these patients. Throat swab samples were tested for SARS-CoV-2 using real-time reverse transcriptase-polymerase chain reaction assays. This family comprised three laboratory confirmed cases with clinical symptoms. All three patients had close contact with a relative from Wuhan, Hubei Province. Chest computerized tomography revealed ground-glass opacities and consolidation. Patient 1 was finally intubated and mechanical ventilated. Patient 2 received high-flow oxygen therapy. The clinical condition of Patient 3 has resolved. SARS-CoV-2 infections tend to clusters. Advanced age and comorbidities are associated with adverse outcomes. Physicians should be aware of contact history so that infected patients can be identified promptly and further spreading prevented. 

March 12, 2020


Clinical Characteristics of COVID-19 in Children Compared with Adults in Shandong, China 


The COVID-19 outbreak spread in China and is a threat to the world. We reported on the epidemiological, clinical, laboratory, and radiological characteristics of children cases to help health workers better understand and provide timely diagnosis and treatment. Retrospectively, two research centers’ case series of 67 consecutive hospitalized cases including 14 children cases with COVID-19 between 23 Jan 2020 to 15 Feb 2020 from Jinan and Rizhao were enrolled in this study. Epidemiological, clinical, laboratory, and radiological characteristics of children and adults were analyzed and compared. Most cases in children were mild (21.4%) and conventional cases (78.6%), with mild clinical signs and symptoms, and all cases were of family clusters. Fever (35.7%) and dry cough (21.4%) were described as clinical manifestations in children cases. Dry cough and phlegm were not the most common symptoms in children compared with adults(p=0.03). In the early stages of the disease, lymphocyte counts did not significantly decline but neutrophils counts did in children compared with adults(p=0.00). There was an elevated level of LDH(p=0.01) and a lower level of CRP(p=0.00) and IL-6(p=0.01) in children compared with adults. There were 8 (57.1%) asymptomatic cases and 6 (42.9%) symptomatic cases among the 14 children cases. The age of asymptomatic patients was younger than that of symptomatic patients(p=0.03). Even among asymptomatic patients, 5(62.5%) cases had pneumonia including 3 (60%) cases with bilateral pneumonia, which was not different compared with that of asymptomatic cases (p=0.58, p=0.74). The clinical symptoms of children are mild, and the positive indicators of laboratory tests are rare, which may easily cause clinical misdiagnoses. 

March 11, 2020

     

Analysis Clinical Features of COVID-19 Infection in Secondary Epidemic Area and Report Potential Biomarkers in Evaluation 


  

Based on the clinical characteristics of infected patients with novel coronavirus in secondary epidemic areas, we aimed to identify potential biomarkers for the evaluation of novel coronavirus-infected patients, guide the diagnosis and treatment of this disease in secondary epidemic areas and provide a reference for the clinical prevention and control of this epidemic situation. Respiratory tract ailments and systemic symptoms were the primary symptoms of novel coronavirus infection in the secondary epidemic area; these symptoms are not typical. The abnormal increase in serum amyloid protein (SAA) may be used as an auxiliary index for diagnosis and treatment. CRP changes before other blood parameters and thus may be an effective evaluation index for patients with COVID-19 infection. 

March 11, 2020


Are Patients with Hypertension and Diabetes Mellitus at Increased Risk for COVID-19 Infection? 


The most distinctive comorbidities of 32 non-survivors from a group of 52 intensive care unit patients with novel coronavirus disease 2019 (COVID-19) in the study by Xiaobo Yang and colleagues1 were cerebrovascular diseases (22%) and diabetes (22%). Another study2 included 1099 patients with confirmed COVID-19, of whom 173 had severe disease with comorbidities of hypertension (23·7%), diabetes mellitus (16·2%), coronary heart diseases (5·8%), and cerebrovascular disease (2·3%). In a third study,3 of 140 patients who were admitted to hospital with COVID-19, 30% had hypertension and 12% had diabetes. Notably, the most frequent comorbidities reported in these three studies of patients with COVID-19 are often treated with angiotensin- converting enzyme (ACE) inhibitors; however, treatment was not assessed in either study. 

March 10, 2020

     

Clinical Characteristics of Coronavirus Disease 2019 (COVID-19) in Patients out of Wuhan from China 


A large-scale global outbreak of coronavirus disease-19 (COVID-19) out of Wuhan, from China, occurred in January 2020. Nine (9/13) COVID-19 patients exhibited mild disease severity, and defined as second-generation, human-to-human transmission cases. Most patients (11/13) had a history of travel to or from Wuhan. There were no differences in sex and age between the mild and severe cases (all P>0.05). A moderate degree of fever (11/13), cough (13/13), and fatigue (8/13) were common symptoms; however, there was no statistical difference between mild and severe cases in this regard (all P>0.05). Oxyhemoglobin saturation and oxygenation index decreased, and C-reactive protein (CRP) and serum amyloid A (SAA) levels were elevated in all patients with COVID-19infection, with statistically significant differences between those with severe disease and mild infection (all P<0.05). Twelve of 13COVID-19patients exhibited changes in chest CT imaging features, and time course changes were different between mild and severe cases (all P<0.05). Most cases of COVID-19 infection were second-generation human-to-human transmissions from Wuhan and were mild in severity. The clinical characteristics of COVID- 19varied.Oxyhemoglobin saturation, oxygenation index, CRP and SAA levels, and CT features were reliable parameters to evaluate the severity of COVID-19 infection. However, a few patients with mild COVID-19 disease lacked typical characteristics such as fever and changes in CT imaging features. 

March 10, 2020


Clinical Course and Outcome of Novel Coronavirus COVID-19 Infection in 107 patients Discharged from the Wuhan Hospital 


In December 2019, Coronavirus Disease 2019 (COVID-19) outbreak was reported from Wuhan, China. We described the clinical courses and prognosis in COVID-19 patients. Retrospective case series of COVID-19 patients from Zhongnan Hospital of Wuhan University in Wuhan, and Xi-shui Hospital, Hubei Province, China, up to February 10, 2020. Epidemiological, demographic and clinical data were collected. Clinical progress of survivors and non-survivors were compared. Risk factors for death were analyzed. A total of 107 discharged patients with COVID-19 were enrolled. The clinical progression of COVID-19 presented as a tri-phasic pattern. Week 1 after illness onset was characterized by fever, cough, dyspnea, lymphopenia and radiological multilobar pulmonary infiltrates. In severe cases, thrombocytopenia, acute kidney injury, acute myocardial injury or adult respiratory distress syndrome were observed. During week 2, in mild cases, fever, cough and systemic symptoms began to resolve and platelet count rose to normal range, but lymphopenia persisted. In severe cases, leukocytosis, neutrophilia and deteriorating multi-organ dysfunction were dominant. By week 3, mild cases had clinically resolved except for lymphopenia. However, severe cases showed persistent lymphopenia, severe acute respiratory dyspnea syndrome, refractory shock, anuric acute kidney injury, coagulopathy, thrombocytopenia and death. Older age and male sex were independent risk factors for poor outcome of the illness. A period of 7–13 days after illness onset is the critical stage in COVID-19 progression. Age and male gender were independent risk factors for death of COVID-19. 

March 10, 2020

     

Multiple Negative of RT-PCR Testing of COVID-19 Pneumonia: A Case Report 


Since the 2019 novel coronavirus outbreak in Wuhan, Hubei Province, China in 2019, there have been a few reports of multiple negative of RT-PCR tests in patients infected by 2019 novel coronavirus. The patient was a 64-year-old man with fever. His son returned from Hubei 17 days before the patient had fever. Ancillary examinations indicated a decreased lymphocyte count and ground-glass opacities in lung. However, the first five reverse transcriptase polymerase chain reaction tests of 2019 novel coronavirus were negative until the sixth turned to positive. When epidemiological history, clinical manifestation and imaging are highly suggestive of COVID-19 Pneumonia, we should repeat reverse transcriptase polymerase chain reaction tests and treat patients in isolation. 

March 10, 2020  


Discharge Criteria for Confirmed COVID-19 Cases –When is it Safe to Discharge COVID-19 Cases from the Hospital or End Home Isolation? 

    

This review suggests criteria to be considered when deciding whether a confirmed COVID-19 case can be safely (i.e. without being infectious) discharged from hospital or released from home isolation. 

March 9, 2020


COVID-19 with Spontaneous Pneumomediastinum 


A 38-year-old man from Wuhan, China, was admitted to the Central Hospital of Wuhan (Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China), on Jan 20, 2020, with a 1-day history of fever without dizziness, cough, and headaches. On presentation, his temperature was 38·1°C. Laboratory tests showed a C-reactive protein concentration of 0·56 mg/dL (normal range 0·00–0·60] mg/dL). Complete blood count showed elevated leukocytes (10060 cells per μL [normal range 3500–9500 cells per μL]), neutrophils (7550 cells per μL [1800–6300 cells per μL]), and monocytes (990 cells per μL [100–600 cells per μL]), while the lymphocyte count (1490 cells per μL) was in the normal range (1100–3200 cells per μL). The patient was negative for influenza A and B viruses, adenovirus, respiratory syncytial virus, and parainfluenza 1, 2, and 3 viruses. Chest CT showed multiple ground-glass opacities in the lower lobes bilaterally. Although the precise mechanism of pneumomedias- tinum is unknown, spontaneous pneumomediastinum is usually a self-limiting disease. However, it can potentially cause severe circulatory and respiratory pathology. Therefore, the occurrence of spontaneous pneumomedias- tinum in COVID-19 patients should be monitored closely as a potential indicator of worsening disease. 

March 9, 2020


Clinical Course and Risk Factors for Mortality of Adult Inpatients with COVID-19 in Wuhan, China: a Retrospective Cohort Study 


  

Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory- confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p<0·0001), and d-dimer greater than 1 μg/mL (18·42, 2·64–128·55; p=0·0033) on admission. Median duration of viral shedding was 20·0 days (IQR 17·0–24·0) in survivors, but SARS-CoV-2 was detectable until death in non-survivors. The longest observed duration of viral shedding in survivors was 37 days. The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. 

March 9, 2020


Imaging Features of Evolving COVID-19 Infection on Computed Tomography: Initial Experience in Zhuhai, China


38 initial scans and 62 follow-up scans were obtained. 28 (74%) patients had the history of travel to or residence in Hubei Province of China in 14 days prior to the illness onset. Common findings included ground-glass opacification (GGO), sometimes mixed with consolidation, and interlobular septal and intralobular interstitial thickening. Follow-up imaging often demonstrated peripheral GGO and consolidations spreading to the remainder of the lungs and the increasing consolidative component reflecting the progression of the disease. 8 patients (21%) whose swabs or serum were positive for COVID-19 had no imaging findings on CT throughout the disease course.