Case 1
A 76 year-old male who lived in Wuhan developed a fever on February 6, 2020, with a maximum body temperature of 39.5°C, accompanied by chills, cough, chest distress and fatigue. He first presented to the fever clinic on February 11 because the symptoms had not self-resolved. Admission test results showed that his white blood cell (WBC) count was normal, while his lymphocyte count was low (decreased to 1.0×109/L); the chest computed tomography scan demonstrated typical viral pneumonia features. He was prescribed ceftezole, ribavirin, and lianhua qingwen capsules for 2 days. On February 13, his oropharyngeal swab test for SARS-CoV-2 RNA was positive, and he was admitted to the isolation ward. Based on his Wuhan resident history, fever symptoms, SARS-CoV-2 nucleic acid test result, and the computed tomography report, the patient was diagnosed with COVID-19.
The patient had a history of bronchiectasis and chronic obstructive pulmonary disease (COPD) for more than 30 years, type 2 diabetes for 15 years, and CHB for more than 20 years. He had undergone successive treatment with lamivudine (LAM), then LAM plus adefovir dipivoxil (ADV) for more than 10 years, and then switched to TDF within the last 2 years. Serologic tests showed that he was HBV DNA-negative, and hepatitis B surface antigen-, hepatitis B e antibody-, and hepatitis B core antibody-positive.
On admission, the patient complained of dyspnea and chest distress after exercise. He showed a pulse of 106 beats per minute and oxygen saturation of 92% while breathing ambient air. After administration of oxygen therapy, delivered by nasal cannula at 3 L per minute, his oxygen saturation values increased up to 97%.
After admission, the patient’s lymphocyte count was decreased to 0.89×109/L and the D-dimer level was elevated to 4.52 mg/L. Alanine aminotransferase (ALT) level was 60 U/L and aspartate aminotransferase (AST) level was 135 U/L. The levels of myocardial enzymes, including creatine kinase (CK), lactate dehydrogenase (commonly referred to as LDH), and myoglobin (referred to as Myo), were elevated (CK of >1,300 U/L, LDH of 497 U/L, and Myo of 287.7 µg/L). C-reactive protein (commonly referred to as CRP) levels were increased significantly (to 168 mg/L), as was erythrocyte sedimentation rate (commonly referred to as ESR) (to 61 mm/h); procalcitonin was normal. Cytokine test indicated that the level of interleukin (IL)-6 was elevated (to 45.84 ng/mL) (Table 1). The levels of lymphocyte subsets, immunoglobulin, and complement were normal. Computed tomography scan of the lungs and the abdomen demonstrated that scattered GGO were present in both lungs, especially in the subpleural area; dense strips were seen in the middle lobe of the right lung and the lingula of the left lung. Emphysema of bilateral lungs and atherosclerosis of coronary and aortic vessels were observed. Liver cirrhosis was suspected in this patient, due to widening of liver fissures and atrophy of the left lobe of the liver (Fig. 1A, D).
Table 1Symptoms, treatments and laboratory results of case 1
| Date | 2.13 | 2.14 | 2.15 | 2.16 | 2.17 | 2.18 | 2.19 | 2.20 | 2.21 | 2.22 | 2.23 | 2.24 | 2.25 | 2.26 | 2.27 | 2.28 | 2.29 | 3.1 | 3.2 |
|---|
| Symptom | | | | | | | | | | | | | | | | | | | |
| Fever, °C | 38.1 | 38.3 | 38.5 | 37.7 | | | | | | | | | | | | | | | |
| Dyspnea | √ | √ | √ | √ | √ | √ | | | | | | | | | | | | | |
| Cough | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | | |
| Treatment | | | | | | | | | | | | | | | | | | | |
| Ceftizoxime | | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | | | | |
| Arbidol | | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | | | | | | | | |
| Vitamin C | | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | | | | |
| Magnesium isoglycyrrhizinate | | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | | | | |
| Chinese herbal | | | | | | | | | | | √ | √ | √ | √ | √ | √ | √ | √ | √ |
| Acarbose and gliclazide | | | | | | | | | | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ |
| TDF | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ |
| Oxygen therapy at 3 L/m | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | | | | | |
| Laboratory results | | | | | | | | | | | | | | | | | | | |
| WBC count as ×109/L | – | 7.68 | – | – | – | – | – | 5.74 | – | – | – | 7.04 | – | 5.88 | – | – | – | – | – |
| Neutrophil count as ×109/L | – | 6.31 | – | – | – | – | – | 4.31 | – | – | – | 5.04 | – | 4.14 | – | – | – | – | – |
| Lymphocyte count as ×109/L | – | 0.89* | – | – | – | – | – | 0.76* | – | – | – | 1.28 | – | 1.11 | – | – | – | – | – |
| Albumin | – | 31.9* | – | – | – | – | – | 32.7* | – | – | – | – | – | – | – | – | – | – | – |
| Globulin | – | 30.3# | – | – | – | – | – | 32.7# | – | – | – | – | – | – | – | – | – | – | – |
| ALT in U/L | – | 60# | – | – | – | – | – | 49# | – | – | – | – | – | – | – | – | – | – | – |
| AST in U/L | – | 135# | – | – | – | – | – | 37 | – | – | – | – | – | – | – | – | – | – | – |
| CK in U/L | – | >1300# | – | – | – | – | – | 107 | – | – | – | – | – | – | – | – | – | – | – |
| LDH in U/L | – | 497# | – | – | – | – | – | 255# | – | – | – | – | – | – | – | – | – | – | – |
| Myo in µg/L | – | 287.7# | – | – | – | – | – | – | – | – | – | 28.3 | – | – | – | – | – | – | – |
| CRP in mg/L | – | 168# | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – |
| hsCRP in mg/L | – | – | – | – | – | – | – | 28.86# | – | – | – | 0.95 | – | 5.95# | – | – | – | – | – |
| Procalcitonin in µg/L | – | <0.13 | – | – | – | – | – | 0.07 | – | – | – | – | – | – | – | – | – | – | – |
| ESR in mm/h | – | – | – | – | – | – | – | 61# | – | – | – | – | – | 60# | – | – | – | – | – |
| IL-2 in mg/L | – | 2.88 | – | – | – | – | – | – | – | – | – | – | – | 5.22# | – | – | – | – | – |
| IL-4 in mg/L | – | 1.95 | – | – | – | – | – | – | – | – | – | – | – | 9.75# | – | – | – | – | – |
| IL-6 in mg/L | – | 45.48# | – | – | – | – | – | – | – | – | – | – | – | 10.4# | – | – | – | – | – |
| IL-10 in mg/L | – | 3.98 | – | – | – | – | – | – | – | – | – | – | – | 6.64# | – | – | – | – | – |
| IFN-α in mg/L | – | 2.96 | – | – | – | – | – | – | – | – | – | – | – | 4.79 | – | – | – | – | – |
| IFN-γ in mg/L | – | 4.9 | – | – | – | – | – | – | – | – | – | – | – | 5.53 | – | – | – | – | – |
The patient had moderate fever in the first 4 days after admission, with a maximum body temperature of 38.5°C, which was controlled by physical cooling. The patient’s symptom of chest distress and dyspnea lasted for 6 days, with the oxygen saturation remaining above 95% on nasal oxygen delivery at 3 L/min. The patient demonstrated intermittent cough and gradual improvement. He was re-tested for SARS-CoV-2 nucleic acid on February 20 and February 22 respectively, and the results were both negative. His chest computed tomography scans on February 22 and February 28 indicated that the lesion was gradually decreasing in size (Fig, 1B, C). Laboratory results demonstrated an improvement in lymphocyte count, ALT, AST, CK, hypersensitivity CRP (referred to as hsCRP), IL-6 (Table 1), and SARS-CoV-2-IgM; IgG test on February 29 was positive. On March 2, the patient was discharged after 18 days of hospitalization and was recommended self-isolation for at least 14 days.
In hospital, he was administered arbidol (200 mg three times daily, oral) as antiviral therapy, ceftizoxime (2 g every 8 h, intravenous) to control lung infection, vitamin C (2 g once daily, intravenous) as antioxidant, and magnesium isoglycyrrhizinate (150 mg once daily, intravenous) to improve liver function. He was also administered acarbose (50 mg three times daily, oral) and gliclazide (60 mg once daily, oral) to control blood glucose level, TDF (300 mg once daily, oral) as an anti-HBV medicine, and traditional Chinese medicine No. 2 according to the Guidelines of the Diagnosis and Treatment of COVID-19 (version 5) published by the National Health Commission of China.
Case 2
A 32 year-old male community worker in Wuhan, who had close contact with COVID-19 patients for 3 weeks due to work requirements, was required by the government to visit a fever clinic to rule out SARS-CoV-2 infection on February 13. He did not exhibit any symptoms of fever, cough, or fatigue. His computed tomography scan showed single small GGO under the pleura in the middle lobe of the right lung (Fig. 1E). Counts for WBC and lymphocytes, and tests for liver function, kidney function, and hsCRP on February 14 were normal. SARS-CoV-2 nucleic acid and IgM tests for mycoplasma pneumoniae, chlamydia pneumoniae, syncytial virus, adenovirus, and coxsackie virus were negative. The SARS-CoV-2 nucleic acid was rechecked on February 15, and the results suggested that the 2019-nCoV open reading coding frame lab (nCoVORFlab) was positive and 2019-nCoV-N gene was negative. Thus, the patient was classified with asymptomatic COVID-19 infection and was admitted to the mobile cabin hospital for isolation.
The patient had received hepatitis B e antigen-positive CHB diagnosis decades prior. He had showed elevated ALT and AST, jaundice, and HBV DNA up to 107 IU/mL the past June, when computed tomography of the abdomen had also suggested fatty liver. He underwent antiviral treatment with TDF (300 mg once daily, oral) last June and his HBV DNA load had dropped to less than 100 IU/mL last November. After that, he continued to take TDF daily.
After admission, the patient was administered arbidol (200 mg three times daily, oral) as antiviral therapy, moxifloxacin (400 mg once daily, oral) to prevent secondary infection, lianhua qingwen capsules (4 capsules three times daily, oral) and traditional Chinese medicine No. 2 (twice daily, oral). His SARS-CoV-2 nucleic acid tests on February 29, March 1, and March 2 were negative and lung computed tomography performed on March 2 demonstrated no obvious abnormalities (Fig. 1F). He was discharged on March 3 and recommended self-isolation for at least 14 days.