Case report for first US case, which is the one that got the experimental REMDESIVIR.
online:
https://www.nejm.org/doi/full/10.105...=featured_home
Downloadable:
https://sci-hub.tw/10.1056/NEJMoa2001191
ITEMS WHICH SEEM NOTABLE TO ME:
Went to clinic on Jan 19th, stated as Illness Day 4.
So Illness Day 1 would be Jan 15.
Hospital Day 1 was Jan 20 so would be Illness Day 5.
On Illness Day 7, his stool & nose showed the virus but serum negative.
The pneumonia developed between illness day 7 (negative x-ray) and 9 (positive x-ray) and his pulse oxygen saturation had dropped to 90%.
On Illness Day 10 he was started on oxygen via cannula.
They started heavy pneumonia antibiotics on illness day 10 but discontinued on illness day 11 when tests showed it was not staph etc.
On illness Day 10 another X-ray showed atypical pneumonia.
They started the REMDESIVIR on illness Day 11.
Improved on Illness Day 12 - taken off oxygen, his own saturation was 94-96%, rales gone, "His appetite improved, and he was asymptomatic aside from intermittent dry cough and rhinorrhea. "
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initial mild symptoms at presentation with progression to pneumonia on day 9 of illness.
presented to an urgent care clinic in Snohomish County, Washington, with a 4-day history of cough and subjective fever.
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% while the patient was breathing ambient air. Lung auscultation revealed rhonchi, and chest radiography was performed, which was reported as showing no abnormalities (Figure 1).
TESTS FOR STANDARD VIRII NEGATIVE
A rapid nucleic acid amplification test (NAAT) for influenza A and B was negative. A nasopharyngeal swab specimen was obtained and sent for detection of viral respiratory pathogens by NAAT; this was reported back within 48 hours as negative for all pathogens tested, including influenza A and B, parainfluenza, respiratory syncytial virus, rhinovirus, adenovirus, and four common coronavirus strains known to cause illness in humans (HKU1, NL63, 229E, and OC43).
Given the patient’s travel history, the local and state health departments were immediately notified.
BECAUSE HE HAD BEEN IN CHINA THEY CONTACTED CDC & WUHAN VIRUS TESTS THE NEXT DAY WERE POSITIVE. SO ADMITTED HIM FOR OBSERVATION & ISOLATION. SEEMS LIKE HE REMAINED UN-ISOLATED FOR THAT DAY, UNTIL THE TESTS CAME BACK.
On admission, the patient reported persistent dry cough and a 2-day history of nausea and vomiting; he reported that he had no shortness of breath or chest pain. Vital signs were within normal ranges.
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.
On days 2 through 5 of hospitalization (days 6 through 9 of illness), the patient’s vital signs remained largely stable, apart from the development of intermittent fevers accompanied by periods of tachycardia (Figure 2). The patient continued to report a nonproductive cough and appeared fatigued.
On the afternoon of hospital day 2 [ILLNESS DAY 6], the patient passed a loose bowel movement and reported abdominal discomfort. A second episode of loose stool was reported overnight;
The stool and both respiratory specimens later tested positive by rRT-PCR for 2019-nCoV, whereas the SERUM remained negative.
Treatment during this time was largely supportive. For symptom management, the patient received, as needed, antipyretic therapy 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 his continued cough and approximately 6 liters of normal saline over the first 6 days of hospitalization.
The nature of the patient isolation unit permitted only point-of-care laboratory testing initially; complete blood counts and serum chemical studies were available starting on hospital day 3. Laboratory results on hospital days 3 and 5 (illness days 7 and 9) reflected leukopenia, mild thrombocytopenia, and elevated levels of creatine kinase (Table 1).
In addition, there were alterations in hepatic function measures: levels of alkaline phosphatase (68 U per liter), alanine aminotransferase (105 U per liter), aspartate aminotransferase (77 U per liter), and lactate dehydrogenase (465 U per liter) were all elevated on day 5 of hospitalization.
Given the patient’s recurrent fevers, blood cultures were obtained on day 4; these have shown no growth to date.
A chest radiograph taken on hospital day 3 (ILLNESS DAY 7) was reported as showing no evidence of infiltrates or abnormalities (Figure 3).
However, a second chest radiograph from the night of hospital day 5 [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 hospital day 5 [ILLNESS DAY 9], when the patient’s oxygen saturation values as measured by pulse oximetry dropped to as low as 90% while he was breathing ambient air.
On HOSPITAL day 6 [ILLNESS DAY 10], the patient was started on supplemental oxygen, delivered by nasal cannula at 2 liters per minute.
Given the changing clinical presentation and concern about hospital-acquired pneumonia, treatment with vancomycin (a 1750-mg loading dose followed by 1 g administered intravenously every 8 hours) and cefepime (administered intravenously every 8 hours) was initiated.
On hospital day 6 (illness day 10), a fourth chest radiograph showed basilar streaky opacities in both lungs, a finding consistent with atypical pneumonia (Figure 5), and rales were noted in both lungs on auscultation.
STARTED WITH EXPERIMENTAL REMDESIVIR ON HOSPITAL DAY 7 (ILLNESS DAY 11)
Given the radiographic findings, the decision to administer oxygen supplementation, the patient’s ongoing fevers, the persistent positive 2019-nCoV RNA at multiple sites, and published reports of the development of severe pneumonia3,4 at a period consistent with the development of radiographic pneumonia in this patient, clinicians pursued compassionate use of an investigational antiviral therapy. Treatment with intravenous remdesivir (a novel nucleotide analogue prodrug in development10,11) was initiated on the evening of day 7, and no adverse events were observed in association with the infusion.
Vancomycin was discontinued on the evening of day 7 [ILLNESS DAY 11], and cefepime was discontinued on the following day, after serial negative procalcitonin levels and negative nasal PCR testing for methicillin-resistant Staphylococcus aureus.
On hospital day 8 [ILLNESS DAY 12], the patient’s clinical condition improved. Supplemental oxygen was discontinued, and his oxygen saturation values improved to 94 to 96% while he was breathing ambient air. The previous bilateral lower-lobe rales were no longer present. His appetite improved, and he was asymptomatic aside from intermittent dry cough and rhinorrhea.
As of January 30, 2020, the patient remains hospitalized. He is afebrile, and all symptoms have resolved with the exception of his cough, which is decreasing in severity.
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