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Kailian Zheng1#,Yaqiong Wang2# ,Ying Xu2#,Yuchao Dong3*
1 Department of General Surgery, Changhai Hospital, Naval Medical University, Shanghai 200433, China.
2 Department of Gastroenterology, Hankou hospital, Wuhan 430000, Hubei, China.
3 Respiratory and Critical Care Medicine Department, Changhai Hospital, Naval Medical University, Shanghai 200433, China.
*Corresponding author: Yuchao Dong, Email:dongyuchao2020@163.com
# Contributed equally

The patient was 42 years old and a medical worker in Wuhan.
Current medical history:
Since January 16, 2020, the patient has cough with white sputum without obvious inducement. The sputum could cough out hardly.There exist no chest pain, no dyspnea, no palpitation,no chest tightness, no abdominal pain, no diarrhea, no nausea,and no vomiting.No treatment was given to the patient. On January 22, the patient developed fever up to 38.5℃, with muscle aches, fatigue, and anorexia.Subsequently he was admitted to the hospital. The patient was healthy, does not smoke nor drink, and without chronic diseases history such as hypertension and diabetes. The patient had multiple contacts with COVID-19 patients before.

Admission physical examination:
Body temperature 36.8℃, pulse 85 /min, respiratory frequency 20/min, blood pressure 120/80 mmHg (1 mmHg = 0.133 kPa). The patient keeps conscious but debilitated.Lymphadenopathy on the surface of the patient could not touched, the trachea centered, the breathing of lungs thick, with no rales, and the heart rate was 85 /min. The heart rhythm was uniform, pathological murmur was not heard in each valve auscultation area.The abdomen was soft,and did not touch the liver and spleen.There was no tenderness nor rebound tenderness in the whole abdomen, bowel sounds normal, and without edema in both lower limbs.

Laboratory inspection after admission:
Blood routine test:
White blood cell count 4.3×109/L (normal reference value: 3.5-9.5×109/L), neutrophil count 2.8×109/L (normal reference value: 1.8-6.3×109/ L), lymphocyte count 1.2×109/L (normal reference value: 1.1-3.2×109/L), hemoglobin 162g/L (normal reference value: 130-175g / L), platelet count 213×109/ L (normal reference value: 125- 350×109/L).

Liver function:
Total protein 70.4 g/L (normal reference value: 60-80 g/L), albumin 41.4 g/L (normal reference value: 34-54 g/L), alanine aminotransferase 48 U/L (normal Reference value: 0-40 U/L), aspartate aminotransferase 31 U/L (normal reference value: 0-40 U/L), lactate dehydrogenase 178 U/L (normal reference value: 120-250 U/L) , Total bilirubin 16.6u mol/L (normal reference value: 3.4-20.5 umol/L), direct bilirubin 5.3 umol/L (normal reference value: 0-8.1 umol/L), serum sodium 143 mmol/L (Normal reference value: 135-145 mmol/L), potassium 4.3 mmol/L (normal reference value: 3.5-5.5 mmol/L), calcium 2.3 mmol/L (normal reference value: 2-2.6 mmol/L), urea Nitrogen 4.36 mmol/L (normal reference value: 3.1-8 mmol/L), creatinine 84 umol/L (normal reference value: 50-120 umol/L).
Procalcitonin 0.11 ng/mL (normal reference value: 0-0.05 ng/mL), hypersensitive CRP 3.39 mg/L (normal reference value: 0-6.00 mg/L), hypersensitive troponin T <3.00 ng/L (normal reference value: 0-14 ng/L).
Erythrocyte sedimentation rate 8.81 mm/1 h (normal reference value: 0-15 mm /1 h).
Pulse oxygen saturation (SpO2) 98% when inhaling air.

Serum virus antibody tests (January 23) Test results for influenza virus, parainfluenza virus, Mycoplasma pneumoniae, and Chlamydia were negative.

Throat swab (January 26) Results show that SARS-CoV-2 nucleic acid is positive.

Imaging examination after admission: Chest CT showed a small amount of ground glass exudation in both lungs (1-22).

Clinical diagnosis: COVID-19.

Treatment process:
After admission, the patient was given oral oseltamivir (75 mg, 2 times per day), intravenous infusion of moxifloxacin (0.4 g, once per day), and cefoperazone-sulbactam (3 g, once per 12 h) Strengthening nutrition and other treatments.
After admission, the body temperature fluctuated from 37 to 38℃, and other symptoms did not change significantly.

On January 26, the patient developed chest tightness, shortness of breath, and SpO2%:94% (oxygen intake 3 L / min). The CT exudation increased on previous examinations (1-27).

On the afternoon of January 28, the patient's body temperature reached the highest 38.4℃, shortness of breath worsening , respiratory rate 28/min, SpO2% 93% (oxygen intake 5 L/min), re-examination of blood white blood cell count 5×109 / L, and central granulocyte count 3.9×109/L, lymphocyte count 0.7×109/L, hemoglobin 164 g/L, platelet count 241×109/L, hypersensitive CRP 19.4 mg / L, procalcitonin 0.087 ng / mL, red blood cell sedimentation rate 44.2 mm/1h (January 28). Methylprednisolone (40 mg, once per day) and human immunoglobulin (10 g, once per day) were infused.

On January 29, the patient's temperature was normal, and his shortness of breath did not improve.

On January 30, the patient's temperature was 40.7℃, respiratory rate 35/min, SpO2 % 83% (oxygen intake 10 L/min), the white blood cell count 11.2×109/L ,and central granulocyte count 10.2×109/L, lymphocyte count 0.5×109/L, hemoglobin 167 g/L, platelet count 193×109/L, and PCT 0.202 ng / mL(January 30). Adjust the methylprednisolone dose (40 mg, 1 / 12 h) and the human immunoglobulin dose (20 g, 1/d), and increase the thymalfasin(1.6 mg, 1/d) ) And other treatments, the patient's temperature was normal, and his shortness of breath improved slightly.

On January 31, SpO2 % was 88% (oxygen intake 10 L / min). A chest CT scan revealed a large exudation of both lungs, and the left lung was obvious (January 31).

On February 1, SpO2 % was 92% (oxygen intake 10 L / min) and respiratory rate 28 / min.

On February 2, SpO2 % was 95% (oxygen intake 5 L/min), respiratory rate was 25/min, and methylprednisolone was reduced to 40 mg once daily.

On February 3, the patient's SpO2 % was 94% (oxygen intake: 3 L/min), blood lymphocyte count was 0.3×109 / L, the hypersensitivity CRP was normal. Review of chest CT, the patient's pulmonary inflammation is less than before (February 3).

On February 4, the patient's SpO2 % was 98% (oxygen intake 3 L / min), and methylprednisolone was reduced to 20 mg once daily.

On February 5, the patient's SpO2 % was 94%, and his dyspnea was significantly improved. The human immunoglobulin was reduced to 10 g once a day. Since January 31, the patient's body temperature has been normal for more than 3 days, and his chest tightness has improved rapidly.

On February 4 and February 9,throat swab results show that SARS-CoV-2 nucleic acid were negative. chest CT, the patient's pulmonary inflammation is less than before (February 9,21).

Lessons Learned:
1. Antiviral drugs do not play a decisive role in the course of the COVID-19.
2. Early use of corticosteroids may affect prognosis.
3. Nutrition is an important supportive treatment.