The patient is a 65-year-old woman with well-controlled SLE. Her long-term treatment for SLE is prednisone (10 mg p.o., once daily) and hydroxychloroquine (0.2 g p.o., twice daily). She lived 6 miles away from Huanan Seafood Wholesale Market where was the earliest epidemic focus of COVID-19 in Wuhan. She had neither been to the market nor closely contacted with confirmed or suspected COVID-19 patients.
On January 22, 2020, the patient presented fever (peak value: 39 C) with chills, rigor, muscular soreness and fatigue. She coughed with small amount of white sputum occasionally. Sometimes, she felt suffocated after movements. The next day, she developed nausea, anorexia, heartburn and diarrhea (liquid stool, three times per day). On January 25, she visited the clinic for the first time and was given oral medicines (oseltamivir 75 mg twice daily, arbidol 0.3 g twice daily, moxifloxacin 0.4 g once daily and Lianhuaqingwen capsules 1.4 g three times daily). The dosage of prednisone and hydroxychloroquine remained the same as her usually used.
After taking the aforementioned drugs for 7 days, the patients' symptoms did not improve and returned to the clinic. The outpatient doctor took nasopharyngeal swabs to test SARS-CoV-2 and influenza A virus by real-time reverse transcription polymerase chain reaction (rRT-PCR), both of which were positive. At the same time, her thoracic CT showed bilateral patchy ground-glass opacities (according to the medical records, images not available). Hence, human immunoglobulin was given intravenously (IVIg, 5 g once daily) with the aforementioned oral medicines and increased dose of prednisone (25 mg once daily) for 5 days since February 4. Intravenous immunoglobulin is immunoglobulin G made from healthy human plasma, and low dose of IVIg was used for nonspecific and wide-spectrum antiviral and antibacterial therapies.
On February 8, the patient' symptoms were relieved partially, but the second thoracic CT showed pulmonary lesions extension (according to the medical records, images not available). Laboratory tests found leucocytosis (11.09 x 109/L), neutrophilic leucocytosis (9.46 x 109/L) and normal lymphocyte count (1.33 x 109/L) (Table 1). Then, the patient was admitted to fever ward of Sino-French New City Branch of Tongji Hospital, a designated hospital for diagnosis and treatment of COVID-19 in Wuhan.
On admission, the patient presented with mild coughing. Physical examination revealed that the conscious of the patient was clear, temperature was 37.1 C, blood pressure was 136/74 mmHg, pulse rate was 77 beats per minute, respiratory rate was 18 breaths per minute and peripheral oxygen saturation under oxygen inhalation (3 L/min) through nasal catheter was 98%. The results of laboratory examinations were presented in Table 1. White blood cell count, neutrophilic granulocyte count and lymphocyte count were normal. Several inflammatory indicators were high. Mild injuries of kidney, myocardium, liver and coagulation function were observed. M. pneumoniae infection was found by serology (Figure 1). Glycosylated hemoglobin was 7.1%, and postprandial blood sugar was higher than 11.1 mmol/L. Routine tests of stool and urine samples were normal.
The patient was diagnosed of SLE combined with COVID-19, influenza A, M. pneumoniae infection and diabetes mellitus. Prednisone (25 mg p.o., once daily) and hydroxychloroquine (0.2 g p.o., twice daily) were given to cover the concurrence of SLE and COVID-19. Pantoprazole (40 mg p.o., once daily) was used to prevent gastric mucosal injury caused by prednisone. Levofloxacin (0.5 g p.o., once daily) was given to deal with bacterial and M. pneumoniae infection. Then, acarbose (50 mg before lunch and dinner daily) was applied to control the blood glucose.
On the 6th day of hospitalization, the symptoms of the patient eased. Thoracic CT (February 14, 2020) showed bilateral ground-glass, patchy and cord-like shadows (Figure 2a), which was better than the second CT (February 8, 2020) before admission (according to the medical records). On the 8th day of hospitalization, some laboratory examinations were retested, and most of which were improved (Table 1). Dosage of prednisone was reduced to 15 mg once daily as pneumonia improved.
On day 15 of hospitalization, laboratory tests revealed that most of the values were better than previous tests (Table 1). Inflammatory indicators such as serum ferritin, high-sensitivity C-reactive protein (hsCRP), erythrocyte sedimentation rate (ESR) and interleukin-6 were lower. Subgroup typing of lymphocytes represented elevation of CD4+ T cells (1517/muL) and reduction of CD8+ T cell (252/muL). The ratio of helper T cell versus suppressor T cell was elevated (6.01). The thoracic CT (February 23, 2020) showed a modest upturn in the lesions (Figure 2b). The dosage of prednisone was then reduced to 10 mg once daily as pneumonia improved. Nasopharyngeal swabs were collected for rRT-PCR of SARS-CoV-2 on day 16 and 18, both of which were negative. Two days later (day 20), the patient developed wrist pain, and loxoprofen (60 mg p.o., twice daily) was used to alleviate it.
On day 22 of hospitalization, no symptoms of the patient were observed. Laboratory findings (Table 1) and thoracic CT (Figure 2c) indicated improvement relative to last time. The rRT-PCR of SARS-CoV-2 of the third nasopharyngeal swab was still negative. Serum immunoglobulin M (IgM) and immunoglobulin G (IgG) of SARS-CoV-2 were 33.73 AU/mL (normal range: <=10 AU/mL) and 198.77 AU/mL (normal range: <=10 AU/mL), respectively. Since the patient met the criteria of discharge (temperature came back to normal for over 3 days, respiratory symptoms significantly improved, thoracic radiology showed obvious improvement in acute exudative lesions and negative results of rRT-PCR of SARS-CoV-2 for two nasal pharyngeal swabs over 24 h), she was discharged on March 4, 2020. She has been in good health without any symptoms after discharge.
 Ethical statements: This study was approved by the Ethics Committee of Tongji hospital, Huazhong University of Science and Technology. All the materials of the patient were anonymous and written informed consent was waived by the ethics committee.