On February 3, 2020, a 43-year-old man developed a fever without a clear cause, and his body temperature was 38 C with no other obvious symptoms. After taking Lianhua Qingwen Capsule himself, his body temperature returned to normal. On February 5, 2020, the patient experienced fever again, with a normal body temperature after measurement, a slight cough, a small amount of white sputum, and reported being more sleepy than usual. On February 6, the patient visited the Fever Clinic of West Lake Hospital, affiliated with Hangzhou Medical College. The patient's past medical history involved generally good health, with no history of high blood pressure, diabetes or heart disease, and no travel to Wuhan, Wenzhou, or other key COVID-19 outbreak areas or exposure history. However, the patient described that he had gone to Lanxi County, Zhejiang Province, where COVID-19 had been confirmed and reported before January 22, and his sister, who lived with him at home, had cough, low fever, diarrhea, and other clinical symptoms before February 3 (later confirmed as COVID-19 by Xixi Hospital in Hangzhou). According to the above description, the patient was immediately requested to undergo chest computed tomography (CT). The CT scans showed multiple lamellar ground glass, nodular, slightly high-density shadows in both lungs, and prominent sculptural shadows. Viral pneumonia was also considered (Figure 1A). As a result, the patient was admitted to the hospital on February 7 with suspected COVID-19.
Physical examination on admission showed (Figure 1B) the following: body temperature, 37.6 C; blood pressure, 129/77 mmHg; respiratory rate, 18 times/min; pulse, 82 times/min; and blood oxygen saturation, 98%. After admission, the patient's vital signs were stable, with a few coughs, a small amount of white sputum, mild congestion of the eyelid conjunctiva, pharynx redness, and no obvious tonsil enlargement. Blood tests showed a decrease in lymphocyte percentage (16.8%, normal: 20-50%) and a lymphocyte count of 1.26 x 109/L (normal: 0.8-4 x 109/L). The proportion of neutrophils was increased (76.6%, normal: 40-75%), the absolute value of neutrophils was normal (5.74, normal: 1.40-7.13 x 109/L), and the hypersensitive C-reactive protein (CRP) was increased (10.77 mg/L, normal < 8 mg/L). The test results for influenza A and B, parainfluenza, respiratory syncytial virus, rhinovirus, adenovirus, and mycoplasma pneumoniae antigen were negative. The test results of two specimens (nasopharyngeal swabs and sputum) of SARS-CoV-2 were positive, and the preliminary diagnosis was COVID-19 (common type).
On February 7, the patient was treated with moxifloxacin hydrochloride tablets (400 mg, once daily, oral administration) to prevent infection. Abidol hydrochloride granule (0.2 g, three times daily, oral administration), ribavirin injection (0.5 g, twice daily, intravenous injection), recombinant human interferon alpha2b injection (6 million U, twice daily, aerosol inhalation), Lianhua Qingwen capsule (1.4 g, three times daily, oral administration) was used to clear away heat and detoxify, and human immunoglobulin (PH4) was injected intravenously (20 g, once daily) to enhance immunity. In addition, patients were treated with antipyretic and fluid supplements according to their symptoms (Figure 1C).
On February 7-9, the patient's vital physical signs were stable, with intermittent fever and blood oxygen saturation fluctuating between 93 and 99%. The patient complained of cough with white mucous sputum, poor gastric uptake, fatigue, loss of appetite, abdominal distension, and occasional retching. Re-examination chest CT showed that the lesion of the bilateral lung infection was larger and thicker than before, and the image showed significant progress compared to before (Figure 1A). On the same day, the ongoing drugs were switched to moxifloxacin hydrochloride injection (0.4 g, once daily, intravenous injection) for anti-infection, the use of lopinavir/ritonavir was increased (2 capsules, twice daily, oral administration), and methylprednisolone sodium succinate was injected (40 mg, once daily, subcutaneous injection) to reduce pulmonary interstitial edema and control the progression of the disease. The patient's third chest CT re-examination on February 11 showed no enlargement of the lesion, and the progress of the disease was basically under control (Figure 1A). Oral Chinese medicine decoction treatment was started on February 12 (the Chinese medicine prescription is shown in Table 1), and Chinese medicine diagnosed "loemia" (damp toxin epidemic). The patient's fourth chest CT on February 14 showed scattered small nodules in the right lung and some absorption of the left lung lesions (Figure 1A). The patient's respiratory symptoms improved, and his body temperature remained normal. The nucleic acid test of SARS-CoV-2 on nasopharyngeal swabs was negative, the sputum specimen was still positive, and as such, the antiviral treatment regimen was maintained.
On February 17 and February 24, the fifth and sixth chest CT scans showed that the scope of the lung lesions narrowed and gradually absorbed. The white blood cell (WBC) count, lymphocyte count, and high-sensitivity CRP (hs-CRP) levels were normal. In the evening of February 25, the patient had a fever with a body temperature of 38.2 C. The sputum and feces of SARS-CoV-2 nucleic acids were all positive. The blood routine examination showed that the WBCs were elevated (9.82 x 109/L, normal, 4.0-10.0 x 109/L), the neutrophils were increased (9.05 x 109/L, normal: 1.40-7.13 x 109/L), the lymphocyte count was decreased (0.50 x 109/L, normal: 0.8-4 x 109/L), and the erythrocyte sedimentation rate was increased by 55 mm/h (normal: 0-15 mm /h). According to the results of laboratory examination, considering bacterial infection, meropenem (1 g, once per 8 h, intravenous injection), azithromycin for injection (0.5 g, once daily, intravenous injection) combined with anti-infection, and abidol hydrochloride granules (0.2 g, three times daily, oral administration), recombinant human interferonalpha-2B injection (6 million U, twice daily, aerosol inhalation) were added to continue the antiviral treatment. On February 27, the patient's temperature returned to normal. On February 29, SARS-CoV-2 nucleic acid (nasopharyngeal swab, sputum, urine, blood) was negative, but diarrhea symptoms appeared (from February 27-29, stopping TCM decoction), and chest tightness was more obvious than before. Azithromycin was discontinued considering the side effects. Azithromycin tablets (0.5 g, once daily, oral administration) and ceftriaxone sodium for injection (2 g, once daily, intravenous injection) were used for anti-infection, and Huangqi Shengmai drink (10 mL, three times daily, oral administration) was added for the treatment of chest tightness. On March 3, diarrhea and chest tightness were better than before. The patient's seventh chest CT re-examination showed that the focus of pulmonary infection was further absorbed than on February 24, and the scope of the focus continued to narrow. Symptomatic treatment and TCM adjuvant treatment were continued. On March 9, the sputum SARS-CoV-2 nucleic acid was recovered, the stool nucleic acid was positive, and other specimens (urine, blood, and throat swabs) were negative. The antiviral regimens were continued, and Chinese medicine enema was used to promote the elimination of SARS-CoV-2 and promote the negative conversion of SARS-CoV-2 nucleic acid in the gut. The detailed medication plans are shown in Table 1 and Figure 1C. On March 17, three consecutive re-examinations of the respiratory tract and feces showed SARS-CoV-2 nucleic acid as being negative. The patient's body temperature remained normal for more than 3 days, and re-examination of chest CT showed improvement in absorption. According to the latest version of the Diagnosis and Treatment Protocol for Novel Coronavirus Pneumonia of China, patients who meet the following criteria can be discharged (http://www.nhc.gov.cn/xcs/fkdt/202002/54e1ad5c2aac45c19eb541799bf637e9.shtml), and the patient was discharged into the isolation point for follow-up observation.
From the first chest CT examination on February 6, 2020, to the re-examination after discharge, the patient underwent a total of eight chest CT scans. In the early stage of the disease (February 6-8), CT showed that the lung lesions had imaging manifestations of continuous progress. From February 11, CT showed that the lesions gradually shrunk. On March 30, the re-examination CT showed that the lung images had returned to normal (Figure 1A).
Clinical samples, nasopharyngeal swabs, feces, urine, whole blood, serum, and sputum were collected. Routine tests were carried out on the day of admission, including blood; sputum; throat swab culture (fungi and bacteria); blood routine (cell count and proportion); liver function [albumin (ALB), alanine aminotransferase (ALT), gamma glutamyl transpeptidase (GGT)]; renal function; inflammatory indexes [hs-CRP, lipopolysaccharide (LPS), procalcitonin (PCT)]; and coagulation function (D-dimer). In addition, common acute respiratory pathogens (influenza A virus, influenza B virus, adenovirus, parainfluenza, and syncytial virus), coronavirus (MERS, SARS, 229E, NL63, OC43, and HKU1), and SARS-CoV-2 nucleic acids were detected. Following identification of the pathogen of infection, serum SARS-CoV-2 antibody, cellular immunity, and humoral immunity were detected. Disease progression was observed by continuous sample collection (Figures 2, 3).