On Jan 30 and Jan 31, 2020, we enrolled a family of 6 patients who were delivered by emergency ambulance. Their relations were summarized in Fig. 1. Patient 1 was the mother of Patient 2, 3, and 5. Patient 4 and Patient 6 were wife of Patient 3 and Patient 5, respectively. All the 6 patients did not leave Nanjing at least half a month before onset. Nothing special happened except that they held a family welcome banquet with Patient A on Jan 23, who was another daughter of Patient 1. Patient A lived in a city of Hubei province, Xiaogan, and travelled back to Nanjing for Spring Festival via high-speed rail on Jan 21, when Patient 3 (her brother) picked her up by the private car and delivered her to home of Patient 1, where Patient 2 (daughter of Patient 1) temporarily stayed to take after her mother. Patient 1, 2 and A stayed together for two days until the family banquet mentioned above, where all the patients (1–6) celebrated the new year. After that, Patient A continued her journey to Zhejiang province to visit her son. The whole family did not take any measures for protection or quarantine when staying with Patient A, since she had no symptom and felt very well. On Jan 24, Patient 5 and 6 went to joined the party with their relatives, Patient 7, 8, 9, and 10 (Fig. 1).
At the midnight of Jan 24, one day later than Wuhan, Xiaogan was declared as epidemic aera and blocked. Patient A started to have fever on Jan 26 and was diagnosed as COVID-19 in a Zhejiang hospital on Jan 29. Once upon confirmation of infection, Patient A immediately informed her family in Nanjing. Unfortunately, it was too late. Actually, on Jan 25, Patient 2 (sister of Patient A) had already had fever. Patient 3 had cough on Jan 26 and Patient 4, 5, 6 and 7 started to feel out of sorts on Jan 27. What’s worse, Patient 8 and 9 were also successively symptomatic. All the patients went to hospital and were admitted since nucleic acid detection of SARS-Cov-2 from throat swab specimens was positive. To our interest, Patient 1 was asymptomatic and did not fell any uncomfortable consciously. However, considering that she was 95-year old and very inconvenient if at home alone, she decided to go to hospital with her family. Patient 10 was also asymptomatic and stayed at the designed place for quarantine until a screening action for close contact person on Feb 11, when she was confirmed by nucleic acid test. Luckily, before the onset of symptoms, all those patients did not go out and contact with others except Patient 3, who went out for shopping shortly with mask.
The median age of these 10 patients was 61.5, with Patient 1 the oldest (95) and Patient 10 the youngest (38) (Table S1). There were four men and six women. Patient 1 and Patient 8 had hypertension and diabetes. Patient 7 had idiopathic thrombocytopenia and hypertension. Patient 9 suffered from relative serious underlying disease, including chronic hepatitis B, cirrhosis, and postoperative hepatocellular carcinoma. The incubation period of these 10 patients spanned from 3 to 17 days, with the median of 5.5. The symptoms at onset were varied, including fever (6/10), dry cough (6/10), fatigue (3/10), chest tightness (1/10), muscle pain (1/10). During the course of disease, the following symptoms were presented: fever (7/10), cough (7/10), chest tightness (4/10), fatigue (4/10), shortness of breath (2/10), poor appetite (1/10), expectoration (2/10), muscle soreness (1/10), nausea (1/10) and diarrhea (1/10). 7 patients had low to middle fever, between 37.3℃ and 38.2℃. Their oxyhemoglobin saturation varied from 94–98% (Table S1).
At admission, Chest CT examination revealed visible lung lesions. All the patients except Patient 9 and 10 had multiple lesions in both lungs, mainly located in the peripheral lung field, near the subpleural area, which presented small patches or large ground-glass opacity, or increased microvascular shadows partly (Fig. 2). For Patient 9 and 10, only a few isolated patches in the dorsal segment of the right lower lung were observed (Fig. 2). The laboratory test results of blood specimens were the followings: leukocyte count decreased (40.0%, 4/10), neutrophils count decreased (40.0%, 4/10), lymphocyte count decreased (10.0%, 1/10), C reactive protein increased (40.0%, 4/10), erythrocyte sedimentation rate (ESR) accelerated (30.0%, 3/10), lactic dehydrogenase (LDH) elevated (40.0%, 4/10), alanine transaminase (ALT) elevated (10.0%, 1/10) and aspartate aminotransferase (AST) elevated (10.0%, 1/10), erythrocyte potassium decreased (30.0%, 3/10), D-dimer elevated (40.0%, 4/10) (Table S2). The traditional inflammatory markers procalcitonin and IL6 were normal. Remarkably, Patients 2 had all the abnormal signs above. After 3 days of hospitalization, his fever and cough aggravated, and wheezing and tightness in chest were more obvious after activity. Analysis of blood gas indicated 1-respiratory failure and reexamination of chest CT found obvious progress of lesions. Analysis of immune function revealed CD3+, CD4+, CD8 + lymphocyte cell count decreased (Table S2).
According to the diagnosis and treatment plan for SARS-Cov-2 pneumonia, recommended by National Health Commission of the People's Republic of China, all patients accepted anti-virus regimens, including aerosol inhalation of IFN-α (5 million unit, BID), Lopinavir/Ritonavir (400/100 mg, po, BID), and Arbidol (0.2 g, po, TID). Since Patient 2 had aggravated symptoms and hypoxemia, we added methylprednisolone through intravenous drip (40 mg, QD) for 5 days, together with anti-virus treatment. Her symptoms improved and the lung lesions were absorbed. To monitor the effect of treatment, qRT-PCR was performed every one day to monitor the virus (Table S3). Fortunately, the clinical symptoms of all the 10 patients were improved after treatment and their specimens of throat swap had become negative. At present, all of them were discharged but asked to stay at the designed site for observation for another 14 days (Fig. 1). Although Patient 1 reached the discharge standard, she was transferred to Department of Rehabilitation for more convenient care.