Case 1 (laboratory confirmed COVID-19)
On 23 January 2020, a 27-year-old male of Wuhan native presented with fever and dry cough for one day and visited a local hospital. Chest computed tomography (CT) images showed viral pneumonia. SARS-CoV-2 RNA was tested positive. The patient’s fever was not controlled with administration of antiviral drug and oral antibiotics. Subsequently, he developed chest distress and shortness of breath. On 3 February, he was transferred to Tongji Hospital, Wuhan, a tertiary hospital designated for quarantine and treatment of COVID-19.
On admission, physical examination revealed vital signs within normal range. However, he had a recurrent fever of 40.3 °C after 8 hours. He denied history of hypertension, diabetes, surgery, trauma, drug abuse and blood transfusion. Serological tests showed leukopenia (2.75 × 109/L) and lymphopenia (0.77 × 109/L), elevated lactic dehydrogenase (345 U/L), and elevated C-reactive protein (CRP) of 85.9 mg/L. Acid-fast bacilli was negative in sputum specimen. Common pathogens tests of blood-transmitted diseases found the patient was positive of HIV. The result was confirmed by centers for disease control (CDC). The patient provided that he was diagnosed with HIV infection 5 years ago when his HIV-RNA was 2.3 × 105 IU/ml and CD4+ T cell count was 295 × 106/L. He received cocktail treatment (zidovudine, lamivudine and efavirenz) regularly at CDC and plasma HIV was tested negative six months later. Although he used to have sexual life and tattoos, the transmission routes remain to be identified. The patient continued to visit local CDC every six months for monitor and treatment.
The antiviral treatment strategy for the patient included lopinavir/ritonavir 400/100 mg per dose twice daily for 20 days, arbidol and inhaled interferon. Glucocorticoid was given at a daily dose of 0.9 mg/kg through intravenous injection. Other treatments included moxifloxacin, γ-globulin and Chinese traditional medicine. On the fourth day after medication therapy, the patient didn’t have a fever again. His cough improved markedly within 12 days after hospitalization. On 11 February, he firstly tested negative for SARS-CoV-2, and continuously tested negative for 3 times. Consistently, the patient showed a remarkable radiological improvement (Fig. 1). Furthermore, abnormal laboratory findings almost got back to normal. The patient was discharged on 1 March 2020 and quarantined for another 14 days. A follow-up CT showed lung lesions has completely gone. He felt well after one month from discharge and retested negative for SARS-CoV-2 RNA.
Case 2 (clinically confirmed COVID-19)
A 56-year-old male patient of Wuhan native was sent to emergency department of Tongji Hospital by ambulance on 20 February 2020. He had repeated fever at the beginning of February 2020 without other respiratory symptoms. However, he aggravated with dyspnea, facial cyanosis and headache two days before admission. Chest CT showed there were multiple GGOs, patchy shadows, and pleural effusions in bilateral lungs. For diagnosed with clinically confirmed COVID-19 according to Chinese guidance on novel coronavirus pneumonia prevention and control program (fifth edition) (http://www.nhc.gov.cn/yzygj/s7653p/202002/3b09b894ac9b4204a79db5b8912d4440/files/7260301a393845fc87fcf6dd52965ecb.pdf. Accessed 5 February 2020), the patient was admitted to quarantine ward. He was in complex condition with history of diabetes, hypertension, coronary heart disease, and post-surgery of cerebral hemorrhage. Additionally, he was diagnosed with acquired immunodeficiency syndrome (AIDS) and received anti-HIV therapy in the past. Monitoring of vital signs showed respiratory rate of 32 breaths per minute, oxygen saturation of 77% at rest, pulse 140 beats per minute. Gas analysis revealed respiratory failure. High-flow nasal cannula oxygen therapy was rapidly performed to ameliorate hypoxemia. Routine tests showed antibodies of treponema pallidum and HIV were both positive, confirmed by CDC, either. Other common respiratory pathogens were tested negative. There were lots of disturbed laboratory parameters in the patient, such as increased inflammatory cytokines (interleukin 2 receptor, interleukin 8, tumor necrosis factor α), elevated liver enzymes, lactic dehydrogenase, and CRP, reduced albumin, increased cardiac troponin and N-terminal pro-brain natriuretic peptide, leukopenia (2.44 × 109/L) and lymphopenia (0.22 × 109/L). On the second day, the patient got worse and was transferred to intensive care unit. Besides mechanical ventilation, comprehensive measures such as controlling inflammation and infection, regulating blood glucose and pressure, anticoagulation, early dehydration, and hepatic protection were adopted to treat both primary pulmonary diseases and comorbidities. Although the oxygen saturation turned better, it was followed with severe conditions of extremely high blood glucose, acidosis, and tachyarrhythmia. On 24 February 2020, the patient with multiple organs dysfunction died of cardiac arrest. The duration from symptoms onset to fatality was 24 days.