key: cord-288307-6dlw2klz
authors: Fisher, Bryant; Seese, Laura; Sultan, Ibrahim; Kilic, Arman
title: The importance of repeat testing in detecting coronavirus disease 2019 (COVID‐19) in a coronary artery bypass grafting patient
date: 2020-05-12
journal: J Card Surg
DOI: 10.1111/jocs.14604
sha: 
doc_id: 288307
cord_uid: 6dlw2klz

While elective cardiac surgeries have been postponed to prevent coronavirus disease 2019 (COVID‐19) transmission and to reduce resource utilization, patients with urgent indications necessitating surgery may still be at risk of contracting the disease throughout their postoperative recovery. We present a case of an 81‐year‐old female who underwent urgent coronary artery bypass grafting and was readmitted following discharge to a nursing facility with a cluster of COVID‐19 cases. Despite symptomatology and imaging concerning for COVID‐19, two initial reverse transcription polymerase chain reaction (RT‐PCR) tests were negative but a third test was positive. This case emphasizes the risks of discharge location in the COVID‐19 era as well as the importance of clinical suspicion, early isolation practices for those presumed positive, and repeat testing, given the marginal sensitivity of available COVID‐19 RT‐PCR.

Given these findings and despite the negative testing, the patient was empirically isolated in a negative-pressure room. The patient was tested for COVID-19 a third time on hospital day 7 with a positive result.

A retest 2 days later was also positive. Over the remainder of her hospital course, the patient was treated with supportive measures and monitoring for worsening respiratory function. Fortunately, she was weaned from her oxygen to room air with improvement in her fever, cough, and shortness of breath. She was discharged on day 10 of her hospitalization with instructions to self-isolate for 14 days. On telemedicine follow-up she continues to improve and her home oxygen saturations have remained stable on room air.

As the COVID-19 pandemic unfolds, the impact on cardiac surgical patients raises complex questions concerning testing and screening.

In this report, we describe the first documented case of a post- Notably, through studies originating in China at the onset of this pandemic, the sensitivity of RT-PCR tests has been shown to be lacking. One study found that nearly 25% of COVID-19 positive individuals were negative on their initial testing with some testing positive after their third or fourth repeat test. 1 Xiao et al 2 similarly reported that over 20% of COVID-19 infected individuals tested positive on their third consecutive test, after two initial negative results. The sensitivity of RT-PCR in several studies has been quoted at 71% and 83%, respectively, corresponding to a false negative rate of up to 30%. 3, 4 Given the reported sensitivity of RT-PCR for COVID-19, repeat testing in patients with high clinical suspicion of COVID-19 infection, and therefore high pre-test probability, is of paramount importance.

Given these findings, early isolation and treatment of high-risk individuals should be based on symptomology, exposure history, and CT findings. In this case, the patient initially presented with fatigue while progressing to fever, cough, shortness of breath, and diarrhea. In retrospective analyses, the most common symptoms attributable to COVID-19 infection included fever, cough, shortness of breath, and fatigue in the vast majority of cases. 5, 6 In postoperative cardiac surgical patients, it may be difficult to differentiate these common symptoms of a postoperative bacterial pneumonia from a new onset COVID-19 infection. For this reason, exposure history and CT findings become vital in the COVID-19 era.

In this case, the patient was exposed to COVID-19 positive individuals at her skilled nursing facility. If an exposure history had not been elicited, it is possible that repeat testing would not have been pursued.

Obtaining CT imaging should also be an integral component of 

Stability issues of RT-PCR testing of SARS-CoV-2 for hospitalized patients clinically diagnosed with COVID-19

False-negative of RT-PCR and prolonged nucleic acid conversion in COVID-19: rather than recurrence [published online ahead of print April 9

Sensitivity of Chest CT for COVID-19: comparison to RT-PCR

Diagnosis of the coronavirus disease (COVID-19): rRT-PCR or CT?

Clinical characteristics and outcomes of older patients with coronavirus disease 2019 (COVID-19) in Wuhan, China (2019): a single-centered, retrospective study

Clinical characteristics of coronavirus disease 2019 (COVID-19) in China: a systematic review and meta-analysis

High-resolution Chest CT features and clinical characteristics of patients infected with COVID-19 in Jiangsu, China

A case report of COVID-19 with false negative RT-PCR test: necessity of chest CT

The importance of repeat testing in detecting coronavirus disease 2019 (COVID-19) in a coronary artery bypass grafting patient