key: cord-0868027-dzzoax9l authors: Mendes Correa, Maria C.; Leal, Fabio E.; Villas Boas, Lucy S.; Witkin, Steven S.; de Paula, Anderson; Tozetto Mendonza, Tania R.; Ferreira, Noely E.; Curty, Gislaine; de Carvalho, Pedro S.; Buss, Lewis F.; Costa, Silvia F.; da Cunha Carvalho, Flavia M.; Kawakami, Joyce; Taniwaki, Noemi N.; Paiao, Heuder; da Silva Bizário, Joao C.; de Jesus, Jaqueline G.; Sabino, Ester C.; Romano, Camila M.; Grepan, Regina M. Z.; Sesso, Antonio title: Prolonged presence of replication‐competent SARS‐CoV‐2 in mildly symptomatic individuals: A report of two cases date: 2021-04-23 journal: J Med Virol DOI: 10.1002/jmv.27021 sha: a4f426971db54664c2af12627850af666cd30680 doc_id: 868027 cord_uid: dzzoax9l It has been estimated that individuals with COVID‐19 can shed replication‐competent virus up to a maximum of 20 days after initiation of symptoms. The majority of studies that addressed this situation involved hospitalized individuals and those with severe disease. Studies to address the possible presence of SARS‐CoV‐2 during the different phases of COVID‐19 disease in mildly infected individuals, and utilization of viral culture techniques to identify replication‐competent viruses, have been limited. This report describes two patients with mild forms of the disease who shed replication‐competent virus for 24 and 37 days, respectively, after symptom onset. Increasing evidence indicates that during the COVID-19 pandemic, SARS-CoV-2 RNA can initially be identified in infected individuals 1-3 days before symptom onset. [1] [2] [3] Viral load, as measured by reverse-transcription polymerase chain reaction (RT-PCR), reaches its highest level during the first week of symptom onset, followed by a gradual decline over time. The mean duration of flu-like symptoms in individuals with mild-to-moderate SARS-CoV-2 infections varies from 11.5 ± 5.7 days. 4 Previous studies estimated that replicationcompetent virus could be found in COVID-19 patients up until 20 days after onset of symptoms. [3] [4] [5] [6] [7] [8] [9] However more recently, prolonged shedding of the viable virus has been described in immunocompromised patients. In a recent review, Beran et al. 10 described a few studies among immunocompromised patients, who This report describes two SARS-CoV-2-infected women with mild disease in which the virus, shown to be replication-competent, persisted for longer periods of time than has been reported previously. 4 Participants were invited to complete an initial screening questionnaire that included information on the type, onset, and duration of symptoms. Those meeting the suspected COVID-19 case definition were then called by a medical student to undergo a risk assessment. Individuals meeting pre-defined triage criteria for the mild disease were offered a home visit in which a self-collected nasopharyngeal swab was obtained for analysis. Individuals positive for SARS-CoV-2 by RT-PCR were followed up to 14 days (a maximum of seven phone calls) after completion of their initial questionnaire that detailed sociodemographic data, clinical comorbidities, and body mass index (BMI). It also included information on the onset, type, duration of symptoms, and recent contacts. Participants were contacted every 48 h by a medical student who completed another risk assessment and recorded any ongoing or new symptoms. The purpose of the follow-up was to assess the evolution of clinical variables. In cases where patients were judged to be deteriorating or developing severe disease, they were assigned to secondary care services and advised to contact the platform for a new consultation if new symptoms developed. Among 1583 confirmed COVID-19 patients with mild forms of disease included in this platform, from April 13 and May 13, 2020, the mean duration of COVID-19 symptoms was 15 days. 11 2.1 | Virus identification: RNA extraction, PCR amplification, and viral culture cific RT-PCR, as described above. RT-PCR analysis was performed using RNA extracted from culture supernatants obtained two passages after the initial inoculation in cell culture. The study was approved by the local ethics committee (CAPPesq, protocol No. 13915; dated June 03, 2020). Case 1 is a woman, 51 years old, whose first contact was April 13, 2020. She denied any previous comorbidity. Her BMI at initial contact was 31.9 kg/m 2 . She reported first experiencing a dry cough, headache, asthenia, arthralgia, and myalgia 20 days previously Prolonged shedding of viable virus (>20 days) has been reported in some adults, either with severe COVID-19 or among immunocompromised patients. 10 However, both of the cases reported here did not report any previous comorbidity and presented with a mild form of the disease with no clinical complications or need for hospitalization. has been shown that obesity may influence influenza virus transmission. Among symptomatic and asymptomatic adults, obesity increased the duration of influenza A shedding by 104%. 15 Indeed, it has recently been proposed that adipose tissue in individuals with obesity may act as a reservoir for more extensive viral spread, with increased shedding, immune activation, and cytokine amplification. 16 More investigations are needed to explore the possible association of obesity with prolonged SARS-CoV-2 persistence and contagion. According to WHO-updated recommendations on the criteria for discharging SARS-CoV-2-positive individuals from isolation, patients must be clinically recovered (symptom-free). 17 Our data reinforce that even mildly symptomatic individuals are potentially contagious. Recently, there have been descriptions of individuals who initially tested positive for SARS-CoV-2 RNA, became virusnegative but subsequently again became PCR-positive. 18, 19 This may be due to either reinfection following exposure to another infected person or by reactivation of the latent virus. 20 Temporal dynamics in viral shedding and transmissibility of COVID-19 Clinical and virologic characteristics of the first 12 patients with coronavirus disease 2019 (COVID-19) in the United States Virological assessment of hospitalized patients with COVID-2019 Clinical and epidemiological characteristics of 1420 European patients with mild-tomoderate coronavirus disease 2019 Viable SARS-CoV-2 in various specimens from COVID-19 patients Prolonged virus shedding even after seroconversion in a patient with COVID-19 Duration and key determinants of infectious virus shedding in hospitalized patients with coronavirus disease-2019 (COVID-19) Predicting infectious SARS-CoV-2 from diagnostic samples Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility Transmissibility and viral replication of SARS-COV-2 in immunocompromised patients Clinical features and natural history of the first 2073 suspected COVID-19 cases in the Corona São Caetano primary care programme: a prospective cohort study Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): a review Severe obesity, increasing age and male sex are independently associated with worse in-hospital outcomes, and higher in-hospital mortality Obesity and mortality of COVID-19. Meta-analysis Obesity increased the duration of influenza A virus shedding in adults Is adipose tissue a reservoir for viral spread, immune activation, and cytokine amplification in coronavirus disease Clinical management of COVID-19 Positive SARS-CoV-2 RNA recurs repeatedly in a case recovered from COVID-19: dynamic results from 108 days of follow-up Clinical characteristics, cause analysis and infectivity of COVID-19 nucleic acid repositive patients: A literature review Reinfection with SARS-CoV-2 and failure of humoral immunity: a case report Prolonged presence of replication-competent SARS-CoV-2 in mildly symptomatic individuals: a report of two cases The authors declare that there are no conflict of interests. All authors made a significant contribution at different stages of the work reported and contributed to data interpretation. Maria C.Mendes Correa and Fabio E. Leal wrote the first draft of the paper and all authors participated in writing subsequent drafts. All authors approved the final version of the manuscript. The data that support the findings of this study are available on request from the corresponding author. https://orcid.org/0000-0001-5655-8108Tania R. Tozetto Mendonza https://orcid.org/0000-0002-5659-1052