key: cord-0949644-re45w37d authors: Sanville, Bradley; Corbett, Rebecca; Pidcock, Wesley; Hardin, Kaitlyn; Sebat, Christian; Nguyen, Minh-Vu; Thompson, George R; Haczku, Angela; Schivo, Michael; Cohen, Stuart title: A Community Transmitted Case of Severe Acute Respiratory Distress Syndrome due to SARS CoV2 in the United States date: 2020-03-30 journal: Clin Infect Dis DOI: 10.1093/cid/ciaa347 sha: ee3f0514ac22781ca7317595487367e602bf7232 doc_id: 949644 cord_uid: re45w37d nan The current novel coronavirus (SARS CoV2) outbreak, which was identified in December 2019 in Wuhan, Hubei, China has spread rapidly causing a significant public health crisis worldwide 1 . The focus of public health measures in the United States has been on individuals with known at risk travel or contacts with at risk individuals 2 . While person-toperson transmission without clear exposure has been observed in other countries 3 , we present a case of the first community transmission of SARS CoV2 in the United States. A patient in their 40s presented to an outside facility with 3-4 days of flu-like symptoms. Chest x-ray upon admission showed a right upper lobe consolidative process with airbronchograms ( Figure 1) . Computed tomography revealed a dense consolidation with airbronchograms in the right upper lobe with minimal areas of ground glass, primarily in the right middle lobe. The remaining lung parenchyma was normal in appearance. Within 24 hours of admission, her respiratory status deteriorated, and she required intubation. Followup imaging showed bilateral dense alveolar filling. She progressed to develop the acute respiratory distress syndrome (ARDS) with refractory hypoxemia requiring a fraction of inspired oxygen (FiO2) as high as 100% with a positive end expiratory pressure (PEEP) of 16 despite intermittent neuromuscular blockade. She developed septic shock requiring large volume crystalloid resuscitation and high dose norepinephrine. Antibiotics were expanded to linezolid, piperacillin-tazobactam, and azithromycin. She underwent bronchoscopy with report from the treatment team of negative bacterial cultures after two days. A respiratory viral panel was in process at time of transfer. The patient was transferred to our facility for consideration of extracorporeal life support (ECLS) given refractory hypoxemia on hospital day 5. Upon arrival the patient had a heart rate of 123 beats per minute and a temperature of 36.9°C. The blood pressure was 117/61, which was maintained by a norepinephrine drip at 0.5 mcg/kg/min. Peripheral saturation of oxygen was 91% on an FiO2 of 90%, respiratory rate of 26 breaths per minute, a PEEP of The patient was immediately placed on droplet and contact precautions, and a respiratory viral panel, respiratory culture, and blood cultures sent. She underwent prone positioning and therapeutic paralysis with cisatracurium to maintain ventilator synchrony for treatment of her severe ARDS. A vasopressin infusion was started for further blood pressure support. Given her critical condition in light of the current outbreak, a suspicion for a potential SARS CoV2 infection was raised. But the patient had no travel to high-risk countries and no contact with an individual with high-risk travel thus, as she did not meet the current Centers for Disease Control (CDC) criteria, testing was not pursued by public health officials. A SARS CoV2 infection was therefore low on our initial differential diagnosis and a typical bacterial infection was thought to be more likely. To date, no source of exposure has been identified for this patient. Therefore, we conclude that she must have had community acquired disease. Although her course was complicated by acute renal failure, dialysis was never required and she did not require ECLS. She improved clinically following a week of therapy, with a significant reduction in ventilator support and interval improvement in her oxygenation and chest radiograph findings ( Figure 3 ). She was successfully extubated 14 days after her hospital transfer and is currently in As a result of the positive SARS CoV2 test, healthcare workers who were exposed to the patient were required to undergo home quarantine with symptom and fever monitoring. Two healthcare workers in contact with the patient at the outside hospital have subsequently tested positive for SARS CoV2. No transmission has been noted to healthcare workers at our institution. While the majority of COVID-19 cases were identified within our patient's age group years), only 18.5% of severe cases were from this age group. Those over the age of 65 comprised 49.2% of severe cases 6, 9 . In a large review of 73,314 cases from China the authors reported 5% of all cases meeting critical illness (i.e. shock, respiratory failure, and/or multi-organ failure) with a case-fatality rate of 49% in that subgroup 9 . Health care personnel that became infected suffered a similar amount of severe and critically ill cases as the general population. Overall, these reviews note a case fatality rate of 1.40-3.46%, though this may be considerably lower when accounting for a likely large number of mild or asymptomatic patients that were not tested 6, 9, 10 DeWit and colleagues from the NIH, Gilead, and Columbia University successfully treated rhesus macaques against a model of MERS 13 . Whether remdesivir is effective against human COVID-19 is not known. The ability to provide early testing and diagnosis would certainly accelerate clinical trial efforts to investigate this compound. As will any novel infection, our knowledge evolves over time as more data from affected individuals is collected and analyzed. Given changes in epidemiologic risk and potential for atypical presentations, the challenge for clinicians to identify whom to test becomes more difficult. This virus has a prolonged incubation time (2.1-11.1 days in the most optimistic 8 estimate of 88 Chinese patients) with a wide range of disease severity 16 . As we have reviewed, its radiographic appearance can be quite varied both in time from symptom onset and overall appearance. A wide variety of symptomology and radiographic appearances create difficulty for providers to identify COVID-19 and differentiate it from other more common respiratory infections. It has also been shown that human coronaviruses persist on inanimate surfaces for up to 9 days, thus, can be picked up without close contact to an infected person 17 . As noted in a recent editorial, diagnosis becomes even more difficult considering the likelihood of a large number of mild or asymptomatic patients who are not formally identified with a SARS CoV2 infection 18, 19 . Because there are individuals in the community that are not manifesting severe enough symptoms to warrant presenting to healthcare providers, we should expect community spread to occur more frequently, challenging our ability to adequately contain the spread of SARS CoV2. Our case has influenced national health policies for revising screening criteria. Nonetheless, to tackle the outstanding burning issues (true prevalence and mortality rate, impact on Update and Interim Guidance on Outbreak of 2019 Novel Coronavirus (2019-nCoV) A Locally Transmitted Case of SARS-CoV-2 Infection in Taiwan Evaluating and Reporting Persons Under Investigation (PUI) CT Imaging Features of 2019 Novel Coronavirus (2019-nCoV) Clinical Characteristics of Coronavirus Disease 2019 in China Time Course of Lung Changes On Chest CT During Recovery From 2019 Novel Coronavirus (COVID-19) Pneumonia COVID-19): Relationship to Duration of Infection Characteristics of and Important Lessons From the COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention Unique epidemiological and clinical features of the emerging 2019 novel coronavirus pneumonia (COVID-19) implicate special control measures The 2019 Novel Coronavirus Outbreak -A Global Threat Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study Prophylactic and therapeutic remdesivir treatment in the rhesus macaque model of MERS-CoV infection Coronaviruses -drug discovery and therapeutic options The nucleoside analog GS-441524 strongly inhibits feline infectious peritonitis (FIP) virus in tissue culture and experimental cat infection studies Incubation period of 2019 novel coronavirus (2019-nCoV) infections among travellers from Wuhan, China Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents Covid-19 -Navigating the Uncharted Presumed Asymptomatic Carrier Transmission of COVID-19