key: cord-0999557-lwxt4587 authors: Song, Lingjie; Xiao, Guibao; Zhang, Xianqin; Gao, Zhan; Sun, Shixia; Zhang, Lin; Feng, Youjun; Luan, Guangxin; Lin, Sheng; He, Miao; Jia, Xu title: A case of SARS-CoV-2 carrier for 32 days with several times false negative nucleic acid tests date: 2020-04-06 journal: nan DOI: 10.1101/2020.03.31.20045401 sha: 1e9e49c61f59af170fdf93aa0442edf7d9d1f15f doc_id: 999557 cord_uid: lwxt4587 In 2019, a novel coronavirus (SARS-CoV-2) was first discovered in Wuhan, Hubei, China, causing severe respiratory disease in humans, and has been identified as a public health emergency of international concern. With the spread of the virus, there are more and more false negative cases of RT-PCR nucleic acid detection in the early stage of potential infection. In this paper, we collected the epidemiological history, clinical manifestations, outcomes, laboratory results and images of a SARS-CoV-2 carrier with no significant past medical history. The patient was quarantined because of her colleague had been diagnosed. After the onset of clinical symptoms, chest CT results showed patchy ground-glass opacity (GGO) in her lungs, but it took a total of nine nucleic acid tests to confirm the diagnosis, among which the first eight RT-PCR results were negative or single-target positive. In addition to coughing up phlegm during her stay in the hospital, she did not develop chills, fever, abdominal pain, diarrhea and other clinical symptoms. Since initial antiviral treatment, the lung lesions were absorbed. But the sputum nucleic acid test was still positive. In combination with antiviral and immune therapy, the patient tested negative for the virus. Notably, SARS-CoV-2 was detected only in the lower respiratory tract samples (sputum) throughout the diagnosis and treatment period. This is a confirmed case of SARS-CoV-2 infection with common symptoms, and her diagnosis has undergone multiple false negatives ,suggesting that it is difficult to identify certain carriers of the virus and that such patients may also increase the spread of the SARS-CoV-2. Since the outbreak of severe acute respiratory syndrome (SARS) coronavirus 2 (SARS-CoV-2) in Wuhan (Hubei, China) in December 2019 [1] , it has spread rapidly across the globe and has become a major public health emergency worldwide. The international commission classification of viruses (ICTV) announced that 2019-nCoV was officially classified as SARS-CoV-2 [2] . The world health organization (WHO) announced that the official name of the disease caused by this virus is coronavirus disease (COVID-19) [3] . The outbreak has led the Chinese government to take drastic measures to contain the outbreak, including isolating millions of residents in Wuhan and other affected cities. According to the "Diagnosis and Treatment of COVID-19 (Trial Version 7)", the disease must be confirmed by reverse transcription polymerase chain reaction (RT-PCR) or pathogen gene sequencing from respiratory, digestive and blood samples. The RT-PCR test is often used for clinical detection. Recently, it has been reported that the patients had clinical symptoms but their nasopharyngeal swab showed negative RT-PCR results [4] . Thus, it is necessary to study the causes of these multiple RT-PCR negative results. In order to better diagnose COVID-19, this study analyzed a case whose eight RT-PCR tests were negative. According to the epidemiological history and clinical data of the case, this study aimed to better diagnose the incubation period and asymptomatic patients by combining different diagnostic methods, thus reducing the spread of the disease. This study investigated a case of highly suspected SARS-CoV-2 infection admitted to a hospital. The results of RT-PCR were negative for eight times and positive for the ninth time. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10.1101/2020.03.31.20045401 doi: medRxiv preprint The epidemiological and clinical data from the information system of the hospital, including possible exposure to pathogens, visits to health facilities, hospitalization, treatment, pathogens and laboratory tests, and clinical results etc. were collected by an investigator. The records were verified by another investigator. A third researcher further verified the data by cross-checking the information in the medical records system and attending physician. The original image of chest computed tomography (CT) was provided by the local county people's hospital. According to the guidelines released by the National Health Commission of People's Republic of China (NHC of China), nucleic acid testing kits were used. The samples were throat swabs, sputum, anal swabs, feces and plasma. The detection kit simultaneously detected three target genes of SARS-CoV-2, including RdRp, envelop protein (E) and nucleocapsid protein (N). The reported case was a middle-aged woman who worked in a hotel and returned home on January 23. She has not been to any other places since returning home, has no contact with people returning from the affected areas, has no travel history to Wuhan and has denied any contact with wild animals. The patient had been admitted to a local health clinic for coughing after a cold. After her colleagues were diagnosed with COVID-19, the patient was transferred to the local county people's Hospital for isolation and observation on February 2. It was later learned that about 8 colleagues were diagnosed with COVID-19. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Arbidol tablets were given on the day of admission for 10 consecutive days and . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint . https://doi.org/10.1101/2020.03.31.20045401 doi: medRxiv preprint chloroquine phosphate tablets were continuous used for 8 days. Imaging examination showed that the lung lesions were absorbed before comparison (Fig3). But the nucleic acid test of sputum fluid was still positive. On March 3, arbidol tablets were discontinued and lopinavir/ritonavir tablets were used instead. Meantime she was treated with aerosolized interferon α1β to continue antiviral treatment. Combined with moxifloxacin antibacterial therapy and immunotherapy, the patient's symptoms were alleviated. After 20 days hospitalization, the patient's physical examination showed good results that the vital signs were normal, clear in mind, mentally acceptable, no dry and wet rales in both lungs, no positive signs were found in heart and abdomen, and the pathological signs were negative. Although the patients still had occasional cough and sputum, a small amount of white foam-like sputum, fearless of cold, fever, dyspnea, but had no abdominal pain and diarrhea, indicating that the general condition of the patient was normal. After discussion by the expert group, the patient met the discharge standards. She was discharged on March 12. Since admission on February 21, a total of eleven SARS-CoV-2 nucleic acid tests have been performed on the patient. The samples that tested positive were sputum, and the rest were negative. The specific test results were shown in Table 2 . This article reported a case of SARS-CoV-2 infection that was negative for eight RT-PCR tests. The patient has had close contact with a confirmed patient and belongs to the third or fourth generation of transmission patients [5] . Other than cough, there were no other clinical symptoms such as fever, fatigue, muscle pain, and the infection status was hidden at early stage. The patient has been infected for at least 32 days, and a total of eight RT-PCR tests were negative or single-target positive before the diagnosis. The . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint . https://doi.org/10.1101/2020.03.31.20045401 doi: medRxiv preprint number of tests was more than the current report and took a long time. Although the nucleic acid test was negative or single-target positive, the low number of white blood cells and lymphocytes in laboratory tests, and GGO in the lungs by CT examination indicated SARS-CoV-2 infection. It can be seen that using RT-PCR as a nucleic acid test cannot completely rule out SARS-CoV-2 infection. There are several factors that may cause the negative results when troubleshooting sampling and transportation issues. First, sample collection. Same as SARS-CoV [6, 7] , the functional receptor targeted by SARS-CoV-2 is angiotensin-converting enzyme 2 (ACE2) [8] . RT-PCR results [4] . For such infected persons, it is necessary to combine the efficient SARS-CoV-2 capture sequencing to detect viral nucleic acids, helping clinical diagnoses. In addition, because the RNA virus is susceptible to mutation, sequencing of . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint . https://doi.org/10.1101/2020.03.31.20045401 doi: medRxiv preprint pathogenic nucleic acid genomes from samples of asymptomatic and occult infected patients is also conducive to studying the virus mutations in the pathogenic genes providing a basis for subsequent virus tracing and epidemiological investigations. As the virus spreads, research data from Chen et al [15] showed that the initial symptoms of newly infected patients seemed to be more subtle, and the virus may lie in asymptomatic carriers for a long time. Similarly, our study also showed that it is also We report the epidemiological history and clinical information of a patient with negative (or single-target positive) SARS-CoV-2 infection with multiple RT-PCR tests. The present case indicates that mild patients with virus-free or low-load in the upper respiratory tract may mainly cause several RT-PCR results false negatives during the diagnosis. Therefore, it is recommended to strengthen the detection and isolation of . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint . https://doi.org/10.1101/2020.03.31.20045401 doi: medRxiv preprint asymptomatic or mild patients to avoid the wide spread of COVID-19. This study was approved by the ethics commissions of the participating hospitals, with a waiver of informed consent. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The authors declare that there are no conflicts of interest. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint . https://doi.org/10.1101/2020.03.31.20045401 doi: medRxiv preprint . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint . https://doi.org/10.1101/2020.03.31.20045401 doi: medRxiv preprint . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint . https://doi.org/10.1101/2020.03.31.20045401 doi: medRxiv preprint . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10.1101/2020.03.31.20045401 doi: medRxiv preprint Table 2 . RT-PCR results of different samples . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not peer-reviewed) The copyright holder for this preprint . https://doi.org/10.1101/2020.03.31.20045401 doi: medRxiv preprint The continuing 2019-nCoV epidemic threat of novel coronaviruses to global health -The latest 2019 novel coronavirus outbreak in Wuhan A new coronavirus associated with human respiratory disease in China A novel coronavirus outbreak of global health concern Negative Nasopharyngeal and Oropharyngeal Swab Does Not Rule Out COVID-19 A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster A crucial role of angiotensin converting enzyme 2 (ACE2) in SARS coronavirus-induced lung injury Tissue distribution of ACE2 protein, the functional receptor for SARS coronavirus. A first step in understanding SARS pathogenesis Structure, Function, and Antigenicity of the SARS-CoV-2 Spike Glycoprotein. Cell Viral load of SARS-CoV-2 in clinical samples