29 Case 2-2020: A 32-year-old male with fever, rhinorrhea and myalgia

A COVID-19 patient with multiple negative results for PCR assays outside Wuhan, China: a case report. BMC Infectious Diseases, 20(1). 2020. doi: 10.1186/s12879-020-05245-7

Chen, L., Li, H., Ye, Y., Wu, Z., Huang, Y., Zhang, W., & Lin, L.

Case Summary 1

A 32-year-old male was admitted with an unexplained fever for six days, nasal congestion, rhinorrhea, fatigue, and myalgia. He had no cough, hemoptysis, headache, sore throat, shortness of breath, nausea, or diarrhea. He had a travel history of Wuhan city 10 days before admission. Five days before admission, no abnormalities were noted in leucocyte and lymphocyte count, chest radiography. Nasopharyngeal swab test for the SARS-CoV-2 nucleic acid was found negative. Six days after the onset of fever, the patient was admitted, and chest computed tomography showed multiple ground-glass opacities in the right lower lung field. The patient’s laboratory results revealed reduced leucocyte and white blood cell counts, and elevated alanine aminotransferase (ALT), aspartate aminotransferase (AST), γ-glutamyl transpeptidase (GGT), and high-sensitivity C-reactive protein (hs-CRP). Three (Jan 29, Jan 30, and Feb 1, 2020) nasopharyngeal swab specimens were collected after admission. However, none of the specimens were positive for COVID-19. This was followed by another, nasopharyngeal swab specimen on Feb 2, 2020, with a positive mild COVID-19 finding using a cycle threshold value (Ct-value) less than 37 for polymerase chain reaction (PCR), and the patient was finally diagnosed as COVID –19. 

 


Learning Objectives

  • Investigating the clinical history of the patient and selecting appropriate examinations needed to diagnosis of COVID-19.
  • Understanding the typical symptoms of COVID-19 and identifying those presented in the patient.
  • Discuss reasons for potential false-positive and false-negative RT-PCR results for COVID-19.

Clinical History 1

  • Age:  32 years old
  • Sex:  Male

Medical History 1

  • No underlying medical condition. 

Travel History 1

  • History of travel to Wuhan city 10 days back. 

Symptoms 1

  • Fever
  • Nasal congestion, rhinorrhea
  • Fatigue
  • Myalgia

 

Examinations (Clinical Assays/Tests/Imaging) 1

Physical Examination 1

  • Body temperature: 38.4oC (normal oral temperature 35.7-37.7oC) 8
  • Respiratory rate: 22 breaths/min (normal range 12 to 20 breaths/min)9
  • Blood pressure: 124/82 mmHg.
  • Pulse rate: 113 beats/min (normal range 60-100 beats/min)10
  • Physical examination of lungs: Normal.

Blood Investigations 1

Blood investigations

Chest X-ray 1

Chest X-ray 5 days before admission showed no abnormality.
Figure 1: Chest X-ray 5 days before admission showed no abnormality. 1

High-Resolution CT (computed tomography) Scan 1

B and C- Chest CT showed multiple ground glass infiltrates (yellow arrows) in right lower lung field (admission day). D- Repeat chest CT displayed larger areas of ground glass opacities (yellow arrows) in both lower lung with a peripheral distribution (day 8). E- Repeat chest CT showed remission of lung lesions, with reduced density of ground glass opacities (day 17).
Figure 3: B and C- Chest CT showed multiple ground-glass infiltrates (yellow arrows) in right lower lung field (admission day). D- Repeat chest CT displayed larger areas of ground-glass opacities (yellow arrows) in both lower lungs with a peripheral distribution (day 8). E- Repeat chest CT showed remission of lung lesions, with reduced density of ground-glass opacities (day 17). 1

 

Question & Answers Leading to Diagnosis: 

Question 1: Based on the patient’s symptoms and travel history what will be the possible diagnosis? What investigation(s) can confirm this diagnosis? 

Question 2: Considering the initial RT-PCR results were negative and normal chest X-ray findings, what investigations can be done to further support this patient’s diagnosis?

Question 3: What is indicative of the elevated alanine aminotransferase, aspartate aminotransferase and y-glutamine transpeptidase?

Question 4: Why does the repeated initial RT- PCR show negative results?

** For answers please check the next chapter.

 

Medical terminology/Abbreviations: 

  • Lymphopenia – Reduced leukocytes count.5 
  • Leukopenia – A low white blood cell count.5
  • Rhinorrhea – Rhinorrhea refers to a thin, mostly clear nasal discharge.6
  • Myalgia – Myalgia describes muscle aches and pain, which can involve ligaments, tendons, and fascia, the soft tissues that connect muscles, bones, and organs.7 

 

References

  1. Chen, L., Li, H., Ye, Y., Wu, Z., Huang, Y., Zhang, W., & Lin, L. (2020). A COVID-19 patient with multiple negative results for PCR assays outside Wuhan, China: a case report. BMC Infectious Diseases, 20(1). doi: 10.1186/s12879-020-05245-7
  2. Pan Y, Zhang D, Yang P, Poon LLM, Wang Q. Viral load of SARS-CoV-2 in clinical samples. Lancet Infect Dis. 2020;20(4):411–2.
  3. Zhang R, Li JM. The way to reduce the “false negative results” of 2019 novel coronavirus nucleic acid detection. Zhonghua Yi Xue Za Zhi. 2020;100(11):801–4.
  4. Carotti, M., Salaffi, F., Sarzi-Puttini, P., Agostini, A., Borgheresi, A., & Minorati, D. et al. (2020). Chest CT features of coronavirus disease 2019 (COVID-19) pneumonia: key points for radiologists. La Radiologia Medica, 125(7), 636-646. doi: 10.1007/s11547-020-01237-4
  5. Low white blood cell count. (2021). Retrieved 6 May 2021, from https://www.mayoclinic.org/symptoms/low-white-blood-cell-count/basics/definition/sym-20050615
  6. Reach for relief from a runny nose. (2021). Retrieved 6 May 2021, from https://www.mayoclinic.org/symptoms/runny-nose/basics/definition/sym-20050640
  7. Myalgia. (2021). Retrieved 6 May 2021, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/myalgia
  8. Sund-Levander, M., Forsberg, C., & Wahren, L. (2002). Normal oral, rectal, tympanic and axillary body temperature in adult men and women: a systematic literature review. Scandinavian Journal Of Caring Sciences, 16(2), 122-128. doi: 10.1046/j.1471-6712.2002.00069.x
  9. Chourpiliadis, C., & Bhardwaj, A. (2021). Physiology, Respiratory Rate. Retrieved 6 May 2021, from https://www.ncbi.nlm.nih.gov/books/NBK537306/
  10. Vital Signs (Body Temperature, Pulse Rate, Respiration Rate, Blood Pressure). (2021). Retrieved 6 May 2021, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/vital-signs-body-temperature-pulse-rate-respiration-rate-blood-pressure
  11. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, HuiDSC, et al. Clinical characteristics of coronavirus disease 2019 in China. NEngl J Med. 2020;382(18):1708–20.
  12. Böger, B., Fachi, M., Vilhena, R., Cobre, A., Tonin, F., & Pontarolo, R. (2021). Systematic review with meta-analysis of the accuracy of diagnostic tests for COVID-19. American Journal Of Infection Control, 49(1), 21-29. doi: 10.1016/j.ajic.2020.07.011
  13. Echocardiogram. (n.d.). Cleveland Clinic. Retrieved March 16, 2021, from https://my.clevelandclinic.org/health/diagnostics/16947-echocardiogram#:~:text=An%20echocardiogram%20(echo)%20is%20a,pumping%20action%20of%20the%20heart
  14. Coronary angiography. (n.d.). Medine Plus. Retrieved March 16, 2021, from https://medlineplus.gov/ency/article/003876.htm
  15. Pasupathy, S. Tavella, R. & Beltrame, J. F. (2017). Myocardial Infarction With Nonobstructive Coronary Arteries (MINOCA)The Past, Present, and Future Management. Circulation, 135(16), 1490-1493. https://doi.org/10.1161/CIRCULATIONAHA.117.027666

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This post is adapted for the Health & Medical Case Studies created by the Master of Medical Biotechnology program of the University of Windsor. This work is licensed under a Creative Commons Attribution-NonCommercial (CC BY-NC-ND) 4.0 International License.

 

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Case 2-2020: A 32-year-old male with fever, rhinorrhea and myalgia Copyright © by Chen, L., Li, H., Ye, Y., Wu, Z., Huang, Y., Zhang, W., & Lin, L. is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, except where otherwise noted.

Digital Object Identifier (DOI)

https://doi.org/10.1186/s12879-020-05245-7

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