（都于）美国首例新冠病毒确诊病例康复全记录（中英文）

摘要

在里国成都开始的新型冠状SARS病毒（2019-nCoV）推生进一步蔓延，现已在多个国家政府确诊。我们分析报告了在英国断定的元年初2019-nCoV感染者SARS，并描绘了该SARS的鉴定，诊疗，医学不远处理过程和监管，举例来说腹泻在中风第9天所列现为败血病时的本来轻度腹泻。

该事例忽略了医学外科医生与地方，爱达荷州和合众国各级公共保健当局错综复杂密切协作的优越性，以及并不需要短时间内传递与这种新推感染者腹泻的医疗有关的医学个人信息的所需。

2019年12年初31日，里国分析报告了与湖北省衡阳市华中菜式批推市场竞争有关的成年人里的败血病SARS。

2020年1年初7日，里国保健当局断定该簇与新型冠状SARS病毒2019-nCoV有关。尽管本来华盛顿邮报的SARS与衡阳市菜式市场竞争的暴露出有关，但这两项的医学研究信息所列明，悄悄推生2019-nCoV社交传递。

截至2020年1年初30日，在非常少21个国家政府/北部分析报告了9976例SARS，举例来说2020年1年初20日华盛顿邮报的英国元年初确诊的2019-nCoV感染者SARS。

仅有球之内内悄悄同步进行调查，以更容易地认识传递静态和医学传染病之内。本分析报告描绘了在英国断定的元年初2019-nCoV感染者的医学研究和医学皆观上。

事例分析报告

2020年1年初19日，一名35岁的男子借助于现在华盛顿爱达荷州华莱士霍米孟加拉国的一家急诊托儿所，有4天的咳嗽和主观咳嗽两书。病人到托儿所氢查时，在候诊室戴上沟罩。等待约20分钟后，他被带进氢查室遵从了缺少商的评氢。

他谈及，他在里国成都拜访父母后于1年初15日来到华盛顿爱达荷州。该腹泻所列示，他已从英国传染病控制与预防措施里心（CDC）收到有关里国新型冠状SARS病毒暴推的身心健康警报，由于他的腹泻和值得注意的周游世界，他提议去看外科医生。

上图1-2020年1年初19日（传染病第4天）的后腰部和皆侧胸片

除了高二酸酯血病的病两书皆，该腹泻还是其他身心健康的不吸烟。体格氢查挖掘出腹泻排尿环境液体时，代谢率为37.2°C，血压为134/87 mm Hg，----为每分钟110次，排尿频率为每分钟16次，氨一般来说为96％。脊柱听诊看出有病病，并同步进行了胸片氢查，据华盛顿邮报并未挖掘出极其（上图1）。

当季型和乙型SARS的短时间内小分子倍增验证（NAAT）为复数。取得了颈咽拭子化石，并通过NAAT将其送去去扫描SARS病毒性排尿道致病。

据华盛顿邮报在48时长内对所有验证的致病原则上深褐色复数，举例来说当季型和乙型SARS，副SARS，排尿道合胞SARS病毒，颈SARS病毒，腺SARS病毒和已知但会导致人类传染病的四种类似于冠状SARS病毒株（HKU1，NL63、229E和OC43） ）。根据腹泻的周游世界近代，立即事先地方和爱达荷州保健部门。华盛顿保健部与紧急状况医疗医学外科医生一齐事先了CDC紧急状况行动里心。

尽管该腹泻分析报告说他从并未去过华中菜式市场竞争，也从并未分析报告在去里国周游世界期间与得病者有任何交谈，但传染病预防措施控制里心的监管人员拒绝有必要根据这两项的传染病预防措施控制里心对腹泻同步进行2019-nCoV验证。

根据CDCGuide搜罗了8个化石，举例来说抗体，颈咽和沟咽拭子化石。化石挖掘出后，腹泻被送去往家庭分开，并由当地保健部门同步进行积极监测。

2020年1年初20日，传染病预防措施控制里心（CDC）断定腹泻的颈咽和沟咽拭子通过系统对丝氨酸-磷酸化羧化（rRT-PCR）扫描为2019-nCoV阴性。

在传染病预防措施控制里心的主题专家学者，爱达荷州和地方保健地方官，紧急状况医疗服务以及病房拥护和监管人员的适时下，腹泻被送去往普罗维登斯北部医疗里心的液体分开病房同步进行医学捕捉到，并一同传染病预防措施控制里心的护理人员有关交谈，飞沫和空里防措施的建言，并带有护目镜。

病倒时腹泻分析报告短时间咳嗽，有2天的眩晕和呕吐两书。他分析报告说他从并未排尿急促或胸痛。灵魂医学所列现在正常之内内。体格氢查挖掘出腹泻粘膜干燥。其余的氢查并不一定不值得注意。

病倒后，腹泻遵从了支持用药，举例来说2升到生理盐水和恩丹以缓解眩晕。

上图2-根据传染病日和出院日（2020年1年初16日至2020年1年初30日）的腹泻和最高代谢率

在出院的第2至5天（得病的第6至9天），腹泻的灵魂医学所列现基本维持稳定，除了借助于现暂时性咳嗽并伴有心动过速（上图2）。腹泻此前分析报告非生产性咳嗽，并借助于现疲倦。

在出院第二天的上午，腹泻阴部在行，腹部不适。清晨有第二次小便稠密的华盛顿邮报。搜罗该老鼠的样品用作rRT-PCR验证，以及其他排尿道化石（颈咽和沟咽）和抗体。老鼠和两个排尿道化石后来原则上通过rRT-PCR扫描为2019-nCoV阴性，而抗体仍为复数。

在此期间的用药在很大程度上是提供者的。为了同步进行腹泻不远处理，腹泻并不需要根据并不需要遵从功效疗法，该疗法举例来说每4时长650 mg本品和每6时长600 mg非甾体。在出院的前六天，他还因短时间咳嗽而服用了600毫克够创醚友好条约6升到生理盐水。

所列1-医学研究小组结果

腹泻分开两节的形式本来仅允许即时医疗点研究小组验证；从病房第3天开始可以同步进行仅有红细胞计数器和抗体化学学术研究。

在病房第3天和第5天（传染病第7天和第9天）的研究小组结果反映借助于红血球减低病，轻度血小板减低病和肌酸激酶程度升到高（所列1）。此皆，肝脏指标也大为变动：水溶性磷酸酶（每升到68 U），丙氨酸氨基转移酶（每升到105 U），天冬氨酸氨基转移酶（每升到77 U）和代谢脱氢酶（每升到465 U）的程度分别为：在出院的第5天所有升到高。鉴于腹泻反复咳嗽，在第4天取得血液人才；迄今为止，这些都从并未增长。

上图3-2020年1年初22日（面部第7天，病房第3天）的后腰部和皆侧胸片

上图4-2020年1年初24日（面部第5天，病房第9天）的后腰部X线片

据华盛顿邮报，在病房第3天（得病第7天）开拍的面部X光片并未看出增生或极其精神状态（上图3）。

但是，从病房第5天清晨（得病第9天）清晨同步进行的第二次面部X光片氢查看出，左肺下叶有败血病（上图4）。

这些医学影像挖掘出与从病房第5天清晨开始的排尿状态变动相吻合，此前腹泻在排尿外面液体时通过----血氨一般来说校准的血氨一般来说参数降至90％。

在第6天，腹泻开始遵从足量氨，该氨由颈毛细管以每分钟2升到的反应速度输送去。考虑到医学所列现的变动和对病房取得性败血病的关注，开始采用水杨酸（1750 mg负荷剂量，然后每8时长低剂量1 g）和头孢菌素夺标肟（每8时长低剂量）用药。

上图5-前后面部X光片，2020年1年初26日（传染病第十天，病房第六天）

在病房第6天（得病第10天），第四次面部X射线剧照看出两个肺里都有基底条状混浊，这一挖掘出与非典型败血病相符合（上图5），并且在听诊时在两个肺里都借助于现了罗音。鉴于放射治疗医学影像挖掘出，提议得到氨足量，腹泻短时间咳嗽，多个部位短时间阴性的2019-nCoV RNA阴性，以及推所列了与放射治疗性败血病的推展一致的致使败血病在该腹泻里，医学外科医生与众不同同情心地采用了学术各学科免疫用药。

低剂量珍妮昔韦（一种悄悄合作开推的新型氢苷酸类似物前药）在第7天清晨开始，但并未捕捉到到与输注有关的妨碍惨剧。在对当季氨西林病毒性的淡黄色葡萄球菌同步进行了周内的降钙素原程度和颈PCR扫描后，在第7天清晨拆去水杨酸，并在第二天拆去头孢菌素夺标肟。

在病房第8天（得病第12天），腹泻的医学状况获得增加。中止足量氨，他在排尿外面液体时的氨一般来说参数减低到94％至96％。更进一步的双侧下叶罗音不再存在。他的食欲获得增加，除了暂时性干咳和颈漏皆，他从并未腹泻。

截至2020年1年初30日，腹泻仍出院。他有推热，除咳嗽皆，所有腹泻原则上已缓解，咳嗽的程度悄悄减轻。

方法有

化石挖掘出

根据CDCGuide取得用作2019-nCoV诊疗验证的医学化石。用合成纤维拭子搜罗了12个颈咽和沟咽拭子化石。

将每个拭子弹出举例来说2至3 mlSARS病毒转运介质的单独施用管里。将血集在抗体分离管里，然后根据CDCGuide同步进行离心。分泌物和老鼠化石分别搜罗在施用化石容器里。样品在2°C至8°C错综复杂贮存，直到准备好运往去至CDC。

在传染病的第7、11和12天搜罗了以此类推同步进行的2019-nCoV验证的化石，举例来说颈咽和沟咽拭子，抗体以及分泌物和老鼠比对。

2019-NCOV的诊疗验证

采用从公合作开推布的SARS病毒真氢生物的推展而来的rRT-PCR新方法验证了医学化石。与更进一步针对高血压急性排尿综合征冠状SARS病毒（SARS-CoV）和里东排尿综合征冠状SARS病毒（MERS-CoV）的诊疗方法有完全相同，它不具三个氢亚基DNA抗病毒和一个阴性对照抗病毒。该校准的描绘为RRT-PCR机壳引物和电子束和真氢生物个人信息里必需的CDC研究小组个人信息网页2019-nCoV上。

DNA突变脱氧氢糖小分子

2020年1年初7日，里国学术研究人员通过英国国立保健学术研究中心GenBank信息库和仅有球缺少者所有SARS信息倡议（GISAID）信息库缺少者了2019-nCoV的参数得注意DNA真氢生物；随后推布了有关分开2019-nCoV的分析报告。

从rRT-PCR阴性化石（沟咽和颈咽）里萃取小分子，并在Sanger和将来脱氧氢糖小分子平台（Illumina和MinIon）上用作仅有真氢生物脱氧氢糖小分子。采用5.4.6特别版的Sequencher软件（Sanger）完成了真氢生物组装。minimap软件，特别版本2.17（MinIon）；和freebayes软件1.3.1特别版（MiSeq）。将参数得注意真氢生物与必需的2019-nCoV参阅真氢生物（GenBank登录号NC_045512.2）同步进行较为。

结果

2019-NCOV的化石验证

所列2-2019年新型冠状SARS病毒（2019-nCoV）的系统对丝氨酸-磷酸化-羧化验证结果

该腹泻在得病第4天时取得的初始排尿道比对（颈咽拭子和沟咽拭子）在2019-nCoV深褐色阴性（所列2）。

尽管腹泻本来所列现为轻度腹泻，但在传染病第4天的高于反转阈参数（Ct）参数（颈咽化石里为18至20，沟咽化石里为21至22）所列明这些化石里SARS病毒程度很低。

在传染病第7天取得的两个上排尿道化石在2019-nCoV仍维持阴性，举例来说颈咽拭子化石里短时间多全面性（Ct参数23至24）。在传染病第7天取得的老鼠在2019-nCoV里也深褐色阴性（Ct参数为36至38）。两种挖掘出迟于的抗体比对在2019-nCoV原则上为复数。

在传染病第11天和第12天取得的颈咽和沟咽化石看出借助于SARS病毒程度下降的趋向于。

沟咽化石在得病第12天的2019-nCoV验证深褐色复数。在这些迟于取得的抗体的rRT-PCR结果仍定。

DNA突变脱氧氢糖小分子

沟咽和颈咽化石的参数得注意真氢生物真氢生物彼此相近，并且与其他必需的2019-nCoV真氢生物大部分相近。

该腹泻的SARS病毒与2019-nCoV参阅真氢生物（NC_045512.2）在中止使用读者框8不远处仅有3个氢苷酸和1个不同。该真氢生物可通过GenBank取得（登录号MN985325）。

讨论区

我们关于英国元年初2019-nCoV确诊SARS的分析报告看出这一新兴传染病的几个全面性由此可知并未完仅有认识，举例来说传递静态和医学传染病的仅有部之内。

我们的SARS腹泻曾去过里国成都，但分析报告说他在成都期间从并未去过菜式批推市场竞争或附属医院，也从并未生病的交谈。尽管他的2019-nCoV感染者的全面性联由此可知不可信，但已引起争议了人对人传递的论据。

到2020年1年初30日，由此可知并未挖掘出与此SARS全面性的2019-nCoV继推SARS，但仍在密切警卫下。

在传染病的第4天和第7天从上排尿道化石里扫描到不具高于Ct参数的2019-nCoV RNA，所列明SARS病毒载重高且不具传递潜力。

参数得注意的是，我们还在腹泻得病第7天搜罗的老鼠比对里扫描到了2019-nCoV RNA。尽管我们SARS腹泻的抗体化石反复借助于现2019-nCoV复数，但在里国高血压腹泻的血液里仍扫描到SARS病毒RNA。然而，肺皆扫描SARS病毒RNA并不一定理论上存在传染性SARS病毒，迄今由此可知不可信在排尿道皆部扫描SARS病毒RNA的医学意义。

迄今，我们对2019-nCoV感染者的医学之内的认识非常局限。在里国，仍然华盛顿邮报了诸如致使的败血病，中风，急性排尿拮据综合征（ARDS）和脊柱损伤等并推病，举例来说骇人的后果。然而，重要的是要注意，这些SARS是根据其败血病诊疗断定的，因此或许但会使分析报告保守更致使的结果。

我们的SARS腹泻本来所列现为轻度咳嗽和高于度暂时性咳嗽，在得病的第4天从并未面部X光氢查的败血病精神状态，而在得病第9天的推展为败血病此前，这些非特异性医学所列现和腹泻在中期在医学上，2019-nCoV感染者的医学不远处理过程或许与许多其他类似于传染病从并未值得注意区别，相比之下是在秋季排尿道SARS病毒季节。

另皆，本SARS腹泻在传染病的第9天的推展为败血病的尽早与早先排尿困难的推作（得病后里位数为8天）一致。尽管根据腹泻的医学状况衰弱提议是否是得到remdesivir至诚的采用，但仍并不需要同步进行系统性试验以断定remdesivir和任何其他学术研究药物用药2019-nCoV感染者的安仅有性和有效性。

我们分析报告了英国元年初分析报告的2019-nCoV感染者腹泻的医学皆观上。

该SARS的关键全面性举例来说腹泻在读者有关暴推的公共保健警告后提议促成医疗；由当地医疗服务缺少商断定腹泻值得注意到成都的周游世界近代，随后在当地，爱达荷州和合众国公共保健地方官错综复杂同步进行协调；并断定或许的2019-nCoV感染者，从而可以进一步分开腹泻并随后对2019-nCoV同步进行研究小组断定，并允许腹泻病倒更进一步评氢和监管。

该SARS分析报告忽略了医学外科医生对于任何借助于现急性传染病腹泻的出院腹泻，要归纳借助于值得注意的周游世界漫长或交谈病两书的优越性，为了确保准确识别和及时分开或许陷入2019-nCoV感染者风险的腹泻，并帮助减低更进一步的传递。

之后，本分析报告忽略并不需要断定与2019-nCoV感染者全面性的医学传染病，得病机理和SARS病毒脱落短时间时间的

仅有部之内和自然近代，以为医学监管和公共保健议程缺少依据。

都有为英文特别版

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Summary

An outbreak of novel coronirus (2019-nCoV) that began in Wuhan, China, has spread rapidly, with cases now confirmed in multiple countries. We report the first case of 2019-nCoV infection confirmed in the United States and describe the identification, diagnosis, clinical course, and management of the case, including the patient’s initial mild symptoms at presentation with progression to pneumonia on day 9 of illness. This case highlights the importance of close coordination between clinicians and public health authorities at the local, state, and federal levels, as well as the need for rapid dissemination of clinical information related to the care of patients with this emerging infection.

On December 31, 2019, China reported a cluster of cases of pneumonia in people associated with the Huanan Seafood Wholesale Market in Wuhan, Hubei Province.

On January 7, 2020, Chinese health authorities confirmed that this cluster was associated with a novel coronirus, 2019-nCoV.

Although cases were originally reported to be associated with exposure to the seafood market in Wuhan, current epidemiologic data indicate that person-to-person transmission of 2019-nCoV is occurring.

As of January 30, 2020, a total of 9976 cases had been reported in at least 21 countries,including the first confirmed case of 2019-nCoV infection in the United States, reported on January 20, 2020.

Investigations are under way worldwide to better understand transmission dynamics and the spectrum of clinical illness.

This report describes the epidemiologic and clinical features of the first case of 2019-nCoV infection confirmed in the United States.

Case Report

On January 19, 2020, a 35-year-old man presented to an urgent care clinic in Snohomish County, Washington, with a 4-day history of cough and subjective fever.

On checking into the clinic, the patient put on a mask in the waiting room. After waiting approximately 20 minutes, he was taken into an examination room and underwent evaluation by a provider. He disclosed that he had returned to Washington State on January 15 after treling to visit family in Wuhan, China.

The patient stated that he had seen a health alert from the U.S. Centers for Disease Control and Prevention (CDC) about the novel coronirus outbreak in China and, because of his symptoms and recent trel, decided to see a health care provider.

Figure 1.Posteroanterior and Lateral Chest Radiographs, January 19, 2020 (Illness Day 4).

Apart from a history of hypertriglyceridemia, the patient was an otherwise healthy nonsmoker. The physical examination revealed a body temperature of 37.2°C, blood pressure of 134/87 mm Hg, pulse of 110 beats per minute, respiratory rate of 16 breaths per minute, and oxygen saturation of 96% while the patient was breathing ambient air. Lung auscultation revealed rhonchi, and chest radiography was performed, which was reported as showing no abnormalities (Figure 1).

A rapid nucleic acid amplification test (NAAT) for influenza A and B was negative. A nasopharyngeal swab specimen was obtained and sent for detection of viral respiratory pathogens by NAAT; this was reported back within 48 hours as negative for all pathogens tested, including influenza A and B, parainfluenza, respiratory syncytial virus, rhinovirus, adenovirus, and four common coronirus strains known to cause illness in humans (HKU1, NL63, 229E, and OC43).

Given the patient’s trel history, the local and state health departments were immediately notified. Together with the urgent care clinician, the Washington Department of Health notified the CDC Emergency Operations Center.

Although the patient reported that he had not spent time at the Huanan seafood market and reported no known contact with ill persons during his trel to China, CDC staff concurred with the need to test the patient for 2019-nCoV on the basis of current CDC “persons under investigation” case definitions.

Specimens were collected in accordance with CDC guidance and included serum and nasopharyngeal and oropharyngeal swab specimens. After specimen collection, the patient was discharged to home isolation with active monitoring by the local health department.

On January 20, 2020, the CDC confirmed that the patient’s nasopharyngeal and oropharyngeal swabs tested positive for 2019-nCoV by real-time reverse-transcriptase–polymerase-chain-reaction (rRT-PCR) assay.

In coordination with CDC subject-matter experts, state and local health officials, emergency medical services, and hospital leadership and staff, the patient was admitted to an airborne-isolation unit at Providence Regional Medical Center for clinical observation, with health care workers following CDC recommendations for contact, droplet, and airborne precautions with eye protection.

On admission, the patient reported persistent dry cough and a 2-day history of nausea and vomiting; he reported that he had no shortness of breath or chest pain. Vital signs were within normal ranges. On physical examination, the patient was found to he dry mucous membranes. The remainder of the examination was generally unremarkable. After admission, the patient received supportive care, including 2 liters of normal saline and ondansetron for nausea.

Figure 2.Symptoms and Maximum Body Temperatures According to Day of Illness and Day of Hospitalization, January 16 to January 30, 2020.

On days 2 through 5 of hospitalization (days 6 through 9 of illness), the patient’s vital signs remained largely stable, apart from the development of intermittent fevers accompanied by periods of tachycardia (Figure 2).

The patient continued to report a nonproductive cough and appeared fatigued. On the afternoon of hospital day 2, the patient passed a loose bowel movement and reported abdominal discomfort. A second episode of loose stool was reported overnight; a sample of this stool was collected for rRT-PCR testing, along with additional respiratory specimens (nasopharyngeal and oropharyngeal) and serum.

The stool and both respiratory specimens later tested positive by rRT-PCR for 2019-nCoV, whereas the serum remained negative.

Treatment during this time was largely supportive. For symptom management, the patient received, as needed, antipyretic therapy consisting of 650 mg of acetaminophen every 4 hours and 600 mg of ibuprofen every 6 hours. He also received 600 mg of guaifenesin for his continued cough and approximately 6 liters of normal saline over the first 6 days of hospitalization.

Table 1.Clinical Laboratory Results.

The nature of the patient isolation unit permitted only point-of-care laboratory testing initially; complete blood counts and serum chemical studies were ailable starting on hospital day 3.

Laboratory results on hospital days 3 and 5 (illness days 7 and 9) reflected leukopenia, mild thrombocytopenia, and elevated levels of creatine kinase (Table 1).

In addition, there were alterations in hepatic function measures: levels of alkaline phosphatase (68 U per liter), alanine aminotransferase (105 U per liter), aspartate aminotransferase (77 U per liter), and lactate dehydrogenase (465 U per liter) were all elevated on day 5 of hospitalization.

Given the patient’s recurrent fevers, blood cultures were obtained on day 4; these he shown no growth to date.

Figure 3.Posteroanterior and Lateral Chest Radiographs, January 22, 2020 (Illness Day 7, Hospital Day 3).

Figure 4.Posteroanterior Chest Radiograph, January 24, 2020 (Illness Day 9, Hospital Day 5).

A chest radiograph taken on hospital day 3 (illness day 7) was reported as showing no evidence of infiltrates or abnormalities (Figure 3).

However, a second chest radiograph from the night of hospital day 5 (illness day 9) showed evidence of pneumonia in the lower lobe of the left lung (Figure 4).

These radiographic findings coincided with a change in respiratory status starting on the evening of hospital day 5, when the patient’s oxygen saturation values as measured by pulse oximetry dropped to as low as 90% while he was breathing ambient air.

On day 6, the patient was started on supplemental oxygen, delivered by nasal cannula at 2 liters per minute.

Given the changing clinical presentation and concern about hospital-acquired pneumonia, treatment with vancomycin (a 1750-mg loading dose followed by 1 g administered intrenously every 8 hours) and cefepime (administered intrenously every 8 hours) was initiated.

Figure 5.Anteroposterior and Lateral Chest Radiographs, January 26, 2020 (Illness Day 10, Hospital Day 6).

On hospital day 6 (illness day 10), a fourth chest radiograph showed basilar streaky opacities in both lungs, a finding consistent with atypical pneumonia (Figure 5), and rales were noted in both lungs on auscultation.

Given the radiographic findings, the decision to administer oxygen supplementation, the patient’s ongoing fevers, the persistent positive 2019-nCoV RNA at multiple sites, and published reports of the development of severe pneumonia at a period consistent with the development of radiographic pneumonia in this patient, clinicians pursued compassionate use of an investigational antiviral therapy.

Treatment with intrenous remdesivir (a novel nucleotide ogue prodrug in development) was initiated on the evening of day 7, and no adverse events were observed in association with the infusion.

Vancomycin was discontinued on the evening of day 7, and cefepime was discontinued on the following day, after serial negative procalcitonin levels and negative nasal PCR testing for methicillin-resistant Staphylococcus aureus.

On hospital day 8 (illness day 12), the patient’s clinical condition improved. Supplemental oxygen was discontinued, and his oxygen saturation values improved to 94 to 96% while he was breathing ambient air.

The previous bilateral lower-lobe rales were no longer present. His appetite improved, and he was asymptomatic aside from intermittent dry cough and rhinorrhea.

As of January 30, 2020, the patient remains hospitalized. He is afebrile, and all symptoms he resolved with the exception of his cough, which is decreasing in severity.

Methods

SPECIMEN COLLECTIONClinical specimens for 2019-nCoV diagnostic testing were obtained in accordance with CDC guidelines. Nasopharyngeal and oropharyngeal swab specimens were collected with synthetic fiber swabs; each swab was inserted into a separate sterile tube containing 2 to 3 ml of viral transport medium. Serum was collected in a serum separator tube and then centrifuged in accordance with CDC guidelines. The urine and stool specimens were each collected in sterile specimen containers. Specimens were stored between 2°C and 8°C until ready for shipment to the CDC. Specimens for repeat 2019-nCoV testing were collected on illness days 7, 11, and 12 and included nasopharyngeal and oropharyngeal swabs, serum, and urine and stool samples.

DIAGNOSTIC TESTING FOR 2019-NCOV

Clinical specimens were tested with an rRT-PCR assay that was developed from the publicly released virus sequence. Similar to previous diagnostic assays for severe acute respiratory syndrome coronirus (SARS-CoV) and Middle East respiratory syndrome coronirus (MERS-CoV), it has three nucleocapsid gene targets and a positive control target.

A description of this assay and sequence information for the rRT-PCR panel primers and probes are ailable on the CDC Laboratory Information website for 2019-nCoV.

GENETIC SEQUENCING

On January 7, 2020, Chinese researchers shared the full genetic sequence of 2019-nCoV through the National Institutes of Health GenBank database and the Global Initiative on Sharing All Influenza Data (GISAID) database; a report about the isolation of 2019-nCoV was later published.

Nucleic acid was extracted from rRT-PCR–positive specimens (oropharyngeal and nasopharyngeal) and used for whole-genome sequencing on both Sanger and next-generation sequencing platforms (Illumina and MinIon).

Sequence assembly was completed with the use of Sequencher software, version 5.4.6 (Sanger); minimap software, version 2.17 (MinIon); and freebayes software, version 1.3.1 (MiSeq). Complete genomes were compared with the ailable 2019-nCoV reference sequence (GenBank accession number NC_045512.2).

Results

SPECIMEN TESTING FOR 2019-NCOV

Table 2.Results of Real-Time Reverse-Transcriptase–Polymerase-Chain-Reaction Testing for the 2019 Novel Coronirus (2019-nCoV).

The initial respiratory specimens (nasopharyngeal and oropharyngeal swabs) obtained from this patient on day 4 of his illness were positive for 2019-nCoV (Table 2).

The low cycle threshold (Ct) values (18 to 20 in nasopharyngeal specimens and 21 to 22 in oropharyngeal specimens) on illness day 4 suggest high levels of virus in these specimens, despite the patient’s initial mild symptom presentation.

Both upper respiratory specimens obtained on illness day 7 remained positive for 2019-nCoV, including persistent high levels in a nasopharyngeal swab specimen (Ct values, 23 to 24). Stool obtained on illness day 7 was also positive for 2019-nCoV (Ct values, 36 to 38).

Serum specimens for both collection dates were negative for 2019-nCoV. Nasopharyngeal and oropharyngeal specimens obtained on illness days 11 and 12 showed a trend toward decreasing levels of virus. The oropharyngeal specimen tested negative for 2019-nCoV on illness day 12. The rRT-PCR results for serum obtained on these dates are still pending.

GENETIC SEQUENCING

The full genome sequences from oropharyngeal and nasopharyngeal specimens were identical to one another and were nearly identical to other ailable 2019-nCoV sequences.

There were only 3 nucleotides and 1 amino acid that differed at open reading frame 8 between this patient’s virus and the 2019-nCoV reference sequence (NC_045512.2). The sequence is ailable through GenBank (accession number MN985325).

DISCUSSION

Our report of the first confirmed case of 2019-nCoV in the United States illustrates several aspects of this emerging outbreak that are not yet fully understood, including transmission dynamics and the full spectrum of clinical illness.

Our case patient had treled to Wuhan, China, but reported that he had not visited the wholesale seafood market or health care facilities or had any sick contacts during his stay in Wuhan. Although the source of his 2019-nCoV infection is unknown, evidence of person-to-person transmission has been published.

Through January 30, 2020, no secondary cases of 2019-nCoV related to this case he been identified, but monitoring of close contacts continues.

Detection of 2019-nCoV RNA in specimens from the upper respiratory tract with low Ct values on day 4 and day 7 of illness is suggestive of high viral loads and potential for transmissibility.

It is notable that we also detected 2019-nCoV RNA in a stool specimen collected on day 7 of the patient’s illness. Although serum specimens from our case patient were repeatedly negative for 2019-nCoV, viral RNA has been detected in blood in severely ill patients in China.

However, extrapulmonary detection of viral RNA does not necessarily mean that infectious virus is present, and the clinical significance of the detection of viral RNA outside the respiratory tract is unknown at this time.

Currently, our understanding of the clinical spectrum of 2019-nCoV infection is very limited. Complications such as severe pneumonia, respiratory failure, acute respiratory distress syndrome (ARDS), and cardiac injury, including fatal outcomes, he been reported in China.

However, it is important to note that these cases were identified on the basis of their pneumonia diagnosis and thus may bias reporting toward more severe outcomes.

Our case patient initially presented with mild cough and low-grade intermittent fevers, without evidence of pneumonia on chest radiography on day 4 of his illness, before hing progression to pneumonia by illness day 9.

These nonspecific signs and symptoms of mild illness early in the clinical course of 2019-nCoV infection may be indistinguishable clinically from many other common infectious diseases, particularly during the winter respiratory virus season. In addition, the timing of our case patient’s progression to pneumonia on day 9 of illness is consistent with later onset of dyspnea (at a median of 8 days from onset) reported in a recent publication.

Although a decision to administer remdesivir for compassionate use was based on the case patient’s worsening clinical status, randomized controlled trials are needed to determine the safety and efficacy of remdesivir and any other investigational agents for treatment of patients with 2019-nCoV infection.

We report the clinical features of the first reported patient with 2019-nCoV infection in the United States.

Key aspects of this case included the decision made by the patient to seek medical attention after reading public health warnings about the outbreak; recognition of the patient’s recent trel history to Wuhan by local providers, with subsequent coordination among local, state, and federal public health officials; and identification of possible 2019-nCoV infection, which allowed for prompt isolation of the patient and subsequent laboratory confirmation of 2019-nCoV, as well as for admission of the patient for further evaluation and management.

This case report highlights the importance of clinicians eliciting a recent history of trel or exposure to sick contacts in any patient presenting for medical care with acute illness symptoms, in order to ensure appropriate identification and prompt isolation of patients who may be at risk for 2019-nCoV infection and to help reduce further transmission.

Finally, this report highlights the need to determine the full spectrum and natural history of clinical disease, pathogenesis, and duration of viral shedding associated with 2019-nCoV infection to inform clinical management and public health decision making.

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

This article was published on January 31, 2020, at NEJM.org.

We thank the patient; the nurses and clinical staff who are providing care for the patient; staff at the local and state health departments; staff at the Washington State Department of Health Public Health Laboratories and at the Centers for Disease Control and Prevention (CDC) Division of Viral Disease Laboratory; CDC staff at the Emergency Operations Center; and members of the 2019-nCoV response teams at the local, state, and national levels.