（重磅）美国首例新冠病毒确诊病例入院全记录（中英文）

摘要

在中都国武昌开始的新型流感HIV（2019-nCoV）爆放不断蔓延，现已在多个第三世界确诊。我们份文件了在American证实的首开2019-nCoV染病个案，并叙述了该个案的鉴别，患者，针灸同类型过程和经营管理，极少限于病患在病情第9天表格现为结质子病时的刚开始轻度病病征。

该案例强调了针灸大多科医生与人口众多，一个州和联邦各级公共健康伊朗政府二者之间密切协作的不可或缺性，以及只能短时间内扩散与这种新放染病病患的照护有关的针灸个人信息的需要。

2019年12月末31日，中都国份文件了与湖北省武昌市海南岛鱼翅批放的产品有关的人群中都的结质子病个案。

2020年1月末7日，中都国健康伊朗政府证实该簇与新型流感HIV2019-nCoV有关。尽管刚开始新闻报道的个案与武昌市鱼翅的产品的暴露有关，但举例来说的流行病学样本表格明，正要放生2019-nCoV社才会群体扩散。

截至2020年1月末30日，在极少极少21个第三世界/邻近地区份文件了9976例个案，极少限于2020年1月末20日新闻报道的American首开确诊的2019-nCoV染病个案。

同类型球性范围内正要透过调查，以更加好地探究扩散动态和针灸病病征范围。本份文件叙述了在American证实的首开2019-nCoV染病的流行病学和针灸形态。

案例份文件

2020年1月末19日，一名35岁的桌球经常出现在林肯一个州斯诺霍米西孟加拉邦的一家急诊诊所，有4天的头痛和主观放烧巨著。患者到诊所健康检查时，在候诊室戴上故名罩。继续前进将近20分钟后，他被带回健康检查室不感兴趣了提供者的分析。

他透露，他在中都国武昌探望家人后于1月末15日赶回林肯一个州。该病患表格示，他已从American病病征控制与预防中都心（CDC）收到有关中都国新型流感HIV暴放的健康强台风，由于他的病病征和最大值得忽略的旅行者，他最终去看大多科医生。

示意图1-2020年1月末19日（病病征第4天）的后腹部和大多侧胸片

除了高三酸酯缺乏病征的病巨著大多，该病患还是其他健康的不吸烟者。体格健康检查推测病患吞咽环境热气时，环境温度为37.2°C，皮质醇为134/87 mm Hg，脉搏为每分钟110次，吞咽频谱为每分钟16次，镁明度为96％。肺泡听诊问道明了有支气管炎，并透过了胸片健康检查，据新闻报道从未推测诱发（示意图1）。

九一和九一流感的短时间内质子酸增为次测试（NAAT）为中性。赢取了舌咽拭子遗骸，并通过NAAT将其还给去检验HIV性吞咽道细菌。

据新闻报道在48同类型程内对所有次测试的细菌大多黄绿色中性，极少限于九一和九一流感，副流感，吞咽道合胞HIV，舌HIV，腺HIV和已知才会导致人类病病征的四种类似流感HIV株（HKU1，NL63、229E和OC43） ）。根据病患的旅行者历巨著，立即告知人口众多和一个州健康部门。林肯健康部与立即照护针灸大多科医生一起告知了CDC立即行动中都心。

尽管该病患份文件问道他无法去过海南岛鱼翅的产品，也无法份文件在去中都国旅行者之后与病重者有任何认识，但病病征预防控制室的人员同意有必要根据举例来说的病病征预防控制室对病患透过2019-nCoV次测试。

根据CDC简要搜集了8个遗骸，极少限于肝脏，舌咽和故名咽拭子遗骸。遗骸通过观察后，病患被还给往贫穷封闭，并由当地健康部门透过积极天气预报。

2020年1月末20日，病病征预防控制室（CDC）证实病患的舌咽和故名咽拭子通过动态中国邻近地区-蛋白酶链式反应（rRT-PCR）检验为2019-nCoV非典型。

在病病征预防控制室的主题专家，一个州和人口众多健康官吏，立即照护服务以及病房领导和人员的再加下，病患被还给往普罗维登斯邻近地区照护中都心的热气封闭病房透过针灸仔细观察，并先是病病征预防控制室的医务人员有关认识，飞沫和空中都防护措施的劝告，并含有护目镜。

复放时病患份文件不间断头痛，有2天的腹痛和腹痛巨著。他份文件问道他无法吞咽急促或胸痛。生命先兆在情况下范围内。体格健康检查推测病患粘膜干旱。其余的健康检查通常不轻微。

复放后，病患不感兴趣了背书用药，极少限于2充生理盐水和恩丹以减缓腹痛。

示意图2-根据病病征日和中风日（2020年1月末16日至2020年1月末30日）的病病征和最高环境温度

在中风的第2至5天（病重的第6至9天），病患的生命先兆必需依然稳定，除了经常出现经年累月放烧并伴有心动过速（示意图2）。病患继续份文件非生产性头痛，并经常出现疲惫。

在中风第二天的下午，病患排便不利于，腹部不适。清晨有第二次大便稀疏的新闻报道。搜集该排泄的容器用做rRT-PCR次测试，以及其他吞咽道遗骸（舌咽和故名咽）和肝脏。排泄和两个吞咽道遗骸后来大多通过rRT-PCR检验为2019-nCoV非典型，而肝脏仍为中性。

在此之后的用药在不小素质上是背书性的。为了透过病病征不远处理，病患只能根据只能不感兴趣解热临床，该临床极少限于每4同类型程650 mg无毒和每6同类型程600 mg布洛芬。在中风的前六天，他还因不间断头痛而服用了600毫克愈来愈创醚和将近6充生理盐水。

表格1-针灸Laboratory结果

病患封闭单元的并不一定刚开始极少允许定时照护点Laboratory次测试；从病房第3天开始可以透过同类型脑组织计数和肝脏无机化学研究工作。

在病房第3天和第5天（病病征第7天和第9天）的Laboratory结果说明了出白细胞增大病征，轻度粒细胞增大病征和肌酸激酶高度充高（表格1）。此大多，败血症这两项也有所波动：溶蛋白酶（每充68 U），天冬氨酸氨基转移酶（每充105 U），丝氨酸氨基转移酶（每充77 U）和乳酸脱氢酶（每充465 U）的高度分别为：在中风的第5天所有充高。鉴于病患重复放烧，在第4天赢取血液培植；为数不多，这些都无法下降。

示意图3-2020年1月末22日（脸部第7天，病房第3天）的后腹部和大多侧胸片

示意图4-2020年1月末24日（脸部第5天，病房第9天）的后腹部X线片

据新闻报道，在病房第3天（病重第7天）拍的脸部X光片从未问道明了增生或诱发痕迹（示意图3）。

但是，从病房第5天清晨（病重第9天）清晨透过的第二次脸部X光片健康检查问道明了，左肺下叶有结质子病（示意图4）。

这些健康检查和推测与从病房第5天清晨开始的吞咽状态波动相吻合，起初病患在吞咽周边热气时通过脉搏血镁明度测的血镁明度最大值降至90％。

在第6天，病患开始不感兴趣多余压缩空气，该压缩空气由舌导管以每分钟2充的速率输还给。考虑针灸表格现的波动和对病房赢取性结质子病的关切，开始可用万古霉素（1750 mg负荷剂量，然后每8同类型程较低剂量1 g）和青霉素锦标肟（每8同类型程较低剂量）用药。

示意图5-前后脸部X光片，2020年1月末26日（病病征第十天，病房第六天）

在病房第6天（病重第10天），第四次脸部X射线特写问道明了两个肺中都都有角化条状混浊，这一推测与非典型结质子病大不相同（示意图5），并且在听诊时在两个肺中都都经常出现了罗音。鉴于放射线健康检查和推测，最终拒绝不感兴趣压缩空气多余，病患不间断放烧，多个部位不间断非典型的2019-nCoV RNA非典型，以及放表格了与放射线性结质子病放展明确的比较严重结质子病在该病患中都，针灸大多科医生富有同情心地可用了研究工作性抗HIV用药。

较低剂量瑞德昔韦（一种正要开放的新型质子苷酸类似物前药）在第7天清晨开始，但从未仔细观察到与静脉注射有关的经常性事件真相。在对乙镁西林耐药的暗红色葡萄球菌透过了连续的降钙素原高度和舌PCR检验后，在第7天清晨废弃万古霉素，并在第二天废弃青霉素锦标肟。

在病房第8天（病重第12天），病患的针灸情形拒绝不感兴趣改善。停止多余压缩空气，他在吞咽周边热气时的镁明度最大值提高到94％至96％。当初的上部下叶罗音不必存在。他的食欲拒绝不感兴趣改善，除了经年累月干咳和舌漏大多，他无法病病征。

截至2020年1月末30日，病患仍中风。他有放热，除头痛大多，所有病病征大多已减缓，头痛的素质正要消除。

方法

遗骸通过观察

根据CDC简要赢取用做2019-nCoV患者次测试的针灸遗骸。用合成橡胶拭子搜集了12个舌咽和故名咽拭子遗骸。

将每个拭子插入构成2至3 mlHIV仓储电磁辐射的单独无菌将水都。将血集在肝脏分离将水都，然后根据CDC简要透过离心。尿液和排泄遗骸分别搜集在无菌遗骸试将水都。容器在2°C至8°C二者之间储存，直到准备好运还给至CDC。

在病病征的第7、11和12天搜集了段落透过的2019-nCoV次测试的遗骸，极少限于舌咽和故名咽拭子，肝脏以及尿液和排泄检验。

2019-NCOV的患者次测试

可用从披露放布的HIV脱镁质子糖质子酸放展而来的rRT-PCR系统性次测试了针灸遗骸。与当初针对门诊急性吞咽病病征流感HIV（SARS-CoV）和中都东吞咽病病征流感HIV（MERS-CoV）的患者方法相同，它含有三个质子核糖多肽基因抗病毒和一个非典型依此抗病毒。该测的叙述为RRT-PCR基板模板和容器和脱镁质子糖质子酸个人信息中都可用的CDCLaboratory个人信息网站2019-nCoV上。

基因分子生物学

2020年1月末7日，中都国研究人员通过American国立健康研究工作院GenBank资料库和同类型球性协作所有流感样本积极支持（GISAID）资料库协作了2019-nCoV的完整基因脱镁质子糖质子酸；随后放布了有关封闭2019-nCoV的份文件。

从rRT-PCR非典型遗骸（故名咽和舌咽）中都提取质子酸，并在Sanger和下一代分子生物学游戏平台（Illumina和MinIon）上用做同类型DNA分子生物学。可用5.4.6英文版的Sequencher软件（Sanger）完成了脱镁质子糖质子酸组装。minimap软件，旧英文版本2.17（MinIon）；和freebayes软件1.3.1英文版（MiSeq）。将完整DNA与可用的2019-nCoV参考脱镁质子糖质子酸（GenBank登录号NC_045512.2）透过比较。

结果

2019-NCOV的遗骸次测试

表格2-2019年新型流感HIV（2019-nCoV）的动态中国邻近地区-蛋白酶-链式反应次测试结果

该病患在病重第4天时赢取的初始吞咽道检验（舌咽拭子和故名咽拭子）在2019-nCoV黄绿色非典型（表格2）。

尽管病患刚开始表格现为轻度病病征，但在病病征第4天的较低循环阈最大值（Ct）最大值（舌咽遗骸中都为18至20，故名咽遗骸中都为21至22）表格明这些遗骸中都HIV高度低。

在病病征第7天赢取的两个上吞咽道遗骸在2019-nCoV仍依然非典型，极少限于舌咽拭子遗骸中都不间断高高度（Ct最大值23至24）。在病病征第7天赢取的排泄在2019-nCoV中都也黄绿色非典型（Ct最大值为36至38）。两种通过观察月份的肝脏检验在2019-nCoV大多为中性。

在病病征第11天和第12天赢取的舌咽和故名咽遗骸问道明了出HIV高度下降的趋向于。

故名咽遗骸在病重第12天的2019-nCoV次测试黄绿色中性。在这些月份赢取的肝脏的rRT-PCR结果仍已未确定。

基因分子生物学

故名咽和舌咽遗骸的完整DNA脱镁质子糖质子酸彼此并不相同，并且与其他可用的2019-nCoV脱镁质子糖质子酸几乎并不相同。

该病患的HIV与2019-nCoV参考脱镁质子糖质子酸（NC_045512.2）在开放学习者框8不远处同类型部都是3个质子苷酸和1个并不相同。该脱镁质子糖质子酸可通过GenBank赢取（登录号MN985325）。

讨论区

我们关于American首开2019-nCoV确诊个案的份文件问道明了这一新兴病病征的几个特别尚从未只不过探究，极少限于扩散动态和针灸病病征的同类型部范围。

我们的个案病患曾去过中都国武昌，但份文件问道他在武昌之后无法去过鱼翅批放的产品或照护机构，也无法生病的认识。尽管他的2019-nCoV染病的来源尚不清楚，但已披露了人对人扩散的证据。

到2020年1月末30日，尚从未推测与此个案特别的2019-nCoV继放个案，但仍在密切监控下。

在病病征的第4天和第7天从上吞咽道遗骸中都检验到含有较低Ct最大值的2019-nCoV RNA，表格明HIV载量高且含有扩散商业价最大值。

最大值得忽略的是，我们还在病患病重第7天搜集的排泄检验中都检验到了2019-nCoV RNA。尽管我们个案病患的肝脏遗骸重复经常出现2019-nCoV中性，但在中都国门诊病患的血液中都仍检验到HIVRNA。然而，肺大多检验HIVRNA未必假定存在传染性HIV，目前尚不清楚在吞咽道大多部检验HIVRNA的针灸意义。

目前，我们对2019-nCoV染病的针灸范围的探究极为有限。在中都国，现在新闻报道了诸如比较严重的结质子病，吞咽衰竭，急性吞咽穷困病病征（ARDS）和心脏损伤等并放病征，极少限于致命的负面影响。然而，不可或缺的是要忽略，这些个案是根据其结质子病患者未确定的，因此不必要使份文件偏重更加比较严重的结果。

我们的个案病患刚开始表格现为轻度头痛和较低度经年累月放烧，在病重的第4天无法脸部X光健康检查的结质子病痕迹，而在病重第9天放展为结质子病在此之后，这些非特异性先兆和病病征在早期在针灸上，2019-nCoV染病的针灸同类型过程可能才会与许多其他类似传染病无法轻微区别，众所周知是在初冬吞咽道HIV季节。

另大多，本个案病患在病病征的第9天放展为结质子病的适时与早先吞咽困难的放作（放病后中都位数为8天）明确。尽管根据病患的针灸情形恶化最终应该拒绝不感兴趣remdesivir慈悲的可用，但仍只能透过随机依此试验性以未确定remdesivir和任何其他研究工作药物用药2019-nCoV染病的有效性和有效性。

我们份文件了American首开份文件的2019-nCoV染病病患的针灸形态。

该个案的关键特别极少限于病患在学习者有关暴放的公共健康警告后最终促成照护；由当地照护服务供应商证实病患最大值得忽略到武昌的旅行者历巨著，随后在当地，一个州和联邦公共健康官吏二者之间透过相互合作；并未确定可能才会的2019-nCoV染病，从而可以不断封闭病患并随后对2019-nCoV透过Laboratory证实，并允许病患复放有利于分析和经营管理。

该个案份文件强调了针灸大多科医生对于任何经常出现急性病病征病病征的就诊病患，要总结出最大值得忽略的旅行者经历或认识病巨著的不可或缺性，为了必需正确标识和及早封闭可能才会遭遇2019-nCoV染病风险的病患，并借助增大有利于的扩散。

最后，本份文件强调只能未确定与2019-nCoV染病特别的针灸病病征，放病内源性和HIV脱落不间断时间的

同类型部范围和自然历巨著，以为针灸经营管理和公共健康决策提供依据。

此表为英文英文版

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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.