Journal Pre-proof

2019 novel coronavirus disease (COVID-19) in Taiwan: Reports of two cases from
Wuhan, China

Wei-Hsuan Huang, Ling-Chiao Teng, Ting-Kuang Yeh, Yu-Jen Chen, Wei-Jung Lo,
Ming-Ju Wu, Chun-Shih Chin, Yu-Tse Tsan, Tzu-Chieh Lin, Jyh-Wen Chai, Chin-Fu
Lin, Chien-Hao Tseng, Chia-Wei Liu, Chi-Mei Wu, Po-Yen Chen, Zhi-Yuan Shi, Po-Yu
Liu

PII: S1684-1182(20)30037-2
DOI: https://doi.org/10.1016/j.jmii.2020.02.009
Reference: JMII 1185

To appear in: Journal of Microbiology, Immunology and Infection

Received Date: 17 February 2020

Accepted Date: 17 February 2020

Please cite this article as: Huang W-H, Teng L-C, Yeh T-K, Chen Y-J, Lo W-J, Wu M-J, Chin C-S, Tsan
Y-T, Lin T-C, Chai J-W, Lin C-F, Tseng C-H, Liu C-W, Wu C-M, Chen P-Y, Shi Z-Y, Liu P-Y, 2019
novel coronavirus disease (COVID-19) in Taiwan: Reports of two cases from Wuhan, China, Journal of
Microbiology, Immunology and Infection, https://doi.org/10.1016/j.jmii.2020.02.009.

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Copyright © 2020, Taiwan Society of Microbiology. Published by Elsevier Taiwan LLC. All rights
reserved.
 1 Short Communications

3 2019 novel coronavirus disease (COVID-19) in Taiwan:

4 Reports of two cases from Wuhan, China

6 Wei-Hsuan Huanga, Ling-Chiao Tengb, Ting-Kuang Yehb, Yu-Jen Chenb,

7 Wei-Jung Lob, Ming-Ju Wub, Chun-Shih Chinc, Yu-Tse Tsand, Tzu-Chieh

8 Lind, Jyh-Wen Chaie, Chin-Fu Linf, Chien-Hao Tsenga, Chia-Wei Liua,

9 Chi-Mei Wug, Po-Yen Chenh, Zhi-Yuan Shii*, Po-Yu Liua,j,k*

10

a
11 Division of Infectious Diseases, Department of Internal Medicine, Taichung

12 Veterans General Hospital, Taichung, Taiwan

b
13 Department of Internal Medicine, Taichung Veterans General Hospital,

14 Taichung, Taiwan

c
15 Division of Chest Medicine, Department of Internal Medicine, Taichung

16 Veterans General Hospital, Taichung, Taiwan

d
17 Department of Emergency Medicine, Taichung Veterans General Hospital,

18 Taichung, Taiwan

e
19 Department of Radiology, Taichung Veterans General Hospital, Taichung

1
 f
20 Department of Pathology and Laboratory Medicine, Taichung Veterans

21 General Hospital, Taichung, Taiwan

g
22 Department of Nursing, Taichung Veteran General Hospital, Taichung

h
23 Department of Pediatrics, Taichung Veterans General Hospital, Taichung,

24 Taiwan

i
25 Infection Control Center, Taichung Veterans General Hospital, Taichung,

26 Taiwan

j
27 Ph.D. Program in Translational Medicine, National Chung Hsing University,

28 Taichung, Taiwan

k
29 Rong Hsing Research Center for Translational Medicine, National Chung

30 Hsing University, Taichung, Taiwan

31

32 * Corresponding authors:

33 Infection Control Center and Division of Infectious Diseases, Department of

34 Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan

35 Boulevard Sect. 4, Taichung, Taiwan

36 E-mail addresses:

37 zyshi@vghtc.gov.tw (Z.-Y. Shi) and pyliu@vghtc.gov.tw (P.-Y. Liu).

38

2
1 Short Communications

3 2019 novel coronavirus disease (COVID-19) in Taiwan:

4 Reports of two cases from Wuhan, China

1
 7 Abstract We reported two cases with community-acquired pneumonia

8 caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

9 who returned from Wuhan, China in January, 2020. The reported cases

10 highlight non-specific clinical presentations of 2019 novel coronavirus disease

11 (COVID-19) as well as the importance of rapid laboratory-based diagnosis.

12

13 KEYWORDS

14 COVID-19

15 SARS-CoV-2

16 Pneumonia

17 Emerging infectious diseases

18 Zoonosis

2
19 Introduction

20 After 17 years, physicians in Taiwan face another novel coronavirus outbreak

21 originated in China.1 With the past experience of severe acute respiratory

22 syndrome (SARS),2, 3 we respond quickly this time. However, a new pathogen

23 inevitably raises new challenges.4 Clinical data and experience sharing may

24 contribute to the control of emerging infectious diseases.5 Here we present two

25 cases of 2019 novel coronavirus disease (COVID-19).

26

27 Case reports

28 Case 1

29 A 74 year-old female visitor from Wuhan City, China presented to the

30 hospital with fever, malaise, and poor appetite. She reported no underlying

31 medical conditions. There was no chillness, cough, rhinorrhea, sore throat,

32 myalgia, chest discomfort, dyspnea, abdominal pain, or diarrhea. Physical

33 examination disclosed body temperature of 38.1°C, b lood pressure of 129/68

34 mm Hg, heart rate of 79 beats per minute, respiratory rate of 18 breaths per

35 minute. Chest radiography (CXR) revealed mild increased infiltration over

36 bilateral lower lung field. Peripheral-blood white-cell count was 3770 per cubic

37 millimeter (with 62.3% neutrophils and 32.1% lymphocytes). Nasopharyngeal

3
38 swab was positive for severe acute respiratory syndrome coronavirus-2

39 (SARS-CoV-2) by real-time reverse-transcriptase polymerase chain reaction

40 (rRT-PCR) assay performed by the Centers for Diseases Control in Taiwan

41 (Taiwan CDC).

42 On day 6 in hospital, the patient remained febrile, malaise and poor

43 appetite. Follow-up CXR revealed increasing opacity at right middle and lower

44 lung fields (Figure 1A). Levofloxacin was initiated. On hospital day 12, after a

45 6-day course of levofloxacin, her fever abated with improved appetite and

46 physical activity. She became free of symptoms afterward.

47

48 Case 2

49 A 74 year-old previously health female visitor returning from Wuhan City 3

50 days ago presented to the hospital with dry cough, fever, malaise and poor

51 appetite. She denied chillness, rhinorrhea, sore throat, chest discomfort,

52 myalgia, dyspnea, abdominal pain, or diarrhea. Her body temperature was

53 38.1°C with blood pressure of 129/68 mm Hg, heart r ate of 79 beats per

54 minute, respiratory rate of 18 breaths per minute. CXR demonstrated

55 non-specific mild increased infiltration over bilateral lower lung field.

56 Peripheral-blood white-cell count was 3770 per cubic millimeter (with 62.3%

4
57 neutrophils and 32.1% lymphocytes). Nasopharyngeal swab was positive for

58 SARS-CoV-2 by rRT-PCR assay reported from Taiwan CDC.

59 On day 6 in hospital, the patient remained febrile, malaise and poor

60 appetite. She reported worsening of cough. Follow-up CXR revealed patchy

61 consolidation over bilateral lower lung field (Figure 1B). Parenteral cefepime

62 and oral clarithromycin therapy were initiated. On day 9, she was afebrile with

63 improved general condition. Antimicrobial therapy was shifted to oral

64 moxifloxacin. She remained free of symptoms afterward.

65

66 Discussion

67 The nonspecific presentations of these two cases are consistent with early

68 reports of COVID-19 from China.6, 7 Fever remains the most common complain.

69 Some cases didn’t have cough, and upper respiratory tract infections (URI)

70 symptoms such as rhinorrhea and sore throat were rare. Similar clinical

71 manifestations have been reported in SARS,8 since URI symptoms were

72 uncommon and cough was not always present in SARS patients. Although

73 routine laboratory testing was not diagnostic, certain patterns of laboratory

74 abnormalities were observed in COVID-19. Leukopenia, lymphopenia, anemia,

75 elevation of liver enzymes and lactate dehydrogenase, have been reported in

76 different series.6, 7 Also, a similar observation has been made in SARS.8

5
77 The clinical utility of CXR in the early diagnosis of COVID-19 is

78 questionable. In this report, initial CXR of both cases was non-diagnostic, and

79 more evident radiological abnormalities were detected on day 6. Similar

80 findings were reported in the first case of COVID-19 in the United States, and

81 pulmonary patch/consolidation was not detected by CXR until day 5 in hospital

82 (day 9 of illness).9 Similarly, in a case series of SARS patients from the Amoy

83 Gardens housing estate, 29.3% (22/75) cases had normal CXR on admission,

84 however four of 22 cases developed acute respiratory distress syndrome

85 (ARDS) afterward.8 In general, 80% (60/75) of cases experienced radiological

86 worsening at a mean of 7.4 days.8 Both unifocal and bilateral lung infiltration

87 could be observed in our report. Of 99 cases of COVID-19 in China, 25%

88 presented with unilateral pneumonia and 75% presented with bilateral

89 pneumonia.7

90 As discussed above, COVID-19 cannot be reliably distinguished by clinical,

91 radiologic, or laboratory criteria from other causes of pneumonia. Moreover, in

92 the clinical setting of community transmission, exposure or travel history alone

93 would be not useful to identify the risk population of COVID-19 cases. Hence,

94 laboratory-based diagnosis is critical. At the present time, RT-PCR assays

95 were most widely used to detect SARS-CoV-2. Current data are insufficient to

6
 96 determine their sensitivity and specificity for SARS-CoV-2. A previous study

97 demonstrated SARS virus could be detected in approximately one-third of

98 patients during early phase of the illness, and most frequently during the

99 second week of illness.8 We believe that the diagnostic performance of

100 molecular testing improves during the decades. However, more data are

101 needed to address the issue.

102 Another challenge is the surge of clinical needs of laboratory testing. It is

103 anticipated that there will be an overwhelming demand for the supply chain of

104 testing reagents and laboratory equipment, and the availability of well trained

105 and experienced staff during the outbreak. There are several alternative

106 diagnostic strategies under development. Feng et al. proposed a

107 CRISPR-based technique for the diagnosis of COVID-19

108 (https://www.broadinstitute.org/files/publications/special/COVID-19%20detecti

109 on%20(updated).pdf). After RNA extraction, the test result could be read using

110 a dipstick in less than a hour. RNA-based metagenomic sequencing is another

111 promising approach,10 and has been used to diagnose COVID-19 in the first

112 cluster related to the Huanan Seafood Market in China.10

113 Currently, clinical management and treatment of COVID-19 is largely

114 supportive. In the cases of pneumonia, our diagnostic capacity could be

7
115 hindered by the nature of isolation units. For example, for the first COVID-19

116 case in the United States, only point-of-care laboratory testing was permitted

117 initially.9 The current rate of co-infection and distribution of coexisting

118 organisms in the cases of COVID-19 remain undefined. Of note, current

119 evidence suggests that co-infection is not uncommon in the patient with

120 community-acquired pneumonia.11 In a prospective study of 2,259 patients

121 with pneumonia and specimens submitted for comprehensive bacterial and

122 viral testing, etiologic agents were detected in only 38% cases. Among these

123 cases, the percentages of co-infections were associated with the severity and

124 geographic regions.11 Clinical guideline for the treatment of

125 community-acquired pneumonia in Taiwan shall be considered for these

126 cases.12

127 In conclusion, we reported the clinical features of two patients with

128 COVID-19 in Taiwan, and highlight the nonspecific nature of clinical

129 presentations of COVID-19 and the importance of laboratory-based diagnosis.

130

131 Declaration of Competing Interest

132 The authors declares no conflicts of interest.

8
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176 Figure 1. Chest radiographs of two patients returned from Wuhan, China, with

177 pneumonia caused by SARS-CoV-2 in middle Taiwan. (A) Case 1: increasing

178 opacity at right middle and lower lung fields at hospital day 6. (B) Case 2:

179 patchy consolidation over bilateral lower lung fields of at hospital day 6.

12
(A) (B)