Covid Positive Then Negative Then Positive Again

• Case study
• Open Access
• Published: 07 October 2020

COVID-xix with repeated positive test results for SARS-CoV-2 past PCR and and then negative test results twice during intensive care: a case report

• Masaru Tobe¹,
• Tomonori Takazawa^one &
• Shigeru Saito¹

Periodical of Medical Instance Reports volume xiv, Article number:191 (2020) Cite this article

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Abstruse

Background

Determining the infectiousness of patients with coronavirus disease 2019 is crucial for patient management. Medical staff usually refer to the results of contrary transcription polymerase chain reaction tests in conjunction with clinical symptoms and computed tomographic images.

Case presentation

We written report a instance of a 62-yr-erstwhile Japanese human being who twice had positive and negative test results by polymerase chain reaction for severe astute respiratory syndrome coronavirus ii over 48 days of hospitalization, including in intensive care. His respiratory symptoms and computed tomographic imaging findings consistent with coronavirus illness 2019 improved following initial intensive care, and the result of his polymerase chain reaction test became negative 3 days before belch from the intensive care unit of measurement. However, 4 days afterwards this first negative result, his polymerase chain reaction test outcome was positive again, and some other 4 days subsequently, he had a negative effect one time more than. Eight days after the second polymerase concatenation reaction negative test result, the patient'southward test outcome over again became positive. Finally, his polymerase chain reaction results were negative 43 days afterwards his beginning hospitalization.

Conclusions

This instance emphasizes the importance of repeat polymerase chain reaction testing and diagnosis based on multiple criteria, including clinical symptoms and computed tomographic imaging findings. Clinical staff should consider that a negative result by polymerase chain reaction does not necessarily certify complete coronavirus disease 2019 recovery.

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Introduction

A number of cases of "unknown viral pneumonia" related to a market place in Wuhan City, Hubei Province, Red china, were reported in December 2019. The novel severe astute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified, causing coronavirus affliction 2019 (COVID-19), which quickly spread from Red china to other countries all over the earth. In the absenteeism of specific therapeutic drugs or vaccines for COVID-19, it is essential to be able to detect the disease at an early stage and immediately isolate the infected person from the healthy population. According to the latest guidelines for the Diagnosis and Treatment of Pneumonitis Caused by 2019 Novel Coronavirus (Trial Version 6) published past the Chinese regime, the diagnosis of COVID-19 requires testing respiratory or blood samples past reverse transcription polymerase chain reaction (RT-PCR) or factor sequencing and is considered the key indicator for hospitalization. Chest computed tomography (CT) reveals typical radiographic features in almost all patients with COVID-19, which include ground-glass opacities, multifocal patchy consolidation, and/or interstitial changes with a peripheral distribution. Nosotros now have a not bad deal of feel in treating patients with frequent changes from positive to negative PCR results, so dorsum to positive and negative again. Nosotros therefore propose that accurate diagnosis and treatment of COVID-19 requires a comprehensive assessment that includes not only PCR results but likewise breast CT images.

Example presentation

A 62-twelvemonth-old Japanese man without coexisting disease initially presented to our infirmary with a persistent fever of 38.0 °C, dyspnea, and hypoxia after close contact with a coworker known to be infected with SARS-CoV-2. His oxygen saturation (SpO_two) on room air at the time of hospitalization was 94%, and CT showed peripheral ground-glass opacities with interlobular septal thickening consistent with a "crazy paving pattern" strongly indicative of COVID-xix (Fig. 1). PCR results on the ground of a pharyngeal swab taken through the nostril were consistent with pneumonia and COVID-19. Considering the patient's SpO₂ decreased to 88% 25 days after hospitalization despite 3 50/infinitesimal oxygen inhalation by confront mask, he was transferred to the intensive care unit (ICU). He was intubated and put on a ventilator (Puritan Bennett 840, Medtronic, Tokyo, Japan; force per unit area control ventilation [PCV] fashion, fraction of inspired oxygen [FiO₂], 0.5, positive end-expiratory pressure [PEEP], x cmH₂O; inspiratory pressure level [Pi], 15 cmH₂O; inspiratory fourth dimension [Ti], ane.five s; frequency [f], 12 per infinitesimal). Other therapeutic procedures included administration of favipiravir, and, given concerns regarding pneumonia due to other pathogens, broad-spectrum antibiotic therapy using tazobactam/piperacillin and levofloxacin was initiated. The results of blood cultures and a respiratory viral console were negative. The patient recovered without further incident and was transferred dorsum to a convalescence ward in an affiliated hospital after confirmation of SARS-CoV-2 negativity by PCR. However, on the aforementioned day as the transfer, the patient complained of shortness of breath and dyspnea, and his respiration rate increased to xx breaths/minute. His SpO₂ decreased to 86% under 10 Fifty/minute of 100% oxygen inhalation by face mask, and he was again intubated. At this time, the finding of PCR was one time once again positive for SARS-CoV-2, and the patient was readmitted to our infirmary and transferred back to the ICU to restart respiratory intendance on a ventilator (PCV, FiO₂, 0.4; PEEP, 8 cmH₂O; Pi, 15 cmH_twoO; Ti, one.five s; f, 12 per infinitesimal). 4 days later readmission, his respiratory condition had improved, and his PCR results were again negative. Nine days after readmission, he was weaned off respirator care, extubated, and transferred to a COVID-xix ward in the aforementioned infirmary. Over the residual of his hospital course, the patient was treated past supportive measures and monitored for any worsening of respiratory part. Despite his respiratory status not worsening, his PCR result once more became positive 3 days after belch from the ICU for the second time. At 8 and eleven days after this, his PCR results were negative one time more. Following confirmation that his clinical condition and CT findings were stable, he was finally discharged from our infirmary 54 days later his kickoff access.

Fig. 1

Computed tomography of the chest demonstrating bilateral patchy ground-glass opacities with interlobular septal thickening consistent with the crazy paving blueprint found in patients with coronavirus disease 2019

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Word

For successful management of the COVID-19 pandemic, diagnosis and discharge criteria have been discussed extensively with reference to the sensitivity and specificity of the clinical and virological status of patients earlier belch. The PCR test is considered the gilded standard for detecting infection and is widely used for diagnosis and public heath surveillance of disease prevalence. In this report, we describe a patient who repeatedly had positive test results and then negative and positive test results again several times during the course of his COVID-19 disease. Although there are several reports of PCR reverting to positivity following a negative effect, twice repeating such a positive and negative course in one patient seems to be rare. Because condom management for clinical staff and the patient him- or herself, the importance of echo testing and screening based on clinical symptoms and exposure history cannot be overstated. PCR has emerged every bit the exam of choice for detection of viral nucleic acids and the infectiousness of infected individuals. Although some reports in the literature emphasize the importance of PCR screening for early on containment of the disease, the sensitivity of PCR tests has been shown to be annihilation merely perfect. A report conducted in Red china found that almost 25% of SARS-CoV-2-positive individuals had had a negative result in initial testing [i]. Some other report reported that over 20% of infected individuals had positive test results on their third consecutive exam later two initial negative results [ii]. The sensitivity of PCR testing in several studies has been reported to exist merely 71–83%, respective to a fake-negative charge per unit of up to 30% [three, 4]. Considering this reported poor sensitivity of PCR for SARS-CoV-2, clinicians should exist cautious when interpreting negative results of PCR testing in patients with clinical suspicion of COVID-19.

Our patient initially presented with fatigue progressing to fever, cough, and shortness of breath, symptoms that are most commonly owing to COVID-nineteen pneumonia [5, 6]. Still, prior to his showtime discharge from the ICU, the patient was completely gratis of these symptoms, and his PCR result was negative. Because the CT images still showed some consolidation in the right upper and middle lung lobes, we consider it possible that the virus was in fact still present and that it moved out to the pharynx during transfer to a different hospital. Although we considered that some kind of coexisting bacterial pneumonia could exist the main reason for the patient'south retarded recovery every bit seen past CT, these CT images may in fact accept more than importance for evaluating COVID-19 illness. A instance report stated that CT imaging should be an integral component of screening for COVID-xix in preoperative patients [7]. Typical CT findings include consolidation, vascular enhancement, air bronchus sign, and bilateral peripheral ground-glass opacities with interlobular septal thickening consequent with a "crazy paving pattern" [viii]. In our patient's case, these features were credible at the initial admission. Nevertheless, such findings were non apparent at the second admission to the ICU. These CT findings are clearly not specific for COVID-19 and may also be present in other viral or bacterial pneumonias. However, increasing numbers of clinical reports are emphasizing the efficacy of CT imaging for treating patients with this viral illness, and several clinical surveys have shown that CT imaging can enhance the accuracy of COVID-19 diagnosis over and in a higher place PCR alone [iii, 9]. These contempo reports support the notion that recovery from SARS-CoV-2 infection and the criteria for deciding on hospital belch criteria should be based non but on the PCR results simply besides on assessment of CT images and clinical symptoms.

Conclusions

First, a negative PCR test result confirms neither recovery from COVID-19 nor that the patient is no longer infectious. Considering the poor sensitivity of PCR, repeat testing is essential to identifying SARS-CoV-two-positive individuals at initial diagnosis. A second important conclusion is that isolation and treatment practices should be guided by a combination of testing, symptomology, and radiologic evidence at the fourth dimension of discharge and should non rely solely on PCR. Careful consideration based on these multiple parameters may prevent premature discharge of the "presumed negative" patients and thus also prevent unexpected exposure of healthcare workers and the population at large.

Availability of data and materials

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Acknowledgements

The authors thank NAI (Tokyo, Nihon) for assistance with manuscript preparation in English.

Funding

The authors have no fiscal relationships to disembalm.

Author information

Affiliations

1. Department of Anesthesiology and Intensive Intendance Unit, Gunma Academy Infirmary, 3-39-fifteen Showa, Maebashi, Gunma, Nippon

   Masafumi Kanamoto, Masaru Tobe, Tomonori Takazawa & Shigeru Saito

Contributions

MK was mainly to manage the patient, reviewed the patients' records and wrote the manuscript. MT, TT and SS were involved in the process of diagnosis and management. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Masafumi Kanamoto.

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Ethics approval and consent to participate

The patient provided written informed consent to participate in this example report, which was approved past the Ethics Committee of Gunma Academy Infirmary.

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Written informed consent was obtained from the patient for publication of this case report and whatsoever accompanying images. A re-create of the written consent is bachelor for review by the Editor-in-Chief of this journal.

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The authors declare that they have no competing interests.

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Kanamoto, Yard., Tobe, M., Takazawa, T. et al. COVID-19 with repeated positive examination results for SARS-CoV-2 by PCR and then negative test results twice during intensive care: a case report. J Med Case Reports 14, 191 (2020). https://doi.org/10.1186/s13256-020-02534-2

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• Received: 12 July 2020

• Accepted: xiv September 2020

• Published: 07 Oct 2020

• DOI : https://doi.org/10.1186/s13256-020-02534-two

Keywords

• COVID-19
• RT-PCR
• Repeat positivity/negativity

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