Clinical features and outcomes of seven patients with COVID-19 in a family cluster

A 40-year-old man with a long history of residence in the epidemic area of Wuhan. On January 16, 2020, he had dinner in Wuhan with an individual who was later confirmed to have COVID-19. He returned to his hometown, Panzhou, Guizhou Province, by car on January 17, 2020. He was admitted to a fever clinic at the local hospital on January 28, 2020, with symptoms of fever (the first symptom), cough, sputum production and fatigue. His throat swab samples were immediately collected and real-time reverse transcription polymerase chain reaction (rRT-PCR) assay confirmed that he had developed COVID-19. Chest CT revealed scattered ground-glass opacities and exudation in both lungs (Fig. 1a, c). Therefore, according to the New Coronavirus Infection Pneumonia Protocol published by the National Health Commission of China, the patient was diagnosed by the local hospital, with a moderate case [7], and treated with inhaled interferon alpha (10 million international units [IUs] daily),oral lopinavir/ritonavir (800/200 mg daily) and traditional Chinese medicine (recipes were adjusted based on different patient situations) for 5 days. After 3 days, the patient had no symptoms. After that, he was admitted to Guizhou Provincial Jiangjun Mountain Hospital on February 4, 2020. The treatment plan was the same as that of the local hospital. After 11 days, all his symptoms had disappeared. On February 15th and 17th, 2020, his throat swab samples tested negative for SARS-CoV-2 antigens by two rRT-PCR tests, taken more than 24 h apart. Reexamination of chest CT showed no abnormalities, and he was discharged from the hospital for 14 days of medical isolation and observation in Guizhou Workers’ Hospital near Guizhou Provincial Jiangjun Mountain Hospital. There, he did not receive any treatment at all. On day 14 of medical isolation, the throat swab tested positive again for SARS-CoV-2 antigens, and he was admitted to the hospital on March 2 and discharged on March 8 again after antiviral treatment. He had no symptoms during this period, and no abnormality was found on chest CT (Fig. 1b, d).

Patient 2, a 38-year-old woman, was the wife of patient 1 and had a history of close contact (such as having dinner) with patient 1. She was admitted to a fever clinic at the local hospital on January 29, 2020, with symptoms of cough (the first symptom) and sputum production. Her throat swab samples were immediately collected and rRT-PCR assay confirmed that the patient had COVID-19. A chest CT scan revealed no abnormalities (Fig. 2a, c). Therefore, the patient was diagnosed by the local hospital, with a mild case of COVID-19 [7]. She was immediately admitted to the isolation ward and treated with inhaled interferon alpha, oral lopinavir/ritonavir and traditional Chinese medicine for antiviral therapy. Since she had sputum production, moxifloxacin was given orally to prevent bacterial infections. After 5 days, on February 5, 2020, the patient was admitted to Guizhou Provincial Jiangjun Mountain Hospital. The treatment plan was the same as that of the local hospital. On February 14th and 16th, 2020, her throat swabs, taken more than 24 h apart, tested negative for SARS-CoV-2 antigens by two rRT-PCR assays. She had no symptoms and was discharged from the hospital for 14 days of medical isolation observation in the hospital above. On day 14, her throat swab sample was negative again. No abnormality was found on chest CT (Fig. 2b, d).

Patient 3, a 10-year-old boy, was the son of patient 1 and had a history of close contact (such as having dinner) with patient 1. He was admitted to a fever clinic at the local hospital on January 29, 2020, with symptoms of sore throat. His throat swab samples were immediately collected and were tested by rRT-PCR assay, and the patient was diagnosed with COVID-19. A chest CT scan revealed no abnormalities (Fig. 3a, c). Therefore, he was diagnosed with a mild case of COVID-19 [7] and then immediately admitted to the isolation ward and treated with inhaled interferon alpha, oral lopinavir/ritonavir and traditional Chinese medicine for antiviral therapy. After 5 days, on February 5, 2020, the patient was admitted to Guizhou Provincial Jiangjun Mountain Hospital. The treatment plan was the same as that of the local hospital. On February 8th and 10th, 2020, his throat swabs tested negative for SARS-CoV-2 antigens by two rRT-PCR assays, more than 24 h apart. At that time, his symptoms had also disappeared. Therefore, he was discharged from the hospital for 14 days of medical isolation observation in the hospital above. On day 14, his throat swab tested negative again. No abnormality was found on the chest CT (Fig. 3b, d).

Patient 4, a 75-year-old man, was the father of patient 1 and had a history of close contact (such as having dinner) with Patient 1. He was admitted to a fever clinic at the local hospital on January 28, 2020, with symptoms of cough (the first symptom), sputum production, chest tightness and shortness of breath. He was complicated by coexisting diseases: postoperative esophageal cancer, bronchiectasis, latent tuberculosis, hypoxemia and anemia. He had a more than 10-year history of smoking and a 20-year history of drinking, and he had quit both for more than 10 years. His throat swab samples were immediately collected and confirmed by rRT-PCR assay. The patient was diagnosed with COVID-19. Chest CT on admission revealed extensive patchy opacities and reticulation in the left lung and changes indicating damage in the upper lobe of the left lung (Fig. 4a, c). Therefore, the patient was diagnosed with a severe case of COVID-19 pneumonia [7] and was immediately admitted to the isolation ward and received supplemental oxygen through a nasal cannula. His oxygenation index ranged from 240 to 250. He was treated with inhaled interferon alpha, oral lopinavir/ritonavir and traditional Chinese medicine for antiviral therapy. Moxifloxacin and piperacillin-tazobactam were given intravenously to prevent bacterial infections. After 5 days, the patient was admitted to Guizhou Provincial Jiangjun Mountain Hospital on February 4, 2020. Laboratory examination showed that his hemoglobin (85 g/L) and lymphocyte counts (0.29× 10⁹/L) were decreased, while BNP (3143 pg/ml) was significantly increased.

The treatment plan was different from that of the local hospital. He was successively given inhaled interferon alpha; lopinavir/ritonavir, Arbidol, and chloroquine phosphate as antiviral therapy; and meropenem, piperacillin-tazobactam sodium and fluconazole to prevent secondary infection. However, laboratory test results of this patient showed a progressive decline in the absolute number of lymphocytes, a delay in viral clearance, no obvious absorption on chest CT, and a progressive rise in procalcitonin. He was admitted to the intensive care unit (ICU) on the 28th day and discharged from the ICU on the 35th day of hospitalization. Intravenous infusion of convalescent plasma was administered 5 times, totaling 1000 ml, to attenuate lung inflammation. Fortunately, the treatment was very effective and successful: his symptoms were alleviated, with an increase in OI and lymphocyte count and a decrease in BNP. On March 9th and 11th, 2020, his throat swab samples were examined again and were negative for SARS-CoV-2 antigens by two rRT-PCR tests, taken more than 24 h apart. Reexamination of chest CT showed significant absorption of extensive patchy opacities in the left lung (Fig. 4b, d). Therefore, he was discharged from the hospital for 14 days of medical isolation observation in the hospital above.

Patient 5, a 43-year-old man, was the brother of patient 1 and had a history of close contact (such as having dinner) with patient 1. He was admitted to a fever clinic at the local hospital on January 28, 2020, with symptoms of chest tightness (the first symptom), low-grade fever, night sweats, and anorexia. He had a coexisting disorder, pneumoconiosis and a history of smoking for more than 20 years. His throat swab samples were collected and tested positive by rRT-PCR assay. Chest CT revealed diffuse small nodules in both lungs (Fig. 5a, c). Laboratory findings of the patient showed no evidence to support a tuberculosis diagnosis. Therefore, the patient was diagnosed by the local hospital, with a mild case of COVID-19 [7]. He was treated with inhaled interferon alpha, oral lopinavir/ritonavir and traditional Chinese medicine for antiviral therapy. After 4 days, on February 4, 2020, the patient was admitted to Guizhou Provincial Jiangjun Mountain Hospital. The treatment plan was different from that of the local hospital.

After some time, his symptoms disappeared. On February 10th and 12th, 2020, two throat swab samples taken more than 24 h apart tested negative for SARS-CoV-2 antigens by two rRT-PCR assays. Reexamination of chest CT showed no significant changes (Fig. 5b, d). Therefore, he was discharged from the hospital for 14 days of medical isolation observation in the hospital above. Similarly, on day 14, his throat swab samples tested negative for SARS-CoV-2 antigens by rRT-PCR. He had no symptoms during this period.

Patient 6, a 41-year-older woman, was the sister-in-law of patient 1 and had a history of close contact (such as having dinner) with patient 1. She was admitted to a fever clinic at the local hospital on January 29, 2020, with a sore throat. Her throat swab samples were immediately collected and rRT-PCR assay confirmed that the patient had COVID-19. Chest CT scan revealed ground-glass opacities in the left lower lung on admission (Fig. 6a, c). The patient was diagnosed by the local hospital with a moderate case of COVID-19 pneumonia [7], and she was then treated with inhaled interferon alpha, oral lopinavir/ritonavir and traditional Chinese medicine for antiviral therapy. After 7 days, on February 7, 2020, the patient was admitted to Guizhou Provincial Jiangjun Mountain Hospital. The treatment plan was the same as that of the local hospital. After a few days, her symptoms disappeared. On February 12th and 14th, 2020, two throat swab samples taken more than 24 h apart tested negative for SARS-CoV-2 antigens by rRT-PCR. Her chest CT revealed that the ground-glass opacities in the lower left lung were mostly absorbed (Fig. 6b, d). Therefore, she was discharged from the hospital for 14 days of medical isolation observation in the hospital above. Similarly, her throat swab samples tested negative for SARS-CoV-2 by rRT-PCR on day 14, and she had no symptoms during the isolation period.

Patient 7, an 18-year-old girl, was the niece of patient 1 and had a history of close contact with patient 1 (such as having dinner). On January 29, 2020, she was admitted to a fever clinic at the local hospital without any symptoms. Her throat swab samples were immediately collected and confirmed by rRT-PCR assay, and the patient was diagnosed with COVID-19. A chest CT scan showed no abnormalities (Fig. 7a, c). Therefore, she was diagnosed in the local hospital with a mild case of COVID-19 [7] and was immediately admitted to the isolation ward and treated with inhaled interferon alpha, oral lopinavir/ritonavir and traditional Chinese medicine for antiviral therapy. After 5 days, on February 5, 2020, the patient was admitted to Guizhou Provincial Jiangjun Mountain Hospital. The treatment plan was the same as that of the local hospital. On February 15th and 17th, 2020, two throat swab samples taken more than 24 h apart tested negative for SARS-CoV-2 antigens by two rRT-PCR assays. On day 14 of medical isolation, her throat swab samples again were negative. Therefore, she was discharged from the hospital, and she had no symptoms during the period (Fig. 7b, d).