Abstract
We report a case series of 6 patients with confirmed coronavirus disease 2019 (COVID-19) in Wakayama prefecture, Japan. All 6 of the patients tested positive via pharyngeal swab polymerase chain reaction (PCR) tests, and 2 of the 6 were still positive at 3 weeks after onset. All of the patients exhibited bilateral ground glass opacities on computed tomography (CT). This article also reports narrative information on the spectrum of symptoms collected directly from the patients. It would be difficult to triage patients with COVID-19 based on the typical symptoms of fever and/or cough, although PCR and CT are definitive in diagnosis.
The novel coronavirus disease (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been spreading since the outbreak of the disease in China in December 2019. The number of COVID-19 cases in Japan has been climbing since mid-February 2020. As of 26 April 2020, 12 388 confirmed cases in Japan have been recorded [1]. Fifty-eight cases have been reported in Wakayama prefecture, Japan.
A new infectious disease law enacted in Japan in February 2020 to manage COVID-19 provides that patients with confirmed COVID-19 must be hospitalized at specialized hospitals for infectious diseases, and that 2 consecutive negative polymerase chain reaction (PCR) results are required for discharge after a patient’s symptoms improve.
While the clinical characteristics of COVID-19 have been reported from China [2], they have not been well understood outside China. In this report we describe a series of patients with confirmed COVID-19 who were treated in our hospital in Wakayama prefecture in February 2020.
METHODS
This single-center, retrospective observational study was conducted at the Japanese Red Cross Wakayama Medical Center (Wakayama, Japan: 873 beds) with a specialized ward for infectious diseases. This study was approved by the Ethical Committee of the Japanese Red Cross Wakayama Medical Center on 26 February 2020. We retrospectively analyzed patients with confirmed COVID-19 who were hospitalized from 13 to 25 February 2020. Each case presentation includes narrative information describing how the patients felt or interpreted their symptoms and excludes personally identifiable information. SARS-CoV-2 was detected by performing a PCR test on specimens of either sputum or pharyngeal swabs, or both, according to laboratory guidance from the Ministry of Health, Labor and Welfare of Japan [3]. The patients were diagnosed with COVID-19 if 2 conditions were met: (1) any clinical symptoms and (2) a positive PCR result for SARS-CoV-2. The day when symptoms appeared is counted as the first day of illness (day 1).
RESULTS
Case 1
A man in his 50s with known hypertension developed fatigue and fever, followed by abdominal pain on day 6. Upon noting blood in his stool, he suspected that his abdominal pain was caused by “ischemic colitis.” A computed tomographic (CT) image taken on day 7 to investigate his abdominal pain showed bilateral ground glass opacity (GGO) of the lungs. He was treated with antibiotics and corticosteroid for pneumonia. Rapid influenza diagnostic tests (RIDTs) were negative on day 6 and day 9. His fever and abdominal pain persisted for 12 days and 9 days, respectively. A PCR test for SARS-CoV-2 performed on day 13 was positive. His next 2 PCR tests, on days 15 and 16, respectively, were negative.
Case 2
A man in his 60s with colon cancer developed a cough (day 1) and was admitted to a hospital for colorectal cancer surgery on day 8. A CT scan was performed on day 9, because the patient exhibited a low-grade fever, chills, and a worsening cough. The CT image showed bilateral GGO of the lungs and his surgery was postponed. His cough remained mild, which led him to believe he was suffering from a “common cold,” until he was diagnosed with pneumonia. A PCR test of a pharyngeal swab was positive, and the patient was referred to our hospital on day 14. The patient has been afebrile since day 16. The consecutive PCR test results finally turned negative on day 25.
Case 3
A man in his 50s presented to a clinic on the second day of fever. Antibiotics and an antitussive were prescribed. Shortly thereafter, he visited a hospital with persistent fever and headache. He suffered a high-grade fever and headache. The headache, he reported, felt like “a heated iron plate in his head.” He was suspected of COVID-19 based on CT imaging and was referred to our hospital on day 6. A PCR test on day 6 was positive. His fever remained until day 9. PCR tests were repeated on days 13 and 14 to confirm that he could be discharged. A CT image taken on the day his fever abated (day 10) showed peripheral ground glass and consolidative opacities that had not been observed in the CT images taken on day 6 (Figure 2).
Case 4
A woman in her 80s who had a history of cerebral infarction and was currently under treatment for diabetes, hypertension, and dyslipidemia developed cough, sputum, and nasal discharge (day 1). “Something is strange,” she reported. “My throat and chills don’t feel like just a common cold.” She underwent the PCR test on day 15 because she had been in close contact with a patient with confirmed COVID-19. A CT image showed bilateral GGO of the lung, and a second PCR test performed on day 16 was positive. She was referred to our hospital on day 17. Two PCR tests on pharyngeal swabs were confirmed to be negative, on days 20 and day 22, respectively.
Case 5
A man in his 60s admitted to hospital for gastric cancer surgery developed a low-grade fever (day 1) 3 days after the surgery. He was tested for SARS-CoV-2 by PCR on day 1 and day 3 because he had been in close contact with a patient with confirmed COVID-19. A CT image showed no pneumonia on day 3. He described his condition as “not that terrible, even though I have a fever.” The PCR test on day 3 came back positive. He was transferred to our hospital on day 5 after developing pneumonia with COVID-19. His fever lasted for 15 days. Two consecutive PCR tests on pharyngeal swabs were confirmed to be negative, on days 21 and 22.
Case 6
A man in his 40s developed chills and fever (day 1) and visited a clinic. An RIDT performed at the clinic came back negative. On day 12, his fever finally abated, but he developed a cough and diarrhea that persisted up to day 17. He suspected that he had contracted “some new type of infectious disease,” judging from his prolonged fever and negative RIDT result. PCR tests of sputum and throat swab were performed on day 21 because he had been in close contact with a confirmed case of COVID-19. He was referred to our hospital on day 22, when a second PCR test of sputum came back positive. A CT image showed bilateral GGO of the lung on day 26. Two PCR tests on pharyngeal swabs were confirmed to be negative, on days 24 and day 25, respectively.
Summary of the Results for the Case Series
Six patients (5 male, 1 female) with confirmed COVID-19 were admitted to our hospital during the study period. The symptoms varied among the 6 cases. Five of the 6 (83%) had fever, 2 (33%) had cough, and 2 (33%) had gastrointestinal symptoms (Figure 1). The patients with similar symptoms interpreted the symptoms differently (Figure 1). No patient developed strong fatigue or dyspnea. All 6 underwent CT scans, and all of the scans manifested peripheral bilateral GGO. The time from onset to the 2 consecutive negative PCR results ranged from 14 to 25 days. PCR tests of 2 of the patients were still positive on day 21 (Figure 1). No patient with COVID-19 was administered oxygen or treated with either antibiotics or antivirals at our hospital. No ground glass or consolidative opacities appeared in the CT images of patient 3 taken on day 6, but both symptoms appeared in a follow-up CT image taken on day 10 (Figure 2).
Clinical courses of the 6 cases. Abbreviations: Abd, abdominal; CT, computed tomography; neg, negative; p, pharyngeal swab; PCR, polymerase chain reaction; pos, positive; s, sputum; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.
Computed tomographic images during the clinical course in case 3, showing peripheral ground glass opacity and linear opacity in the bilateral lower lobe on day 6 (white arrows) and peripheral ground glass and consolidative opacities in the right lower lobe on day 10 (arrowhead).
DISCUSSION
We have described 6 confirmed cases with COVID-19 in Wakayama prefecture, Japan. Cough was less frequent (33% vs 82%) and gastrointestinal symptoms were more frequent (33% vs 3%) in our study than in a previous study [2]. Nearly 20% of reported patients with COVID-19 in China have developed severe pneumonia [4]. Empiric therapy with antimicrobial agents (antibiotics and anti-influenza agents) is recommended in the therapeutic strategy applied in Wuhan, China [5]. In contrast, none of the patients in our study have been administered antimicrobial agents, and all of them had mild symptoms and no signs of severe pneumonia.
According to Zou et al, the higher viral loads detected in the nasal passages or throats of patients soon after symptom onset suggested that the SARS-CoV-2 infection followed a pattern resembling that of influenza [6]. In most of their patients infected with SARS-CoV-2, the viral load was markedly reduced within 2 weeks after symptom onset [6]. Nevertheless, SARS-CoV-2 was detected in our patients 3 weeks after onset, after their symptoms had already subsided (Figure 1). This finding suggests that infection prevention and control measures are still required after patients recover.
The follow-up CT image of patient 3 suggested that consolidated opacities can be found after the symptoms improve. This finding is consistent with a previous study showing that consolidation in CT images was more frequently detected in the late stage after COVID-19 onset, compared to the early stage [7]. The consolidated opacities found after symptom abatement also suggest that it can be difficult to detect pneumonia by chest radiograph in COVID-19 patients at the early stage of the clinical course.
The strength of our study is the narrative information directly taken from the patients. As the terms patients use to describe their symptoms differ from those used by health personnel [8], their complaints should be categorized and/or classified using medical terminology to summarize their clinical characteristics in a descriptive study with a large number of cases. A careful recording of the patients’ own descriptions of their histories could reveal how common symptoms of COVID-19, such as fever or cough, differ from the symptoms of other acute respiratory infections. A third of our patients experienced gastrointestinal symptoms, and 1 of the patients with gastrointestinal symptoms was free of respiratory symptoms. We know, therefore, that grounds for suspecting pneumonia may be absent in some COVID-19 patients. A previous study reported that healthcare workers were presumed to have been infected by a single COVID-19 patient who presented with abdominal pain [9]. The symptom of abdominal pain in COVID-19 should be carefully treated for infection prevention and control. Narrative information from patients is important to our efforts to understand the clinical characteristics of a novel disease with potentially unknown symptoms, such as COVID-19.
The case series reported here describes patients in Japan. The complaints exhibited and described by the COVID-19 patients in this series varied from case to case. It would be difficult to triage patients with COVID-19 based on typical symptoms of fever and/or cough, although PCR and CT are definitive in diagnosis.
Notes
Acknowledgments. The authors thank the Wakayama-City Health Center and Wakayama-City Institute of Public Health for the severe acute respiratory syndrome coronavirus polymerase chain reaction tests.
Potential conflicts of interest. All authors: No reported conflicts of interest.
All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
