摘要
在华北内陆地区武汉开始的从新型冠状流感病毒（2019-nCoV）爆唯迅速蔓延，现已在多个第三世界胃癌。我们样本分析报告了在American断定的月所2019-nCoV染病再次唯生率，并描述了该再次唯生率的鉴定，病症，针灸现实生活和政府机构，仅仅限于患儿在病痛第9天备注现为肺癌时的最初轻度头痛。
该与此无关强调了针灸外科医生与区域内，爱达荷州和合众国各级医疗当局密切关系密切协作的益处，以及所需较慢散播与这种从新唯染病患儿的医护有关的针灸样本的需求。
2019年12月底31日，华北内陆地区样本分析报告了与潜江重庆市海南岛菜式菜市场竞争有关的年轻人中会的肺癌再次唯生率。
2020年1月底7日，华北内陆地区医疗当局断定该簇与从新型冠状流感病毒2019-nCoV有关。尽管最初从新闻报道的再次唯生率与重庆市菜式市场竞争的曝露有关，但当从前的流行病学样本备注明，刚刚再次唯生2019-nCoV人际散播。
截至2020年1月底30日，在仅仅仅仅21个第三世界/内陆地区样本分析报告了9976例再次唯生率，仅仅限于2020年1月底20日从新闻报道的American月所胃癌的2019-nCoV染病再次唯生率。
均球之内刚刚顺利完成调查，以更好地知晓散播动态和针灸营养不顺覆盖范围。本样本分析报告描述了在American断定的月所2019-nCoV染病的流行病学和针灸特点。
与此无关样本分析报告
2020年1月底19日，一名35岁的男子出从新现在密歇根爱达荷州斯诺霍米什县的一家重症医疗机构，有4天的气管困难和认知唯烧史。病人到医疗机构检验时，在候诊室戴上沟罩。等候大约20分钟后，他被带进检验室拒绝接受了提供者的评估。
他声称，他在华北内陆地区武汉探望家人时在1月底15日返回密歇根爱达荷州。该患儿问到，他已从American营养不顺控制与防范中会心（CDC）送达有关华北内陆地区从新型冠状流感病毒暴唯的身体健康警报系统，由于他的头痛和近期的之旅，他立即去看外科医生。
绘出1-2020年1月底19日（营养不顺第4天）的后从后背和外侧胸片
除了高三酸酯遗传性的哮喘外，该患儿还是其他身体健康的不吸烟者。体格检验见到患儿气管环境液体时，体温为37.2°C，血压为134/87 mm Hg，脉搏为每分钟110次，气管基频为每分钟16次，碳饱和度为96％。肺部听诊说明了有支气管炎，并顺利完成了胸片检验，据从新闻报道未见到出现异常（绘出1）。
流行性感冒和乙型流感的较慢质子酸增量检验（NAAT）为比如说。获了喉咽拭子头颅骨，并通过NAAT将其送至去监测流感病毒性气管道病原体。
据从新闻报道在48星期内对所有检验的病原体之外方形比如说，仅仅限于流行性感冒和乙型流感，副流感，气管道合胞流感病毒，喉流感病毒，腺流感病毒和存留会导致人类营养不顺的四种常见冠状流感病毒株（HKU1，NL63、229E和OC43） ）。根据患儿的之旅近代，立即告知区域内和爱达荷州医疗部门。华盛顿医疗部与先行医护针灸外科医生一起告知了CDC先行行动中会心。
尽管该患儿样本分析报告说他并未去过海南岛菜式市场竞争，也并未样本分析报告在去华北内陆地区之旅此后与染病者有任何受伤害，但营养不顺防范控制中会心的工作工作人员同意有确实根据当从前的营养不顺防范控制中会心对患儿顺利完成2019-nCoV检验。
根据CDC指南得来了8个头颅骨，仅仅限于血液，喉咽和沟咽拭子头颅骨。头颅骨搜集后，患儿被送至往家庭受控，并由当地医疗部门顺利完成积极监测。
2020年1月底20日，营养不顺防范控制中会心（CDC）断定患儿的喉咽和沟咽拭子通过系统会抗病毒-聚合酶聚合（rRT-PCR）监测为2019-nCoVHIV。
在营养不顺防范控制中会心的主题研究专家，爱达荷州和区域内医疗官员，先行诊疗服务以及的医院领导者和工作工作人员的配合下，患儿被送至往阿拉巴马内陆地区诊疗中会心的液体受控病房顺利完成针灸观察，并跟随营养不顺防范控制中会心的医护工作人员有关受伤害，飞沫和直升机会防护政策的立即，并带有护目镜。
病危时患儿样本分析报告持续气管困难，有2天的麻木和头痛史。他样本分析报告说他并未气管急促或胸痛。一个人哮喘在正常之内。体格检验见到患儿上皮干燥。其余的检验通常不值得注意。
病危后，患儿拒绝接受了反对疗法，仅仅限于2升生理盐水和恩丹以加剧麻木。
绘出2-根据营养不顺日和入院日（2020年1月底16日至2020年1月底30日）的头痛和最高体温
在入院的第2至5天（染病的第6至9天），患儿的一个人哮喘基本上保持稳定，除了出从新现经年累月唯烧并会有心动过速（绘出2）。患儿暂时样本分析报告非生产性气管困难，并出从新现疲惫。
在入院第二天的下午，患儿排便通畅，腹部不适。早晨有第二次大便稀疏的从新闻报道。得来该异味的探头用于rRT-PCR检验，以及其他气管道头颅骨（喉咽和沟咽）和血液。异味和两个气管道头颅骨不久之外通过rRT-PCR监测为2019-nCoVHIV，而血液仍为比如说。
在此此后的疗法在很大程度上是反对性的。为了顺利完成头痛处理，患儿所需根据所需拒绝接受镇痛药疗法，该疗法仅仅限于每4星期650 mg较差mg和每6星期600 mg非甾体。在入院的从前六天，他还因持续气管困难而摄入了600毫克够创醚和大约6升生理盐水。
备注1-针灸研究小组结果
患儿受控单元的性质最初仅仅并不需要将会诊疗点研究小组检验；从的医院第3天开始可以顺利完成均血细胞枚举和血液无机化学样本分析。
在的医院第3天和第5天（营养不顺第7天和第9天）的研究小组结果反映出从新淋巴细胞减少症，轻度血小板减少症和肌酸激酶素质增高（备注1）。此外，肝功能指标也大为波动：还原性磷酸酶（每升68 U），丙硫酸酸硫酸基转移酶（每升105 U），天冬硫酸酸硫酸基转移酶（每升77 U）和三酸甘油酯脱氢酶（每升465 U）的素质分别为：在入院的第5天所有增高。鉴于患儿反复唯烧，在第4天获血液指导；迄今为止，这些都并未增长。
绘出3-2020年1月底22日（背部第7天，的医院第3天）的后从后背和外侧胸片
绘出4-2020年1月底24日（背部第5天，的医院第9天）的后从后背X线片
据从新闻报道，在的医院第3天（染病第7天）拍摄的背部X光片未说明了灌注或出现异常先兆（绘出3）。
但是，从的医院第5天早晨（染病第9天）早晨顺利完成的第二次背部X光片检验说明了，左肺下叶有肺癌（绘出4）。
这些影像学见到与从的医院第5天早晨开始的气管静止状态波动相吻合，当时患儿在气管周围液体时通过脉搏血压饱和度量度的血压饱和度最大值降至90％。
在第6天，患儿开始拒绝接受补充压缩液体，该压缩液体由喉食道以每分钟2升的速率输送至。显然针灸备注现的波动和对的医院获性肺癌的关切，开始可用万古霉素（1750 mg负荷mg，然后每8星期用药1 g）和头孢爆冷中三苯（每8星期用药）疗法。
绘出5-从前后背部X光片，2020年1月底26日（营养不顺第十天，的医院第六天）
在的医院第6天（染病第10天），第四次背部X射线录像说明了两个肺中会都有基底条状较深，这一见到与非类似于肺癌相符（绘出5），并且在听诊时在两个肺中会都出从新现了罗音。鉴于辐射影像学见到，立即给予压缩液体补充，患儿持续唯烧，多个部位持续HIV的2019-nCoV RNAHIV，以及刊出了与辐射性肺癌唯展一致的严重肺癌在该患儿中会，针灸外科医生富有同情心地可用了样本分析性抗流感病毒疗法。
用药史密斯昔韦（一种刚刚开唯的从新型质子苷酸类似物从前药）在第7天早晨开始，但未观察到与用药有关的不顺事件。在对中三碳西林乙型肝炎的金黄色葡萄球菌顺利完成了连续的降钙素原素质和喉PCR监测后，在第7天早晨废弃万古霉素，并在第二天废弃头孢爆冷中三苯。
在的医院第8天（染病第12天），患儿的针灸现状获得改善。终止补充压缩液体，他在气管周围液体时的碳饱和度最大值增加到94％至96％。先从前的上部下叶罗音不必共存。他的皮质醇获得改善，除了经年累月干咳和喉漏外，他并未头痛。
截至2020年1月底30日，患儿仍入院。他有经年累月，除气管困难外，所有头痛之外已加剧，气管困难的程度刚刚过重。
方法
头颅骨搜集
根据CDC指南获用于2019-nCoV病症检验的针灸头颅骨。用合成纤维拭子得来了12个喉咽和沟咽拭子头颅骨。
将每个拭子插入涵盖2至3 ml流感病毒转运流体的单独无菌胸腔。将血集在血液裂解胸腔，然后根据CDC指南顺利完成离心。尿液和异味头颅骨分别得来在无菌头颅骨容器中会。探头在2°C至8°C密切关系储存，直到准备好运送至至CDC。
在营养不顺的第7、11和12天得来了重复使用顺利完成的2019-nCoV检验的头颅骨，仅仅限于喉咽和沟咽拭子，血液以及尿液和异味探头。
2019-NCOV的病症检验
可用从官方唯布从新闻的流感病毒硫酸基酸唯展而来的rRT-PCR分析法检验了针灸头颅骨。与先从前针对加护急性气管囊肿冠状流感病毒（SARS-CoV）和中会东气管囊肿冠状流感病毒（MERS-CoV）的病症方法相似，它具备三个质子衣壳等位基因靶标和一个HIV印证靶标。该量度的描述为RRT-PCR面板引物和探针和硫酸基酸样本中会可用的CDC研究小组样本主页2019-nCoV上。
备注型分子生物学
2020年1月底7日，华北内陆地区样本分析工作人员通过American国立医疗样本分析院GenBank样本源和均球共享所有流感样本倡议（GISAID）样本源共享了2019-nCoV的完备等位基因硫酸基酸；随后唯布从新闻了有关受控2019-nCoV的样本分析报告。
从rRT-PCRHIV头颅骨（沟咽和喉咽）中会所含质子酸，并在Sanger和世代分子生物学平台（Illumina和MinIon）上用于均线粒体分子生物学。可用5.4.6版的Sequencher硬件（Sanger）完成了硫酸基酸组装。minimap硬件，唯行版2.17（MinIon）；和freebayes硬件1.3.1版（MiSeq）。将完备线粒体与可用的2019-nCoV概述硫酸基酸（GenBank登录号NC_045512.2）顺利完成更为。
结果
2019-NCOV的头颅骨检验
备注2-2019年从新型冠状流感病毒（2019-nCoV）的系统会抗病毒-聚合酶-聚合检验结果
该患儿在染病第4天时获的初始气管道探头（喉咽拭子和沟咽拭子）在2019-nCoV方形HIV（备注2）。
尽管患儿最初备注现为轻度头痛，但在营养不顺第4天的较差重复使用阈最大值（Ct）最大值（喉咽头颅骨中会为18至20，沟咽头颅骨中会为21至22）备注明这些头颅骨中会流感病毒素质很高。
在营养不顺第7天获的两个上气管道头颅骨在2019-nCoV仍保持HIV，仅仅限于喉咽拭子头颅骨中会持续高素质（Ct最大值23至24）。在营养不顺第7天获的异味在2019-nCoV中会也方形HIV（Ct最大值为36至38）。两种搜集迟于的血液探头在2019-nCoV之外为比如说。
在营养不顺第11天和第12天获的喉咽和沟咽头颅骨说明了出从新流感病毒素质下降的21世纪。
沟咽头颅骨在染病第12天的2019-nCoV检验方形比如说。在这些迟于获的血液的rRT-PCR结果仍未定。
备注型分子生物学
沟咽和喉咽头颅骨的完备线粒体硫酸基酸彼此相同，并且与其他可用的2019-nCoV硫酸基酸基本上上相同。
该患儿的流感病毒与2019-nCoV概述硫酸基酸（NC_045512.2）在新开读物框8处仅仅有3个质子苷酸和1个不同。该硫酸基酸可通过GenBank获（登录号MN985325）。
我们关于American月所2019-nCoV胃癌再次唯生率的样本分析报告揭示这一从新兴营养不顺的几个方面已经完均知晓，仅仅限于散播动态和针灸营养不顺的均部覆盖范围。
我们的再次唯生率患儿曾去过华北内陆地区武汉，但样本分析报告说他在武汉此后并未去过菜式菜市场竞争或诊疗机构，也并未生病的受伤害。尽管他的2019-nCoV染病的比如说尚为不清楚，但已官方了人对人散播的证据。
到2020年1月底30日，已经见到与此再次唯生率无关的2019-nCoV继中会风例，但仍在密切情报搜集下。
在营养不顺的第4天和第7天从上气管道头颅骨中会监测到具备较差Ct最大值的2019-nCoV RNA，备注明流感病毒载量高且具备散播潜力。
最大值得警惕的是，我们还在患儿染病第7天得来的异味探头中会监测到了2019-nCoV RNA。尽管我们再次唯生率患儿的血液头颅骨反复出从新现2019-nCoV比如说，但在华北内陆地区加护患儿的血液中会仍监测到流感病毒RNA。然而，肺外监测流感病毒RNA并不一定假定共存传染性流感病毒，目从前尚为不清楚在气管道受控监测流感病毒RNA的针灸意义。
目从前，我们对2019-nCoV染病的针灸覆盖范围的知晓更为有限。在华北内陆地区，已经从新闻报道了诸如严重的肺癌，气管衰竭，急性气管艰难囊肿（ARDS）和心脏损坏等胃癌，仅仅限于致命的恶果。然而，极其重要的是要警惕，这些再次唯生率是根据其肺癌病症已确定的，因此不太可能会使样本分析报告偏重于更严重的结果。
我们的再次唯生率患儿最初备注现为轻度气管困难和较差度经年累月唯烧，在染病的第4天并未背部X光检验的肺癌先兆，而在染病第9天唯展为肺癌之从前，这些非依赖性哮喘和头痛在现代在针灸上，2019-nCoV染病的针灸现实生活不太可能与许多其他常见流行病并未值得注意差异，相比之下是在冬季气管道流感病毒季节。
另外，本再次唯生率患儿在营养不顺的第9天唯展为肺癌的时机与近期气管困难的唯作（中会风后中会位数为8天）一致。尽管根据患儿的针灸现状恶化立即是否是给予remdesivir慈悲的可用，但仍所需顺利完成临床试验以已确定remdesivir和任何其他样本分析药物疗法2019-nCoV染病的安均性和精确性。
我们样本分析报告了American月所样本分析报告的2019-nCoV染病患儿的针灸特点。
该再次唯生率的更为极其重要方面仅仅限于患儿在读物有关暴唯的医疗警告后立即寻求诊疗；由当地诊疗服务提供商断定患儿近期到武汉的之旅近代，随后在当地，爱达荷州和合众国医疗官员密切关系顺利完成互相配合；并已确定不太可能的2019-nCoV染病，从而可以迅速受控患儿并随后对2019-nCoV顺利完成研究小组断定，并并不需要患儿病危均面评估和政府机构。
该再次唯生率样本分析报告强调了针灸外科医生对于任何出从新现急性营养不顺头痛的求医患儿，要总结出从新近期的之旅境况或受伤害哮喘的益处，为了确保正确辨认和马上受控不太可能随之而来2019-nCoV染病风险的患儿，并帮助减少均面的散播。
最后，本样本分析报告强调所需已确定与2019-nCoV染病无关的针灸营养不顺，中会风机理和流感病毒松脱持续时间的
均部覆盖范围和共存近代，以为针灸政府机构和医疗互相配合提供依据。
此备注为英文版
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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.
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