SARS-CoV-2 positivity in a discharged COVID-19 patient: a case report

Recurrence, Reactivation, or Inflammatory Rebound of SARS-CoV-2 Infection With Acute Vestibular Symptoms: A Case Report and Revision of Literature

A case of recurrent coronavirus disease 2019 (COVID-19) with neurovestibular symptoms was reported. In March 2020, a physician working in an Italian pediatric hospital had flu-like symptoms with anosmia and dysgeusia, and following a reverse transcription PCR (RT/PCR) test with a nasopharyngeal swab tested positive for SARS-CoV-2. After home quarantine, 21 days from the beginning of the symptoms, the patient tested negative in two subsequent swabs and was declared healed and readmitted to work. Serological testing showed a low level of immunoglobulin G (IgG) antibody title and absence of immunoglobulin M (IgM). However, 2 weeks later, before resuming work, the patient complained of acute vestibular syndrome, and the RT/PCR test with mucosal swab turned positive. On the basis of the literature examined and reviewed for recurrence cases and vestibular symptoms during COVID-19, to our knowledge this case is the first case of recurrence with vestibular impairment as a neurological symptom, and we defined it as probably a viral reactivation. The PCR retest positivity cannot differentiate re-infectivity, relapse, and dead-viral RNA detection. Serological antibody testing and viral genome sequencing could be always performed in recurrence cases.

Conundrum of re-positive COVID-19 cases: A systematic review of case reports and case series

Background

The systematic review was conducted to summarize and synthesize evidence from all available case series and case reports published on re-positive COVID-19 cases.

Methods

The systematic review was registered with Prospero (CRD42020210446). PRISMA guidelines were followed for conducting the systematic review. Inclusion criteria for studies included case reports and case series which have documented cases of positive reverse transcriptase polymerase chain reaction (RT-PCR) after a period of clinical improvement or a negative RT-PCR report. Reviews, opinions, and animal studies were excluded. Methodological quality was assessed using the modified Murad scale.

Results

A total of 30 case reports/case series were included in the study, wherein a total of 219 cases were included. In re-positive cases, the age range varied from 10 months to 91 years. The pooled proportion of positive cases after follow-up using random-effects was 12% (95% confidence interval [CI]: 09%-15%). Among the re-positives, a total of 57 cases (26%) had comorbidities. A total of 51 (23.3%) and 17 (7.8%) re-positive cases had been treated with antivirals and corticosteroids, respectively. Only a few studies have confirmed the presence of antibodies after the first episode. Studies that included contact tracing of re-positives did not find any positive cases among close contacts of re-positive cases.

Conclusion

The systemic review found that reinfection is a possibility within 123 days of a negative RT-PCR test in a small number of cases of COVID-19. This has wider ramifications in framing clinical, preventive, and public health policy guidelines.

Continued nucleic acid tests for SARS-CoV-2 following discharge of patients with COVID-19 in Lu'an, China

BACKGROUND

Studies have shown that discharged Coronavirus disease 2019 (COVID-19) patients have retested positive for SARS-CoV-2 during a follow-up RT-PCR test. We sought to assess the results of continued nucleic acid testing for SARS-CoV-2 patients in COVID-19 patients after they were discharged in Lu'an, China.

METHODS

We conducted RT-PCR tests on sputum, throat swabs, fecal or anal swabs, and urine samples collected from 67 COVID-19 patients following discharge. Samples were collected on the 7th and 14th days following discharge. Patients testing positive on the 7th or 14th day were retested after 24 hours until they tested negative twice.

RESULTS

Seventeen (17/67, 25.4%) discharged COVID-19 patients had a positive RT-PCR retest for SARS-CoV-2. Among them, 14 (82.4%) were sputum positive, five (29.4%) were throat swab positive, seven (41.2%) were fecal or anal swab positive, one (5.9%) was urine sample positive, five (29.4%) were both sputum and throat swab positive, four (23.5%) were both sputum and fecal test positive, and one (5.9%) was positive of all four specimens. The shortest period of time between discharge and the last positive test was 7 days, the longest was 48 days, and the median was 16 days. The proportion of positive fecal or anal swab tests increased from the third week. The median Cq cut-off values after onset were 26.7 after the first week, 37.7 the second to sixth week, and 40 after the sixth week. There were no significant differences between the RT-PCR retest positive group and the unrecovered positive group.

CONCLUSIONS

There was a high proportion of patients who retested positive for COVID-19. Discharge criteria have remained fairly consistent so we encourage regions affected by COVID-19 to appropriately amend their current criteria.

Reinfection or Reactivation of Severe Acute Respiratory Syndrome Coronavirus 2: A Systematic Review

As the pandemic continues, individuals with re-detectable positive (RP) SARS-CoV-2 viral RNA among recovered COVID-19 patients have raised public health concerns. It is imperative to investigate whether the cases with re-detectable positive (RP) SARS-CoV-2 might cause severe infection to the vulnerable population. In this work, we conducted a systematic review of recent literature to investigate reactivation and reinfection among the discharged COVID-19 patients that are found positive again. Our study, consisting more than a total of 113,715 patients, indicates that the RP-SARS-CoV-2 scenario occurs plausibly due to reactivation, reinfection, viral shedding, or testing errors. Nonetheless, we observe that previously infected individuals have significantly lower risk of being infected for the second time, indicating that reactivation or reinfection of SARS-CoV-2 likely have relatively less impact in the general population than the primary infection.

A systematic review and meta-analysis of discharged COVID-19 patients retesting positive for RT-PCR

BACKGROUND

With the increased number of patients discharged after having COVID-19, more and more studies have reported cases whose retesting was positive (RP) during the convalescent period, which brings a new public health challenge to the world.

METHODS

We searched PubMed, Web of Science, The Cochrane Library, CNKI, WanFang and VIP from December 1, 2019 to December 31, 2020. The included studies were assessed using JBI critical appraisal tools and Newcastle-Ottawa Scale. The RP rate of discharge patients was analyzed by a meta-analysis. We adhered to PRISMA reporting guideline.

FINDINGS

We have included 117 studies with 2669 RP participants after discharge. The methodological quality of 66 case reports were low to high, 42 case series and 3 cohort study were moderate to high, 3 case-control studies were moderate and 3 cross-sectional studies were low to moderate. The clinical manifestations of most RP patients were mild or asymptomatic, and CT imaging and laboratory examinations were usually normal. The existing risk factors suggest that more attention should be paid to sever patients, elderly patients, and patients with co-morbidities. The summary RP rate was 12·2% (95% CI 10·6-13·7) with high heterogeneity (I²  = 85%).

INTERPRETATION

To date, the causes and risk factors of RP result in discharged patients are not fully understood. High-quality etiological and clinical studies are needed to investigate these issues to further help us to make strategies to control and prevent its occurrence.

Is recurrence possible in coronavirus disease 2019 (COVID-19)? Case series and systematic review of literature

Can a patient diagnosed with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) be infected again? This question is still unsolved. We tried to analyze local and literature cases with a positive respiratory swab after recovery. We collected data from symptomatic patients diagnosed with SARS-CoV-2 infection in the Italian Umbria Region that, after recovery, were again positive for SARS-CoV-2 in respiratory tract specimens. Samples were also assessed for infectivity in vitro. A systematic review of similar cases reported in the literature was performed. The study population was composed of 9 patients during a 4-month study period. Among the new positive samples, six were inoculated in Vero-E6 cells and showed no growth and negative molecular test in culture supernatants. All patients were positive for IgG against SARS-CoV-2 nucleoprotein and/or S protein. Conducting a review of the literature, 1350 similar cases have been found. The presumptive reactivation occurred in 34.5 days on average (standard deviation, SD, 18.7 days) after COVID-19 onset, when the 5.6% of patients presented fever and the 27.6% symptoms. The outcome was favorable in 96.7% of patients, while the 1.1% of them were still hospitalized at the time of data collection and the 2.1% died. Several hypotheses have been formulated to explain new positive respiratory samples after confirmed negativity. According to this study, the phenomenon seems to be due to the prolonged detection of SARS-CoV-2 RNA traces in respiratory samples of recovered patients. The failure of the virus to replicate in vitro suggests its inability to replicate in vivo.

Recurrence of SARS-CoV-2 viral RNA in recovered COVID-19 patients: a narrative review

Many studies have shown that re-positive tests for SARS-CoV-2 by RT-PCR in recovered COVID-19 patients are very common. We aim to conduct this review to summarize the clinical and epidemiological characteristics of these patients and discuss the potential explanations for recurrences, the contagiousness of re-detectable positive SARS-CoV-2 virus, and the management of COVID-19 patients after discharge from hospital. The proportion of re-positive tests in discharged COVID-19 patients varied from 2.4 to 69.2% and persisted from 1 to 38 days after discharge, depending on population size, age of patients, and type of specimens. Currently, several causes of re-positive tests for SARS-CoV-2 in recovered COVID-19 patients are suggested, including false-negative, false-positive RT-PCR tests; reactivation; and re-infection with SARS-CoV-2, but the mechanism leading to these re-positive cases is still unclear. The prevention of re-positive testing in discharged patients is a fundamental measure to control the spread of the pandemic. In order to reduce the percentage of false-negative tests prior to discharge, we recommend performing more than two tests, according to the standard sampling and microbiological assay protocol. In addition, specimens should be collected from multiple body parts if possible, to identify SARS-CoV-2 viral RNA before discharge. Further studies should be conducted to develop novel assays that target a crucial region of the RNA genome in order to improve its sensitivity and specificity.

Medium Term Follow-Up of 337 Patients With Coronavirus Disease 2019 (COVID-19) in a Fangcang Shelter Hospital in Wuhan, China

Background: With the adoption of powerful preventive and therapeutic measures, a large number of patients with COVID-19 have recovered and been discharged from hospitals in Wuhan, China. Prevention of epidemic rebound is a top priority of current works. However, information regarding post-discharge quarantine and surveillance of recovered patients with COVID-19 is scarce.

Methods: This study followed up 337 patients with COVID-19 in a Wuhan East-West Lake Fangcang shelter hospital during the post-discharge quarantine. Demographic, clinical characteristics, comorbidities, and chest computed tomography (CT) image, mental state, medication status, and nucleic acid test data were summarized and analyzed.

Results: 21/337 (6.2%) patients were SARS-CoV-2 nucleic acid re-positive, and 4 /337(1.2%) patients were suspected positive. The median day interval between the discharge to nucleic acid re-positivity was 7.5 days (IQR, 6–13), ranging from 6 to 13 days. Cough/expectoration are the most common symptoms, followed by chest congestion/dyspnea during the 2 weeks post-discharge quarantine. Risk factors of nucleic acid re-positivity including the number of lobes infiltration (odds ratio[OR], 1.14; 95% CI, 1.09–1.19), distribution (OR, 0.16; 95% CI, 0.13–0.19), CT imaging feature of patchy shadowing accompanying with consolidation (OR, 9.36; 95% CI, 7.84–11.17), respiratory symptoms of cough accompanying with expectoration (OR, 1.39; 95% CI, 1.28–1.52), and chest congestion accompanying by dyspnea (OR, 1.42; 95% CI, 1.28–1.57).

Conclusion: The 2 weeks post-discharge quarantine may be an effective measure to prevent the outbreak from rebounding from the recovered patients. The second week is a critical period during post-discharge quarantine. Special attention should be paid to cough, expectoration, chest congestion, and dyspnea in recovered COVID-19 patients. A few recovered patients may prolong the quarantine based on clinical symptoms and signs and nucleic acid results in the 2 weeks of medical observation.