A 38-year-old female translator who worked in Cameroon returned to China two days before hospitalization, with a history of 12 hours of chills, fever (body temperature up to 41 ℃), fatigue, headache, bilateral lower limb muscle soreness, stomach colic discomfort, slightly nausea. The day of second hospitalization was defined as Day-1. She was confirmed with COVID-19 95 days ago, with four times of negative Nucleic acid testing for SARS-CoV-2 after the treatment (Figure 1). She left Cameroon airport and arrived at Cairo airport in Egypt for four days of isolation. After that, she returned to China and was sent to a hotel for isolation. During the whole journey, she wore protective clothes and mask. There was no vomiting, sore throat, expectoration, expectoration, nasal obstruction, runny nose, diarrhea, olfactory taste loss, conjunctivitis for her. Physical examination revealed that her body temperature was 38.2°C, blood pressure was 109/72 mmHg, heart rate was 99 beats per minute, respiratory rate was 21 breaths per minute. There was nothing wrong with her liver, heart, mind and other systems during the physical test. The third hospitalization was in Day-20 with her fever and was started from Day-20 to Day-35. After that, the patient discharged from the hospital with two-weeks’ follow-up.
The laboratory tests showed she had inflammations with high Procalcitonin (PCT, 0.652 ng/ml), high C-reactive protein (CRP, 17.35 mg/L), high Serum amyloid A protein (SAA, 38.44 mg/L), high Neutrophil ratio (82.8%), and lymphopenia (0.31*10^9/L). Treatment of the patient should pay attention to the Aspartate aminotransferase (39 U/L) which was slightly elevated. Infectious diseases such as HIV, Syphilis, HCV, and HBV were negative. A nasal swab was sent for Reverse Transcription-Polymerase Chain Reaction (RT-PCR) to SARS-CoV-2 and was found to be positive, but the other three types of samples were negative. The serum SARS-CoV-2 IgG was positive (43.2 AU/mL), but the IgM was negative (Table 1). A rapid serum detection for malaria was finished and found with Plasmodium falciparum, and a malaria smear also showed ring form of Plasmodium falciparum (Figure 2) with a parasitemia of 1.2%. Pulmonary Computed Tomography showed a small patch of ground glass in the basal segment of the right lower lobe, and it kept un-changed during the whole treatment.
Table 1
Laboratory test on the day of second admission in China
Laboratory items | Result | Reference range |
Aspartate aminotransferase | 39 U/L | 14-36 |
Creatinine | 62 µmol/L | 41-81 |
Glucose | 6.74 mmol/L | 3.9-6.1 |
Sodium | 134.9 mmol/L | 137-147 |
Chlorine | 98.5 mmol/L | 99-110 |
Procalcitonin | 0.652 ng/ml | 0-0.5 |
Fibrinogen | 3.79 g/L | 1.8-3.5 |
D-Dimer | 1.98mg/L | 0-0.55 |
White blood cell count | 3.36*10^9/L | 3.5*10^9-9.5*10^9 |
Neutrophil ratio | 82.8% | 40.0%-75.0% |
lymphopenia | 0.31*10^9/L | 1.10*10^9-3.20*10^9 |
Hemoglobin | 148 g/L | 115-150 |
Platelet | 137*10^9/L | 125*10^9/L-350*10^9/L |
C-reactive protein | 17.35mg/L | 0-10 |
Serum amyloid A protein | 38.44mg/L | 0-10 |
HIV/Syphilis/HCV/HBV | Negative | Negative |
SARS-CoV-2 IgG | 43.2 AU/mL | 0-10 |
SARS-CoV-2 IgM | 0.7 AU/mL | 0-10 |
SARS-CoV-2 (Nasal swab) | Positive | Negative |
SARS-CoV-2 (Throat swab/ Sputum/ Stool) | Negative | Negative |
Plasmodium | Positive (Plasmodium falciparum) | Negative |
Dengue | Negative | Negative |
Considering the high level of Neutrophil ratio, CRP, SAA, and PCT, the patient received Levofloxacin via intravenous drip for anti-infection for 8 days. After the diagnosis of Plasmodium falciparum, Dihydroartemisinin Piperaquine (DP) tablets were taken orally and the parasite was gone in the blood smear in Day-7(Figure 1). The persistence of anti-malaria drug lasted three days to make sure the full clear of the parasite. The treatment of the COVID-19 was Lopinavir (LPV), Arbidol Hydrochloride Granules (AHG), and Recombinant Human interferon a2b atomization inhalation (IAI). A course of anti-viral LPV/AHG regime started from Day-4 to Day-14 and then changed to Thymosin in Day-14 to improve her immunity, but the IAI started from Day-4 to Day-10. The Silibinin Capsules was used to protect the liver function from Day-4 to Day-16, and the traditional Chinese medicine from Day-4 to the end was to protect the lung. The patient had insomnia and depression in the third hospitalization which was provided with the Zolpidem, Paroxetine, and Diazepam (Figure 1) to control her anxiety. The detailed dosage of the drugs can be seen in the supplementary material S1.