Chun Gao1, Li Zhu1, Cheng Cheng Jin1, Yi Xin Tong1, Ai Tang Xiao1, Sheng Zhang2. 1. Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China. 2. Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China. Electronic address: aloof3737@126.com.
Abstract
Since December 2019, Coronavirus Disease 2019 (COVID-19) has emerged as a global pandemic. We aimed to investigate the clinical characteristics and analyzed the risk factors for prolonged viral RNA shedding. We retrospectively collected data from 112 hospitalized COVID-19 patients in a single center in Wuhan, China. Factors associated with prolonged viral RNA shedding (≥28 days) were investigated. Forty-nine (43.8%) patients had prolonged viral RNA shedding. Patients with prolonged viral shedding were older and had a higher rate of hypertension. Proinflammatory cytokines, including interleukin-2R (IL-2R) and tumor necrosis factor-α (TNF-α), were significantly elevated in patients with prolonged viral shedding. Multivariate analysis revealed that hypertension, older age, lymphopenia and elevated serum IL-2R were independent risk factors for prolonged viral shedding. This comprehensive investigation revealed the distinct characteristics between patients with or without prolonged viral RNA shedding. Hypertension, older age, lymphopenia and high levels of proinflammatory cytokines may be correlated with prolonged viral shedding.
Since December 2019, Coronavirus Disease 2019 (COVID-19) has emerged as a global pandemic. We aimed to investigate the clinical characteristics and analyzed the risk factors for prolonged viral RNA shedding. We retrospectively collected data from 112 hospitalized COVID-19patients in a single center in Wuhan, China. Factors associated with prolonged viral RNA shedding (≥28 days) were investigated. Forty-nine (43.8%) patients had prolonged viral RNA shedding. Patients with prolonged viral shedding were older and had a higher rate of hypertension. Proinflammatory cytokines, including interleukin-2R (IL-2R) and tumor necrosis factor-α (TNF-α), were significantly elevated in patients with prolonged viral shedding. Multivariate analysis revealed that hypertension, older age, lymphopenia and elevated serum IL-2R were independent risk factors for prolonged viral shedding. This comprehensive investigation revealed the distinct characteristics between patients with or without prolonged viral RNA shedding. Hypertension, older age, lymphopenia and high levels of proinflammatory cytokines may be correlated with prolonged viral shedding.
The entire world has been threatened by the outbreak of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) [1,2]. As of May 5th, 2020, over 3,500,000 cases were confirmed worldwide with a rough death rate of approximately 5.5%.Clinical manifestations of COVID-19 are variable, and they vary from asymptomatic to mild, moderate, severe and critical. In most cases, COVID-19patients present with symptoms including fever, cough, dyspnea, chest tightness, fatigue, gastrointestinal symptoms, myalgia and headache. Laboratory findings featuring lymphopenia and radiographic findings of pneumonia are common evidence of the diagnosis. Severe or critical patients might suffer from acute respiratory failure, acute respiratory distress syndrome (ARDS) and other serious complications involving multiple systems [3,4]. Real-time reverse transcription polymerase chain reaction (RT-PCR) for SARS-CoV-2 is the standard laboratory examination to confirm the diagnosis of COVID-19 [5].Many studies have found that older patients have a higher risk of having a severe case and they have a higher death rate from COVID-19, which may be related to a weaker host immune response for antiviral defense and an uncontrolled proinflammatory cytokine storm [3,4,6]. A recent report by Qin et al. showed that severe cases of COVID-19 had a profound dysregulation of their immune response. This might be part of the pathological process of COVID-19 and be related to the clinical outcome [7]. Viral shedding patterns of SARS-CoV-2 have been revealed in several studies, and the dynamics of viral shedding have been reported [8]. According to recent reports of the SARS-CoV-2 viral nucleic acid shedding pattern, a certain proportion of patients may experience a longer duration of viral nucleic acid negative conversion [9,10].Therefore, this retrospective study aimed to analyze the clinical characteristics of COVID-19patients who experienced prolonged viral shedding and to investigate the contributing risk factors.
Methods
Study design and participants
We retrospectively enrolled 112 hospitalized patients (admission date from Jan 21st to Feb 16th, 2020) with confirmed SARS-CoV-2 infection at Tongji Hospital of Huazhong University of Science and Technology in Wuhan, China. All enrolled patients were laboratory confirmed to have COVID-19 according to the diagnosis and treatment guidelines for SARS-CoV-2 from the Chinese National Health Committee (5th version) as previously reported [[10], [11], [12]].This study was approved by the Ethics Committee of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology. Written informed consent was waived by the Ethics Commission of the designated hospital for emerging infectious diseases. All data were retrospectively collected up to the final follow-up date (April 20th, 2020).
Data collection and definitions
Data were collected from the electronic medical record system. The following information was collected for analysis: 1. Demographic characteristics such as age, sex, smoking, and comorbidities; 2. Clinical characteristics such as signs, symptoms, date of onset (defined as the first date when the symptoms were reported), date of admission and date of discharge. The onset time of signs and symptoms were reported by the patients when they were admitted to the hospital; 3. Laboratory results including routine blood tests, serum proinflammatory cytokines and infection-related markers; 4. SARS-CoV-2 viral test results. Throat and/or nasal swabs were collected for SARS-CoV-2 viral nucleic acid detection at sequential time points by RT-PCR assays. The end of viral RNA shedding was defined as two consecutive negative results. Time to the end of viral RNA shedding was considered as the time period between symptom onset and the date of the first negative RT-PCR test result. Prolonged viral RNA shedding was defined as prolonged detection (>28 days) of SARS-CoV-2 virus RNA by RT-PCR from nasal or throat swab specimens.
Real-time reverse transcription polymerase chain reaction assay for SARS-CoV-2
Throat swab samples or deep nasal cavity swab samples were collected for extracting RNA to confirm the diagnosis of COVID-19infection as previously reported [10]. The collected swabs were placed into a collection tube with 200 μL of virus preservation solution, and total RNA was extracted within 2 h using magnetic beads (Tianlong, Xi'an, China). The extraction solution was used for a one-step RT-PCR assay of COVID-19 RNA. Two target genes, open reading frame 1ab (ORF1ab) and nucleocapsid protein (N), were simultaneously amplified and tested during the real-time RT-PCR assay. The real-time RT-PCR assay was performed using a COVID-19 nucleic acid detection kit according to the manufacturer's protocol (Shanghai Huirui Biotechnology Co., Ltd.). The reaction mixture contained 7.5 μL of RT-PCR reaction buffer, 5 μL of ORF 1ab/N gene reaction solution, 1.5 μL of enzyme mixture, and 11 μL of the RNA specimen. RT-PCR assays was performed under the following conditions: reverse transcription reaction at 50 °C for 15 min, initial denaturation at 95 °C for 5 min, 45 cycles of denaturation at 95 °C for 10 s and extending and collecting the fluorescence signal at 55 °C for 45 s. A cycle threshold value (Ct-value) less than 37 was defined as a positive test result, and a Ct-value of 39.2 or more was defined as a negative test. A medium load, defined as a Ct-value of 37 to less than 39.2, required confirmation by retesting.
Statistical analysis
We present the continuous variables as the mean ± standard error of the mean (SEM) or median (interquartile range, IQR) and analyzed them with the chi-square test or Mann-Whitney U test. We report the categorical variables as whole numbers and percentages. Univariate logistic regression was used to evaluate potential risk factors for prolonged viral shedding. Only factors with a p-value<0.1 in univariate analysis were included in the final multivariate analysis model. We employed multivariate Cox regression to identify independent predictive factors for the length of viral RNA shedding. All p values were reported as two-sided with a significance level of 0.05. All statistical tests were calculated using SPSS version 24.0 (IBM, NY, USA).
Results
Demographic and clinical characteristics of COVID-19 patients with prolonged viral shedding
We included 112 patients diagnosed with COVID-19 in this study. The majority of patients (94.6%) were classified as moderate. No patient was transferred to the ICU or intubated. The median age was 64 years (IQR, 51–69; range, 28–83 years). Fifty-one (45.5%) patients were men, and 61 (54.5%) were women. The median period of symptom onset to viral RNA shedding was 28 days (IQR, 21–41). We categorized patients with a ≥ 28-day viral shedding period as the prolonged group. Compared with the nonprolonged group, patients in the prolonged group were significantly older (68 years [IQR, 64–72] vs. 59 years [IQR, 45–67], p < 0.001). Meanwhile, patients in the prolonged group had a higher rate of hypertension (p ≤ 0.001). Regarding signs and symptoms, patients with prolonged viral shedding were more likely to have expectoration (p = 0.001), breath shortness (p = 0.012), chest distress (p = 0.023) and fatigue (p < 0.001). The median time from symptom onset to admission was 11 days (IQR, 9–17) and 10 days (IQR, 7–12) for the prolonged and nonprolonged groups, respectively (p = 0.159) (See Table 1
).
Table 1
The demographic and clinical characteristics of patients with COVID-19.
The demographic and clinical characteristics of patients with COVID-19.For p-value: Boldface type indicates significant difference.COPD, Chronic obstructive pulmonary disease; IQR, interquartile range; COVID-19, coronavirus disease 2019.
Laboratory and radiological characteristics of COVID-19 patients with prolonged viral RNA shedding
The baseline laboratory and radiological characteristics of patients with and without prolonged viral RNA shedding are shown in Table 2
. Compared with the nonprolonged group, patients with prolonged viral shedding had a significantly lower lymphocyte count (0.9 × 10 [8]/L vs 1.1 × 10 [8]/L, p < 0.001) and a higher neutrophil count (4.3 × 10 [8]/L vs 3.3 × 10 [8]/L, p < 0.001). Prolonged cases showed significantly elevated serum infection markers, such as C-reactive protein (CRP) and ferritin (p < 0.001). Levels of proinflammatory cytokines, such as interleukin (IL)-2R (p < 0.001) and tumor necrosis factor-α (TNFα) (p < 0.001), were significantly higher in patients in the prolonged group. Moreover, serum albumin was lower in the prolonged group (p < 0.001). On admission, the proportion of bilateral pneumonia was similar between the two groups (p = 0.181).
Table 2
Laboratory and radiological findings of patients with COVID-19.
Variables
Normal Range
Median (IQR)
p-value
All Patients (N = 112)
Non-prolonged viral shedding (n = 63)
Prolonged viral shedding (n = 49)
Blood routineLeucocytes, *109/L
3.5–9.5
5.4 (4.3–7.1)
4.9 (3.9–6.5)
5.8 (4.9–7.7)
0.018
Neutrophil count, *109/L
1.8–6.3
3.7 (2.6–5.5)
3.3 (2.3–4.6)
4.3 (3.5–6.2)
0.004
Lymphocyte count, *109/L
1.1–3.2
1.0 (0.8–1.4)
1.1 (0.9–1.6)
0.9 (0.6–1.3)
0.013
NLR
3.3 (2.1–6.4)
2.6 (1.6–4.6)
4.2 (2.5–9.7)
<0.001
Monocyte count, *109/L
0.1–0.6
0.5 (0.3–0.6)
0.5 (0.3–0.6)
0.5 (0.3–0.6)
0.678
Eosinophils count, *109/L
0.02–0.52
0.02 (0.02–0.07)
0.02 (0.02–0.07)
0.02 (0.00–0.07)
0.505
Liver and renal functionALT, U/L
9–50
23 (16–41)
23 (13–39)
26 (18–42)
0.498
AST, U/L
15–40
26 (19–41)
25 (19–36)
27 (21–43)
0.781
Albumin, g/L
40–55
34.1 (30.3–38.0)
36.4 (32.1–38.7)
31.9 (29.0–34.9)
<0.001
Globulin, g/L
20–30
33.5 (31.0–37.2)
33.2 (31.5–36.8)
34.4 (30.2–37.9)
0.719
Prealbumin, mg/L
200–400
105 (80–150)
116 (88–206)
80 (80–143)
0.054
eGFR, mL/min
>90
90.3 (79.8–101.7)
96.2 (86.2–107.0)
85.5 (67.4–94.5)
<0.001
Infection biomarkersC-reactive protein, mg/L
0–10
38.7 (7.7–69.7)
26.3 (6.8–58.6)
52.7 (11.4–112.5)
<0.001
ESR, mm/h
0–15
42 (27–64)
40 (26–64)
49 (33–65)
0.278
Ferritin, ng/mL
15–200
581.3 (382.6–926.3)
546.9 (312.6–839.1)
675.1 (455.1–940.9)
0.314
Procalcitonin, ng/mL
0–0.05
0.06 (0.03–0.10)
0.05 (0.03–0.06)
0.08 (0.06–0.19)
0.007
Inflammatory cytokinesInterleukin-1β, pg/mL
0–5.0
5.0 (5.0–5.0)
5.0 (5.0–5.0)
5.0 (5.0–5.0)
0.359
Interleukin-2R, U/mL
223–710
670.5 (453.5–981.5)
529.0 (432.0–688.0)
953.0 (726.0–1089.5)
<0.001
Interleukin-6, pg/mL
0–7.0
5.4 (2.6–17.9)
4.1 (1.5–15.0)
9.0 (3.3–22.6)
0.917
Interleukin-8, pg/mL
0–62.0
11.5 (7.2–20.3)
10.3 (7.2–18.6)
15.8 (7.7–21.6)
0.872
Interleukin-10, pg/mL
0–9.1
5.0 (5.0–5.6)
5.0 (5.0–5.6)
5.0 (5.0–5.8)
0.326
TNFα, pg/mL
0–8.1
8.6 (6.9–10.5)
8.0 (6.5–9.1)
9.9 (7.2–11.9)
<0.001
Chest CTBilateral infiltration, No. (%)
102 (91.1%)
55 (87.3%)
47 (95.9%)
0.181
For p-value: Boldface type indicates significant difference.
Independent risk factors associated with prolonged viral shedding in COVID-19
In the multivariate survival analysis, we identified that age (≥65 yrs. vs. <65 yrs), preoperative lymphocyte count, serum interleukin-2R and hypertension were independent risk factors associated with prolonged viral RNA shedding in COVID-19patients, with hazard ratios (HRs) of 2.00 (p = 0.044, 95% CI 1.02–3.95), 0.53 (p = 0.051, 95% CI 0.28–1.00), 1.01 (p = 0.050, 95% CI 1.00–1.02) and 4.13 (p < 0.01, 95% CI 1.57–18.18), respectively (Table 3
).
Table 3
Multivariate analysis of risk factors for prolonged viral shedding.
Variable
HR (95% CI)
p value
Age (≥65 yrs. vs. <65 yrs)
2.00 (1.02–3.95)
0.044
Lymphocyte count
0.53 (0.28–1.00)
0.051
Interleukin-2R
1.01 (1.00–1.02)
0.050
Hypertension (Yes vs. No)
4.13 (1.87–18.18)
<0.01
HR, hazard ratio; CI, confidence interval.
Multivariate analysis of risk factors for prolonged viral shedding.HR, hazard ratio; CI, confidence interval.Dynamic profile of neutrophil (A), lymphocyte (B), c-reactive protein (C) and ferritin (D) in prolonged (red line) and nonprolonged (blue line) viral RNA shedding. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)Dynamic profile of IL-2R (A), TNFα (B), IL-1β (C), IL-6 (D) and IL-8 (E) in prolonged (red line) and nonprolonged (blue line) viral RNA shedding. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
Treatment of COVID-19 patients with prolonged viral RNA shedding
We investigated the differences in treatments between patients with nonprolonged and prolonged viral shedding. As shown in Table 4, of 112 patients, 52 (46.4%) received intravenous corticosteroids. A total of 92.9%, 22.3%, 19.6% and 26.8% of patients received arbidol, oseltamivir, interferon inhalation, lopinavir and ritonavir, respectively, as antiviral treatments. A total of 22.3% of patients received hydroxychloroquine. A total of 57.2% of patients received immune-enhancing regimens, with 31.3% and 25.9% receiving immunoglobulin and thymalfasin, respectively. Compared with the nonprolonged group, patients with prolonged viral shedding were more likely to receive corticosteroids (p = 0.022) and hydroxychloroquine (p = 0.007). The differences in the other treatments between the two groups were not statistically significant (p > 0.05). In addition, we also analyzed the influence of different therapies on laboratory characteristics such as lymphocytes and proinflammatory factors (Supplementary Fig. 1, Supplementary Fig. 2, Supplementary Fig. 3, Supplementary Fig. 4).
Table 4
Treatments of patients with COVID-19.
Treatments
No. (%)
p-value
All Patients (N = 112)
Non-prolonged viral clearance (n = 63)
Prolonged viral clearance (n = 49)
Oxygen
100 (89.3%)
54 (85.7%)
46 (93.9%)
0.625
Corticosteroid
52 (46.4%)
23 (36.5%)
29 (59.2%)
0.022
Arbidol
104 (92.9%)
58 (92.1%)
46 (93.9%)
1.000
Interferon inhalation
22 (19.6%)
8 (12.7%)
14 (28.6%)
0.054
Lopinavir and ritonavir
30 (26.8%)
16 (25.4%)
14 (28.6%)
0.830
Oseltamivir
25 (22.3%)
15 (23.8%)
10 (20.4%)
0.820
Hydroxychloroquine
25 (22.3%)
8 (12.7%)
17 (34.7%)
0.007
Immunoglobulin
35 (31.3%)
22 (34.9%)
13 (26.5%)
0.413
Thymalfasin
29 (25.9%)
13 (20.6%)
16 (32.7%)
0.193
For p-value: Boldface type indicates significant difference.
COVID-19, coronavirus disease 2019.
Supplementary Fig. 1
Dynamic profile of lymphocytes (A), IL-2R (B), IL-6 (C) and TNFα (D) in patients who received immunoglobulin (red line) or not (blue line).
Supplementary Fig. 2
Dynamic profile of lymphocytes (A), IL-2R (B), IL-6 (C) and TNFα (D) in patients who received corticosteroids (red line) or not (blue line).
Supplementary Fig. 3
Dynamic profile of lymphocytes (A), IL-2R (B), IL-6 (C) and TNFα (D) in patients who received hydroxychloroquine (red line) or not (blue line).
Supplementary Fig. 4
Dynamic profile of lymphocytes (A), IL-2R (B), IL-6 (C) and TNFα (D) in patients who received lopinavir and ritonavir (red line) or not (blue line).
Distinct dynamics of inflammatory cytokines in patients with prolonged viral RNA shedding
The dynamics of neutrophils, lymphocytes, infection markers and proinflammatory cytokines were investigated during hospitalization in all included patients. As demonstrated in Fig. 1, the pooled mean neutrophil count and ferritin level were higher in patients with prolonged viral shedding and continued to decline until the end of observation (week 7 after symptom onset) (Fig. 1A&D). On the other hand, the lymphocyte count was lower in the prolonged group and continued to increase until the end of observation (Fig. 1B). The pooled mean value of the C-reactive protein in the nonprolonged group was elevated on admission and decreased to the normal range (<10 mg/L) at week 3 after symptom onset. The pooled mean value of CRP was higher and fluctuated above the normal range in patients with prolonged viral shedding (Fig. 1C) (Supplementary Tables 1&2).
Fig. 1
Dynamic profile of neutrophil (A), lymphocyte (B), c-reactive protein (C) and ferritin (D) in prolonged (red line) and nonprolonged (blue line) viral RNA shedding. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
The dynamics of the proinflammatory cytokines between the prolonged and nonprolonged groups demonstrated distinct patterns (Fig. 2). The pooled mean values of IL-2R and TNF-α were higher with a declining trend during the observation period in patients with prolonged viral shedding (Fig. 2A&B). IL-1β and IL-8 showed a fluctuation curve from week 1 to week 7, and the differences between the two groups were not significant. IL-6 was significantly higher in the prolonged group and continued to decline until week 4, with a slightly increasing trend thereafter. Details of the pooled mean values of proinflammatory cytokines are shown in Supplementary Table 2.
Fig. 2
Dynamic profile of IL-2R (A), TNFα (B), IL-1β (C), IL-6 (D) and IL-8 (E) in prolonged (red line) and nonprolonged (blue line) viral RNA shedding. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
Discussion
The fast transmitted COVID-19 has emerged as a global pandemic and has challenged the healthcare system all over the world. Until now, no specific treatment has been validated for COVID-19. The key to limiting virus spread is the diagnosis and quarantine of infected cases. This is a comprehensive report of 112 COVID-19patients investigating the distinct characteristics and risk factors for prolonged SARS-CoV-2 viral RNA shedding.Treatments of patients with COVID-19.For p-value: Boldface type indicates significant difference.COVID-19, coronavirus disease 2019.In our study, we found that COVID-19patients with prolonged viral shedding were older (p < 0.001) and presented with a higher rate of hypertension (p < 0.001). Symptoms such as expectoration, breath shortness, fatigue and chest distress were more frequent in patients with prolonged viral shedding. Previous studies have suggested that older patients with COVID-19 are more likely to have a poor outcome, among whom immunopathogenesis and the induction of a proinflammatory cytokine storm might be the culprit [3,4,13,14]. In laboratory findings, we noted that patients with prolonged viral shedding had a significantly higher neutrophil count and a lower lymphocyte count at admission. Together with higher levels of infection-related markers such as C-reactive protein and ferritin, this evidence indicated that patients with impaired immune function complicated with bacterial infection might have a prolonged period of viral shedding.Proinflammatory cytokines and chemokines play an important role in the immune reaction during virus infections and can predict the severity of clinical outcomes [15,16]. Qin's study of 425 COVID-19patients showed that severe cases had a higher level of pro-inflammatory factors at admission, such as interleukin-2R, interleukin-6, interleukin-8 and interleukin-10 [6]. Hyperinflammatory responses in severe COVID-19 cases may correlate with the clinical outcomes and prognosis. In our study, we first demonstrated that elevated serum IL-2R and TNFα may correlate with prolonged viral RNA shedding by COVID-19patients. Similar to the results of our study, a recent report by Lin et al. found that long-term infection with SARS-CoV-2 may result in an increase in the cytokines IL-6, TNF-α, IFN-γ, IL-2, IL-4 and IL-10 [17]. Elevated levels of proinflammatory cytokines could be indicators of the immune response against viral replication and predictors of viral shedding.The host immune response is the first-line defense triggered by virus infection, which will induce cell death and cytopathy [18]. Inflammatory storms induced by uncontrolled cell death are associated with poor clinical outcomes. A previous study showed that patientsinfected by SARS with exceedingly high levels of proinflammatory cytokines involving IL-1β, IL-6 and TNFα often had a poor clinical outcome [19]. A recent report by Zhou et al. revealed that pathogenic T cells and inflammatory monocytes may incite an inflammatory storm in severe COVID-19patients [20]. Together with the above evidence, we showed for the first time that elevated levels of proinflammatory cytokines, such as IL2R, IL-6 and TNFα, may correlate with prolonged viral shedding. Prolonged viral shedding in certain cases may arise when the host antiviral defense and immune system are not strong enough to completely block virus replication.In our study, we found that a higher proportion of patients in the nonprolonged group received immunoglobulin (34.9% vs. 26.5%). Although the difference is not significant, it might provide a clue for the application of immune enhancers in the early stage of disease in selected patients [21]. In addition, inhibitors such as ruxolitinib that block the JAK1/JAK2 signal transduction pathway induced by pro-inflammatory cytokines may be promising treatments for prolonged viral RNA shedding [22].Various reports have revealed the phenomenon of SARS-CoV-2 “recurrence” or “repositive” [23,24]. Current guidelines suggest that two consecutive negative RT-PCR test results are one of the criteria for discharge. We argued that due to the high false negative rate of the viral test and an underestimated proportion of patients with prolonged viral shedding, the above patients may experience prolonged viral shedding rather than “recurrence” [25]. According to our results, we recommend actively monitoring proinflammatory cytokines in selected COVID-19patients with a high risk of prolonged viral shedding.The world is now facing a pandemic caused by SARS-CoV-2. This study focused on investigating the risk factors for COVID-19patients with prolonged viral shedding. We also monitored the dynamics of proinflammatory cytokines in patients with prolonged viral shedding. The present study has several limitations that should be taken into consideration. First, in this retrospective setting, some data were incomplete. Second, the treatments varied among patients. In clinical practice, patients would not receive antiviral treatment when they were first admitted to the hospital. Tentative antiviral treatments such as hydroxychloroquine or lopinavir and ritonavir were prescribed in patients with persistent detection of SARS-CoV-2 by RT-PCR. Therefore, it is difficult to analyze the effects of remaining positive, which might bias the results and not reflect the results of treatment.
Conclusions
In summary, in this study, we investigated the distinct dynamics of the inflammatory response in COVID-19patients with prolonged viral RNA shedding. Hypertension, older age, lymphopenia and high levels of proinflammatory cytokines were correlated with prolonged viral shedding. We suggest longer observation and monitoring of serum proinflammatory cytokines in selected high-risk patients.The following are the supplementary data related to this article.
Supplementary Table 1
Dynamics of neutrophils and lymphocytes in patients with COVID-19.
Supplementary Table 2
Dynamics of pro-inflammatory factors and infection markers in patients with COVID-19.Dynamic profile of lymphocytes (A), IL-2R (B), IL-6 (C) and TNFα (D) in patients who received immunoglobulin (red line) or not (blue line).Dynamic profile of lymphocytes (A), IL-2R (B), IL-6 (C) and TNFα (D) in patients who received corticosteroids (red line) or not (blue line).Dynamic profile of lymphocytes (A), IL-2R (B), IL-6 (C) and TNFα (D) in patients who received hydroxychloroquine (red line) or not (blue line).Dynamic profile of lymphocytes (A), IL-2R (B), IL-6 (C) and TNFα (D) in patients who received lopinavir and ritonavir (red line) or not (blue line).
Funding
No funding resources to declare for this study.
Ethical approval
This study was approved by the Ethics Committee of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology. All procedures followed in this study were in accordance with the 1964 Helsinki Declaration and later versions.
Informed consent
Written informed consent was waived by the Ethics Commission of the designated hospital for emerging infectious diseases.
Availability of data and materials
The database used and/or analyzed during the current study is not publicly available (to maintain privacy) but can be obtained from the corresponding author on reasonable request.
Declaration of Competing Interest
All authors declare that there are no conflicts of interest.
Authors: Victor M Corman; Olfert Landt; Marco Kaiser; Richard Molenkamp; Adam Meijer; Daniel Kw Chu; Tobias Bleicker; Sebastian Brünink; Julia Schneider; Marie Luisa Schmidt; Daphne Gjc Mulders; Bart L Haagmans; Bas van der Veer; Sharon van den Brink; Lisa Wijsman; Gabriel Goderski; Jean-Louis Romette; Joanna Ellis; Maria Zambon; Malik Peiris; Herman Goossens; Chantal Reusken; Marion Pg Koopmans; Christian Drosten Journal: Euro Surveill Date: 2020-01
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Fig. 1
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