Case 2
A 67-year-old woman with a medical history of hypertension developed fever and myalgia and diagnosed as COVID-19 via SARS-CoV-2 rRT-PCR on March 6. The next day, she was admitted to a local public medical center and received hydroxychloroquine 400 mg once daily and lopinavir/ritonavir 400 mg/100 mg twice daily with empirical antibiotics. However, on day 3, she was transferred to the tertiary-care hospital due to increased oxygen demand and worsening infiltrative shadows in the left lower lung. At that time, her oxygen saturation checked 93% on 4 L/min oxygen flow via nasal cannula with a respiratory rate of 24 times per minute. Routine blood tests showed mild leukocytosis (12.67 × 103/µL) with lymphopenia (0.7 × 103/µL), elevated CRP, IL-6 and LDH. (131.1 mg/L, 474.7 pg/mL, 344 IU/L, respectively) Routine chemistry, electrolyte, and blood coagulation tests showed no abnormalities. Bacterial cultures and the PCR for other respiratory viruses were all negative.
She received high flow oxygen therapy but bilateral infiltration and oxygenation were deteriorated, so intubation and mechanical ventilator care started on day 4. Intravenous methylprednisolone (0.5 mg/kg/day daily) was also added. She had sustained high fever with rapidly increasing CRP (314 mg/L), WBC (21.79 × 103/µL), and persistent lymphopenia (0.5 × 103/µL). PaO2/FiO2 fell to 76, consistent with severe ARDS. After applying for the prone position according to the management of ARDS with the use of steroids, chest images and the oxygen demand began to be improved.
On day 6, convalescent plasma was obtained from a male donor in his 20s who had recovered from COVID-19 for 18 days. He was diagnosed as COVID-19 presenting fever, cough and pneumonia however, showed complete recovery and serial PCRs for SARS-CoV-2 were all negative after hospital discharge. Donor screening and plasma collection were performed as mentioned above in the Case 1. OD ratio for IgG was 0.532 and the plasma was administered to the patient in the same way as Case 1. There was no adverse reaction during the plasma transfusion. Leukocytosis and lymphopenia were immediately recovered after convalescent plasma infusion. On day 9, the density of bilateral infiltration on chest X-ray much improved with increased PaO2/FiO2 to 230. The level of CRP and IL-6 also recovered to the normal range (Figs. 3 and 4). SARS-CoV-2 was quantified by rRT-PCR; the value of Ct changed from 20.51 on day 5 to 36.33 on day 9 after plasma infusion (Fig. 3). The patient is successfully extubated and discharged from the hospital on day 24. SARS-CoV-2 was negative after day 20.
Fig. 3  Case 2, responses to treatment. (A) Timelines of changes in PaO2/FiO2 and CRP during hospitalization. (B) Timelines of detection of the RNA-dependent RNA polymerase region of the ORF1b gene of severe acute respiratory syndrome coronavirus-2 in sputum by real-time reverse transcription polymerase chain reaction; cycle threshold is shown.
CRP = C-reactive protein.
Fig. 4  Chest X-rays of Case 2 taken before and after convalescent plasma infusion. Taken on day 2, before the convalescent plasma infusion (left). Taken on day 6 shows marked improvement of bilateral infiltrations (right). The images are published under agreement of the patient.