On the afternoon of his first day back at work, the patient had rapid onset of fever, chills, rigors, dry cough, and shortness of breath. On arrival at the emergency department of Mount Sinai Hospital, on the same afternoon as symptom onset (hospital day 1), his temperature was 39·4°C, blood pressure 142/80 mm Hg, heart rate 130 beats per min, and respiratory rate20 breaths per min. Oxygen saturation ranged from 89% to 99% at ambient air. On examination, he appeared acutely ill and in mild distress with normal breath sounds. Plasmalyte (2 L), vancomycin (1 g once every 12 h), and ceftriaxone (2 g once a day) were administered intravenously; all medications are detailed in the appendix (pp 1–2). The patient's white blood cell count was 13 900 cells per μL (reference range 4500–11 000), with a lymphocyte count of 9·2% (15–50). Chest radiograph revealed an ill-defined nodule in the right mid-lung (figure 1A ). The patient was admitted to the hospital. On hospital day 1, a respiratory viral panel test of an NP swab was negative, including for influenza. On day 2, RT-PCR (Roche Cobas 6800 System, Roche, Basel, Switzerland) of an NP swab was negative for SARS-CoV-2. This assay targets open-reading frame 1, a region that is unique to SARS-CoV-2, and has a sensitivity of 1–5 copies per μL.6 An HIV test was negative, and intravenous azithromycin (500 mg once a day) was started. The remainder of the laboratory tests are summarised in the appendix (pp 1–2).
Figure 1 Imaging with chest radiograph, chest CT, and radial EBUS
(A) Admission chest radiograph (hospital day 1) with right mid-lung nodule (arrow). (B) First chest CT (day 2) with right lower lobe rounded opacity with possible halo sign (arrow). A second chest CT (day 6) showed new right upper lobe nodular opacities (C; arrows), a new large ground glass opacity in the right lower lobe (D; arrow); and enlargement of the right lower lobe rounded opacity with possible reverse halo sign (E; green arrow) and a new left lower lobe rounded opacity (E; blue arrow). (F) Radial EBUS image of right lower lobe rounded opacity (arrow) used to target the transbronchial lung biopsy on day 9. EBUS=endobronchial ultrasound.