Infectious Diseases

ISSN: 2374-4235 (Print) 2374-4243 (Online) Journal homepage: https://www.tandfonline.com/loi/infd20

Re-infection by COVID-19: a real threat for the

future management of pandemia?

Marco Bongiovanni & Fiorpaolo Basile

To cite this article: Marco Bongiovanni & Fiorpaolo Basile (2020): Re-infection by
COVID-19: a real threat for the future management of pandemia?, Infectious Diseases, DOI:
10.1080/23744235.2020.1769177

To link to this article: https://doi.org/10.1080/23744235.2020.1769177

Published online: 21 May 2020.

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INFECTIOUS DISEASES,
2020; VOL. 0,
NO. 0, 1–2
LETTER TO THE EDITOR
Re-infection by COVID-19: a real threat for the future
management of pandemia?
To the Editor,
In a recent study of COVID-19 reported in this journal,
11 of 22 patients were again found positive by RT PCR
test results after 2 or 3 consecutively negative results
[1]. Moreover, recent studies indicated that the repeated
virus nucleic acid tests remain positive, in some cases,
after hospital discharge [2,3]. There are no doubt difficul-
ties associated with interpretation of recurring positive
test results and this occurred when we handled two eld-
erly patients with COVID-19 pneumonia. They both had
complete clinical remission and two consecutive nega-
tive nasopharyngeal swabs, but early after discharge
they presented with new milder symptoms and
repeated nasopharyngeal swab test positive for
COVID-19.
The first patient was an 81 years old, diabetic woman
admitted to our hospital for fever and severe acute
respiratory failure in the last 7 days (arterial oxygen sat-
uration 83%). She underwent ventilatory support by
means of a continuous positive airway pressure (C-PAP)
therapy during her stay in the emergency department.
CT scan of the thorax showed findings compatible with
severe interstitial pneumonia. Nasopharyngeal swab test
for COVID-19 resulted positive on quantitative reverse-
transcriptase-polymerase-chain reaction (qRT-PCR) assay
[4]. Treatment with hydroxychloroquine (200 mg twice
daily for 7 days) and heparin (at prophylactic, subcutane-
ous dosage of 4000 IU daily) was promptly started.
An improvement in patient’s clinical condition was
observed in few days, with progressive reduction of oxy-
gen supply and complete discontinuation of C-PAP ther-
apy after 4 days. Fever completely disappeared in 3 days.
A cohort isolation (patient shared room with other
COVID-19 positive subjects) was done during all the hos-
pitalisation period. Nasopharyngeal swabs were repeated
after 14 and 21 days from the first one and resulted
https://doi.org/10.1080/23744235.2020.1769177
positive; nasopharyngeal swab was repeated again after
28 days resulting negative and was negative also after
30 days (results of nasal swabs are usually available in
2-days in our hospital).
The patient showed complete clinical recovery at the
time of last nasopharyngeal swab test and was dis-
charged to the rehabilitation department the day we
received the second result, sharing the room with nega-
tive subjects. Two days later, the patient developed mild
malaise and muscle pain not associated with other clin-
ical findings; blood tests were repeated and were nor-
mal regarding both inflammation and respiratory
parameters. Nasopharyngeal swab was then repeated
resulting positive and remained positive in the next two
samples a week later.
A second patient was an 85 years old, hypertensive
woman admitted to our emergency department for
fever (>39 C) and moderate respiratory failure (arterial
oxygen saturation 90%). Oxygen supply was adminis-
tered; CT scan of the thorax showed severe interstitial
pneumonia and nasopharyngeal swab test for COVID-19
resulted positive. Hydroxychloroquine (200 mg twice
daily for 7 days) and heparin (4000 IU subcutaneous
daily) were started and cohort isolation was maintained
during the hospitalisation. The patient was progressively
weaned by oxygen supply and clinically recovered; naso-
pharyngeal swab remained positive after 14 days, but
got negative after 21 and 23 days.
The patient was transferred in the Medicine ward,
sharing the room with a negative patient; five days later,
her roommate was discovered to be COVID-19 positive
(she had cough and fever); therefore, a new nasopharyn-
geal swab was done to our patient (in the meantime,
she developed malaise and muscle pain) and resulted
positive. In the next few days, she had mild fever and
dry cough, not requiring further oxygen supply. Both
inflammation and respiratory parameters maintained
2 M. BONGIOVANNI AND F. BASILE
normal. Nasopharyngeal swab remained positive for
2 additional weeks.
Nasopharyngeal swab is at the moment the gold
standard to diagnose and manage COVID-19 infection.
Currently, clinical recovery patients with two consecu-
tive, negative, swabs repeated after 24–48 h of time
from each other are considered as signs of full recovery
from COVID-19 infection, despite a certain percentage of
false negative due to inadequate technique, technical
transport, laboratory issues and low viral load or inter-
mittent viral shedding. Until now, antibodies tests are
not available on a large scale in Italy to be used for the
diagnosis in the current clinical practice; therefore, very
few data are available on the duration of immunity after
clinical recovery and on the risk of re-infection.
No definitive conclusions can be drawn by these two
clinical cases; at the moment, it is impossible to discrim-
inate between new infection and intermittent shedding
of viral RNA. Nonetheless, both patients developed new
milder symptoms which might have been due to re-
infection. Old age and comorbidity might have contrib-
uted to a liability to renewed infection.
These two cases may possibly indicate a risk for re-
infection in COVID-19 within a very short time after clin-
ical recovery and, at least in our two patients, occurred
with milder symptoms. Obviously, no definitive conclu-
sions can be drawn by these observations, but these
findings, if confirmed on a larger scale, can be worrying
for the future management of the pandemic.
Acknowledgements
Authors are grateful to dr. Piergiorgio Caccia e Marco Aliverti for
their support in the clinical management of these patients. Our
thanks go to nursing and medical colleagues in ASST
Rhodense hospitals.
Disclosure statement
The authors declare that they have no known competing financial
interests or personal relationship that could have appeared to
influence the work reported in this paper.
References
[1] Liang C, Cao J, Liu Z, et al. Positive RT-PCR results after
consecutively negative results in patients with COVID-19.
Infect Dis (London). 2020. DOI:10.1080/23744235.2020.
1755447
[2] Wei F, Qian C, Tao W. Three cases of re-detectable positive
SARS-CoV2 RNA in recovered COVID-19 patients with anti-
bodies. J Med Virol. 2020. DOI:10.1002/jmv.25968
[3] Wu J, Liu J, Li S, et al. Detection and analysis of nucleic
acid in various biological samples of COVID-19 patients.
Travel Med Infect Dis. 2020;101673. DOI:10.1016/j.tmaid.
2020.101673
[4] Corman V, Bleicker T, Brunink S, et al. Diagnostic detection
of Wuhan coronavirus 2019 by real-time RT-PCR. Geneva:
World Health Organization; 2020. (http://www.who.int/
docs/default-source/coronaviruse/wuhan-virus-assay-v199
1527e5122341d99287a1b17c111902.pdf).
Marco Bongiovanni and Fiorpaolo Basile
Department of Medicine, Ospedale di Circolo di Rho, ASST
Rhodense, Corso Europa 250, Rho, 20017, Milan, Italy
mbongiovanni@asst-rhodense.it
Received 2 May 2020; revised 6 May 2020; accepted
7 May 2020
ß 2020 Society for Scandinavian Journal of Infectious Diseases