SARS-CoV-2 re-infection: a case report from Qatar
Authors: Alanoud AlFehaidi, Syed Ali Ahmad, Ehab Hamed
Journal: Journal of Infection (2020)

Dear Editor, We read with interest the study of Gousseff et al.1Gousseff M. Penot P. Gallay L. Batisse D. Benech N. Bouiller K. et al.Clinical recurrences of COVID-19 symptoms after recovery: viral relapse, reinfection or inflammatory rebound?.J Infect. 2020; (Jun 30 [cited 2020 Sep 12]; Available from: /pmc/articles/PMC7326402/?report=abstract)Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar The study reported a second acute COVID-19 episode in 11 patients. A novel coronavirus (SARS-CoV-2) caused a pandemic end of 2019. Common signs of SARS-CoV-2 include fever, cough and shortness of breath with no definitive treatment to date.2Wiersinga W.J. Rhodes A. Cheng A.C. Peacock S.J. Prescott H.C. Pathophysiology, transmission, diagnosis, and treatment of coronavirus disease 2019 (covid-19): a review.JAMA. 2020; 324 ([cited 2020 Sep 28]. Available from): 782-793https://pubmed.ncbi.nlm.nih.gov/32648899/Crossref PubMed Scopus (3196) Google Scholar Reverse transcriptase polymerase chain reaction (RT-PCR)–based assays are the current reference diagnostic test.3Cheng M.P. Papenburg J. Desjardins M. Kanjilal S. Quach C. Libman M. et al.Diagnostic testing for severe acute respiratory syndrome-related coronavirus 2: a narrative review.Ann Intern Med. 2020; 172 (NLM (Medline)[cited 2020 Sep 28]Available from): 726-734https://www.acpjournals.org/doi/abs/10.7326/m20-1301Crossref PubMed Scopus (432) Google Scholar Positive result does not necessitate the presence of infection and viral RNA shedding declines following the resolution of symptoms. Viral nucleic acid could be detectable in throat swabs up to 6 weeks after symptom onset.2Wiersinga W.J. Rhodes A. Cheng A.C. Peacock S.J. Prescott H.C. Pathophysiology, transmission, diagnosis, and treatment of coronavirus disease 2019 (covid-19): a review.JAMA. 2020; 324 ([cited 2020 Sep 28]. Available from): 782-793https://pubmed.ncbi.nlm.nih.gov/32648899/Crossref PubMed Scopus (3196) Google Scholar Different reports have proposed the reactivation of SARS-CoV-2 infection, with 2 RT-PCR positive results following resolving symptoms and interim RT-PCR negative results.1Gousseff M. Penot P. Gallay L. Batisse D. Benech N. Bouiller K. et al.Clinical recurrences of COVID-19 symptoms after recovery: viral relapse, reinfection or inflammatory rebound?.J Infect. 2020; (Jun 30 [cited 2020 Sep 12]; Available from: /pmc/articles/PMC7326402/?report=abstract)Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar, 4Zhou L. Liu K. Liu H.G. Cause analysis and treatment strategies of "recurrence" with novel coronavirus pneumonia (COVID-19) patients after discharge from hospital.Zhonghua Jie He He Hu Xi Za Zhi. 2020; 43 (Apr 12 [cited 2020 Sep 12]Available from:): 281-284http://www.ncbi.nlm.nih.gov/pubmed/32118391PubMed Google Scholar, 5Ye G. Pan Z. Pan Y. Deng Q. Chen L. Li J. et al.Clinical characteristics of severe acute respiratory syndrome coronavirus 2 reactivation.J Infect. 2020; 80 (May 1 [cited 2020 Sep 12]Available from:): e14-e17https://pubmed.ncbi.nlm.nih.gov/32171867/Abstract Full Text Full Text PDF PubMed Scopus (228) Google Scholar, 6Loconsole D. Passerini F. Palmieri V.O. Centrone F. Sallustio A. Pugliese S. et al.Recurrence of COVID-19 after recovery: a case report from Italy.Infection. 1. Springer, 2020https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228864/Google Scholar, 7Yoo S.Y. Lee Y. Lee G.H. Kim D.H. Reactivation of SARS-CoV-2 after recovery. 62. Pediatrics International. Blackwell Publishing, 2020: 879-881https://pubmed.ncbi.nlm.nih.gov/32421910/Google Scholar, 8Chen D. Xu W. Lei Z. Huang Z. Liu J. Gao Z. et al.Recurrence of positive SARS-CoV-2 RNA in COVID-19: a case report.Int J Infect Dis. 2020; 93 (Apr 1 [cited 2020 Sep 12]Available from:): 297-299https://pubmed.ncbi.nlm.nih.gov/32147538/Abstract Full Text Full Text PDF PubMed Scopus (240) Google Scholar, 9Jiang M. Li Y. Han M. Wang Z. Zhang Y. Du X. Recurrent PCR positivity after hospital discharge of people with coronavirus disease 2019 (COVID-19) [Internet].J Infect. 2020; 81 (W.B. Saunders Ltd;[cited 2020 Sep 12]Available from:): 147-178https://pubmed.ncbi.nlm.nih.gov/32289343/Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 10Peng J. Wang M. Zhang G. Lu E. Seven discharged patients turning positive again for SARS-CoV-2 on quantitative RT-PCR.Am J Infect Control. Mosby Inc. 2020; 48 ([cited 2020 Sep 12]Available from:): 725-726https://pubmed.ncbi.nlm.nih.gov/32317126/Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Early studies reported patients with negative results having positive results within one week of discharge. Later, reports used 3 weeks (21 days) as the cut-off point, following which another positive RT-PCR result with symptoms would support the possibility of reinfection.1Gousseff M. Penot P. Gallay L. Batisse D. Benech N. Bouiller K. et al.Clinical recurrences of COVID-19 symptoms after recovery: viral relapse, reinfection or inflammatory rebound?.J Infect. 2020; (Jun 30 [cited 2020 Sep 12]; Available from: /pmc/articles/PMC7326402/?report=abstract)Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar A recent report confirmed the possibility of reinfection with genetically distinct SARS-CoV-2 infection in 2 different cases.11Gupta V. Bhoyar R.C. Jain A. Srivastava S. Upadhayay R. Imran M. et al.Asymptomatic reinfection in two healthcare workers from India with genetically distinct SARS-CoV-2.Clin Infect Dis. 2020; ([cited 2020 Sep 29]; Available from:)https://doi.org/10.1093/cid/ciaa1451Crossref Scopus (110) Google Scholar Here we describe a case with 2 positive RT-PCR results in a symptomatic female with 84 days apart, patient had a complete resolution of symptoms and interim negative swab results on day 13. A 46-year-old female attended primary healthcare settings in Qatar with a history of SARS-CoV-2 contact and sore throat on the 23rd of May 2020. The patient SARS-CoV-2 RT-PCR results swab result was positive. Her vital signs, blood investigations and chest X-ray were normal. The patient had a past medical history of mild asthma, which was controlled with only occasional use of salbutamol inhaler. The patient was admitted to a quarantine facility for observation. The patient PCR swab result was negative on the 5th of June and she was discharged on the 6th June. On the 11th of August she presented with fever, sore throat and body pain following a second contact with SARS-CoV-2 positive case. SARS-CoV-2 RT-PCR results swab result was inconclusive on 13th August. The patient also reported chest pain, cough, and mild dyspnea. Her vital signs were normal, but blood investigations showed leucocytes of 1.7 × 109 cells per L and lymphocytes 0.9 × 109 cells per L. A repeat COVID-19 PCR swab was positive on the 15th of August with CT value of 25.49. Chest X-ray was normal and patient progression to recovery was unremarkable. She was discharged home on the 29th of August 2020. During both events, the patient received only symptomatic treatment. Early studies reported that re-detectable positive virus nucleic acid among patients with SARS-CoV-2 with an average duration of 15 days from discharge to a re-positive results.12Gao Z. Xu Y. Guo Y. Xu D. Zhang L. Wang X. et al.A systematic review of re-detectable positive virus nucleic acid among COVID-19 patients in recovery phase.Infect Genet Evol. 2020; 85 (Elsevier B.V.)Crossref Scopus (23) Google Scholar Patients in those early reports did not show signs of infection with the second positive results and had negative swab results within one week later. Researchers have suggested the persistence of viral RNA with no recurrence of infection. The COCOREC (Collaborative study COvid RECurrences) study suggested that recurrence of infection is likely if the patient has two confirmed SARS-CoV-2 RT-PCR positive results over 15 days apart with one major clinical sign and no other cause to explain the symptoms. The study identified 11 patients similar to our case. The longest time to second positive test results in this cohort of patients was 49 days.1Gousseff M. Penot P. Gallay L. Batisse D. Benech N. Bouiller K. et al.Clinical recurrences of COVID-19 symptoms after recovery: viral relapse, reinfection or inflammatory rebound?.J Infect. 2020; (Jun 30 [cited 2020 Sep 12]; Available from: /pmc/articles/PMC7326402/?report=abstract)Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar Our case presented with symptoms, positive contact history and positive swab results with a timeline significantly longer than any reported case. The persistence of positive RT-PCR for SARS-CoV-2 is reported only up to 6 weeks.1Gousseff M. Penot P. Gallay L. Batisse D. Benech N. Bouiller K. et al.Clinical recurrences of COVID-19 symptoms after recovery: viral relapse, reinfection or inflammatory rebound?.J Infect. 2020; (Jun 30 [cited 2020 Sep 12]; Available from: /pmc/articles/PMC7326402/?report=abstract)Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar A re-infection or to the least a re-activation following long-lasting carriage seems more likely in this patient report. Reports of such occurrences are rare to date in view of the number of worldwide reporting of the infection rates which is reassuring. This case report adds to current evidence of possibility of reinfection and provides a basis for future cohort studies. Detection of viral RNA in symptomatic1Gousseff M. Penot P. Gallay L. Batisse D. Benech N. Bouiller K. et al.Clinical recurrences of COVID-19 symptoms after recovery: viral relapse, reinfection or inflammatory rebound?.J Infect. 2020; (Jun 30 [cited 2020 Sep 12]; Available from: /pmc/articles/PMC7326402/?report=abstract)Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar patients following complete remission of symptoms and full recovery should be considered as reinfection or recurrence at the least. The patient gave consent for the material to appear in scientific publication. The case report received ethical approval from Primary Health Care corporation (PHCC) research committee. The patient consented to publication and reporting is fully anonymized. All Authors have contributed to the drafting and the critical revision of the article. The final version approved by all authors. None. We acknowledge the support we receive from Primary Health Care Corporation (PHCC) research committee.