A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version)

Abstract

In December 2019, a new type viral pneumonia cases occurred in Wuhan, Hubei Province; and then named "2019 novel coronavirus (2019-nCoV)" by the World Health Organization (WHO) on 12 January 2020. For it is a never been experienced respiratory disease before and with infection ability widely and quickly, it attracted the world's attention but without treatment and control manual. For the request from frontline clinicians and public health professionals of 2019-nCoV infected pneumonia management, an evidence-based guideline urgently needs to be developed. Therefore, we drafted this guideline according to the rapid advice guidelines methodology and general rules of WHO guideline development; we also added the first-hand management data of Zhongnan Hospital of Wuhan University. This guideline includes the guideline methodology, epidemiological characteristics, disease screening and population prevention, diagnosis, treatment and control (including traditional Chinese Medicine), nosocomial infection prevention and control, and disease nursing of the 2019-nCoV. Moreover, we also provide a whole process of a successful treatment case of the severe 2019-nCoV infected pneumonia and experience and lessons of hospital rescue for 2019-nCoV infections. This rapid advice guideline is suitable for the first frontline doctors and nurses, managers of hospitals and healthcare sections, community residents, public health persons, relevant researchers, and all person who are interested in the 2019-nCoV.

Keywords: 2019 novel coronavirus; 2019-nCoV; Clinical practice guideline; Evidence-based medicine; Infectious diseases; Pneumonia; Rapid advice guideline; Respiratory disease.

Fig. 1

Typical CT imaging manifestation (case 1). A 38 years old male with fever without obvious inducement (39.3 ℃), dry cough and shortness of breath for 3 days. Laboratory test: normal white blood cells (6.35 × 10⁹/L), decreased lymphocytes percentage (4.1%), decreased lymphocytes count (0.31 × 10⁹/L), decreased eosinophil count (0 × 10⁹/L)), increased C-reaction protein (170.91 mg/L), increased procalcitonin (0.45 ng/ml). Imaging examination: multiple patches, grid-like lobule and thickening of interlobular septa, typical “paving stone-like” signs. a SL(Slice): 6 mm; b high-resolution computed tomography(HRCT). HRCT. high-resolution computed tomography

Fig. 2

Typical CT / X-ray imaging manifestation (case 2). A 51 years old male with general muscle ache and fatigue for 1 week, fever for 1 day (39.1 ℃), anemia. Laboratory test: normal white blood cells (9.24 × 10⁹/L), lymphocytes percentage (5.1%), decreased lymphocytes (0.47 × 10⁹/ L), decreased eosinophil count (0 × 10⁹/L), increased C-reaction protein (170.91 mg/L), increased procalcitonin (0.45 ng/ml), increased erythrocyte sedimentation rate (48 mm/h). Imaging examination: a shows patchy shadows in the outer region of the left lower lobe, b shows large ground-glass opacity in the left lower lobe, and c shows subpleural patchy ground-glass opacity in posterior part of right upper lobe and lower tongue of left upper lobe, d shows large ground-glass opacity in the basal segment of the left lower lobe

Fig. 3

Typical CT / X-ray imaging manifestation (case 3). A 65 years old male with fever for 4 days (38.7 ℃). Laboratory test: normal white blood cells (3.72 × 10⁹/L), decreased lymphocytes (0.9 × 10⁹/ L), decreased eosinophil count (0 × 10⁹/L), increased C-reaction protein (53.0 mg/L), increased procalcitonin (0.10 ng/ml), reduced liver function, hypoproteinemia, and mild anemia. Imaging examination: a and b showed large consolidation in the right middle lobe, patchy consolidation in the posterior and basal segment of the right lower lobe, with air-bronchogram inside, c showed patchy consolidation in the outer and basal segment of the left lower lobe, and a small amount of effusion in the right chest

Fig. 4

Atypical CT / X-ray imaging manifestation (case 1). An 83 years old female with fever for 4 days (maximum temperature of 38.8 ℃), cough, chills, sore throat, dry cough for 1 week, chest tightness and shortness of breath aggravating for 1 week. Laboratory test: normal white blood cells (4.6 × 10⁹/L), normal neutrophil percentage (65.8%), decreased lymphocytes percentage (19.9%). Imaging examination: a and b showed diffuse interlobular septum thickening in both lungs to form a grid opacity, thickening of bronchial wall, and consolidation in the left sublobal lung. c showed diffused grid-like opacities in both lungs, especially in the left lung

Fig. 5

Atypical CT / X-ray imaging manifestation (case 2). A 56 years old female with fever for 3 days. Laboratory test: decreased total protein (54.0 g/L),decreased albumin (35.5 g/L),decreased globulin (18.5 g/L), normal white blood cells (4.87 × 10⁹/L), decreased lymphocytes percentage (10.1%), decreased lymphocytes (0.49 × 10⁹/ L), decreased eosinophil count (0 × 10⁹/L)), decreased eosinophil count percentage (0%). Imaging examination: a showed two consolidation nodulesat the center of the lateral segment of middle lobe of the right lung which was surrounded by ground-glass opacities; b showed patchy ground-glass opacity in the anterior segment of the right upper lung with patchy consolidation lesions in it; c showed patchy ground-glass opacities in both lungs with patchy consolidation lesions in it. d showed patchy consolidation in the ground-glass opacities in the middle lobe and dorsal segment of lower lobe of right lung

Fig. 6

CT imaging of ultra-early stage. a A 33 years old female with patchy ground-glass opacities after occupational exposure. b A 67 years old male with a history of contact with infected patients, showing large ground-glass opacity. c A 35 years old female exhibiting large consolidated opacity with air-bronchogram inside after occupational exposure

Fig. 7

CT imaging of early stage. Male, 38 years old, fever without obvious inducement (39.3 ℃), dry cough and shortness of breath for 3 days. Laboratory test: decreased white blood cells (3.01 × 10⁹/L), decreased lymphocytes (0.81 × 10⁹/ L), increased C-reaction protein (60.8 mg/L), increased procalcitonin (0.16 ng/ml). Imaging examination: a (thin layer CT) and b (high-resolution CT) showed multiple patchy and light consolidation in both lungs and grid-like thickness of interlobular septa

Fig. 8

CT imaging of rapid progression stage. A 50 years old female with anorexia, fatigue, muscle soreness, nasal congestion and runny nose for 1 week, sore and itching throat for 2 days. Laboratory test: increased erythrocyte sedimentation rate (25 mm/h), normal white blood cells (4.08 × 10⁹/L), decreased lymphocytes (0.96 × 10⁹/ L), increased C-reaction protein (60.8 mg/L). Imaging examination: a (thin layer CT) and b (high-resolution CT) showed multiplepatchy and light consolidation in both lungs and grid-like thickness of interlobular septa

Fig. 9

CT imaging of consolidation stage. A 65 years old male with fever (maximum temperature of 39 ℃). Laboratory test: hypoproteinemia (decreased total protein (62.20 g/L), decreased albumin (35.70 g/L)), abnormal liver function (increased alanine aminotransferase (79 U/L), increased aspartate aminotransferase (72 U/L)), increased procalcitonin (0.10 ng/ml), increased C-reaction protein (53 mg/L), decreased white blood cells (3.72 × 10⁹/L), decreased lymphocytes (0.9 × 10⁹/ L), mildanemia (decreased red blood cells (4.10 × 10¹²/L), decreased hemoglobin (131.10 g/L), decreased hematocrit (39.0%). Imaging examination: a (thin layer CT) and b (high-resolution CT) showedmultiple patchyand large consolidation in right middle lobe, posterior and basal segment of right lower lobe and outer and basal segment of left lower lobe, with air-bronchogram inside

Fig. 10

CT imaging of dissipation stage. A 79 years old female with intermittent fever. Laboratory test after 3 days of comprehensive treatment: decreased red blood cells (3.73 × 10¹²/L), hemoglobin (107 g/L), decreased hematocrit (31.8%), decreased lymphocytes percentage (13.9%), decreased lymphocytes (0.62 × 10⁹/ L), decreased eosinophil count percentage (0%), decreased eosinophil count (0 × 10⁹/L), increased alanine aminotransferase (46 U/L), deceased total protein (56.8 g/L), decreased albumin (33.5 g/L), normal C-reaction protein and procalcitonin. Imaging examination: a patchy ground-glass opacity and grid-like thickening of interlobular septa in the tongue-like segment of left upper lobe, and patchy consolidation in the posterior segment of right middle and lower lobe. b 9 days after admission to hospotial, CT scan showed absorption of lesions in the middle lobe, narrowing of lesions in the lower lobe of the right lung, and absorption of lesions in the tongue-like segment of left upper lobe which exhibited a cord-like change