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Related Fangcang hospitals have suspended discharges. However, it is not clear whether the death of this mild patient was caused by a recurrence of COVID-19.
[Caixin] (Reporter Yuan Suwen, Bao Zhiming, Intern Reporter Huang Yuxin) On the calendar of Wang Mei's (pseudonym) home, March 10th was circled with a pen, with the word "happy" written next to it. Her husband, Li Liang, had already been "cured" in the Fangcang shelter hospital and entered an isolation point for observation. This was supposed to be the day he would be released from isolation and regain his freedom.
But Li Liang didn't wait for that day. According to the "Certificate of Death Medicine," he passed away at 5:08 pm on March 2nd. The three causes of death were recorded as: COVID-19, sudden death due to respiratory obstruction, and respiratory circulatory failure.
Yang Xinghai, the director of the Wuhan Han Yang Guobo Fangcang Hospital (referred to as Han Yang Fangcang), where Li Liang was treated, told Caixin reporters that Han Yang Fangcang has temporarily stopped discharging patients. "This is not our decision, it is the command center's requirement, and it is not just us who have stopped."
Unexpected Changes
At 3:30 pm on March 2nd, Wang Mei received a call from the Vienna Hotel in Qiaokou District, Wuhan, where her husband was quarantined. The voice on the other end of the phone told her that during the ward rounds in the afternoon, her husband was under a lot of pressure and not feeling well, so she rushed to the community to get a pass and rode her bike to the hotel. Room 509, where Li Liang was staying, was open, and Wang Mei found her husband lying on the bed with the blanket pushed aside and no socks on.
When they had a video call at 10 am that morning, Li Liang told Wang Mei that his body temperature was only 35.3 degrees Celsius. Wang Mei thought it was because of the cold weather and told him to put on socks. However, when Wang Mei arrived at the isolation point in the afternoon, she found that Li Liang was already weak. When Li Liang heard his wife's voice, he couldn't sit up. Wang Mei helped him up, and he said he was thirsty. Wang Mei tried to feed him water, but it spilled out. Li Liang said, "Wife, I want to go home."
Li Liang developed a fever on February 3rd and was sent to a community isolation point on February 8th. He never made it back home. He tested positive for the novel coronavirus nucleic acid on the evening of February 9th and was transferred to the Han Yang Guobo Fangcang Hospital on February 12th. After 14 days of treatment, he was allowed to be discharged after evaluation by an expert group. According to the new regulations to prevent "re-positive" cases of COVID-19, Li Liang entered a community isolation point for another 14 days of quarantine after leaving the shelter.
Based on the discharge criteria, Li Liang was "cured." After leaving the shelter hospital on February 26th, he shared the news of his victory over the disease with all his relatives and friends. At the isolation point, he told his wife that he had antibodies and could donate blood to save lives, and he could also return to the isolation point as a volunteer. Li Liang didn't have a medical license, but his social identity was that of a doctor. He worked at an orthopedic rehabilitation clinic and studied under traditional Chinese medicine expert Zhang Xuelian. The clinic was near the Wuhan Central Hospital, where ophthalmologist Li Wenliang had sought treatment from him.
Li Liang called out Wang Mei's name, his consciousness blurred. A nurse came and lifted his closed eyelids before leaving in a hurry. The hotel front desk called the room and asked Wang Mei to contact emergency services. At around 4:40 pm on March 2nd, Wang Mei received a call from emergency services, and Li Liang was taken to the nearby Pu'ai Hospital by an ambulance. Soon after, news of his death came. Li Liang's body was immediately cremated.
From Community to Shelter
Li Liang, 36 years old, was well-built and worked at a clinic as a bone setter. On February 3rd, he had a slight fever, and the next morning, he went to the nearby Pu'ai Hospital for a CT scan of his lungs. The images showed "scattered multiple ground-glass opacities and linear shadows in the right middle lobe, right lower lobe, and left lung." In the summary section of the report, the doctor wrote, "Bilateral lung infection, suspected viral pneumonia."
On February 8th, Li Liang was sent to the Speed 8 Hotel isolation point by the community. The next day, he was tested for nucleic acid at the isolation point, and the results came back positive in the evening. The doctor prescribed Lianhua Qingwen Granules and anti-inflammatory drugs for him.
On February 12th, Li Liang was transferred to the Han Yang Guobo Fangcang Hospital as a mild patient. Wang Mei recalled that her husband had mild symptoms, only a slight fever and cough. After being transferred to the shelter hospital, he stopped taking the medication prescribed by the previous hospital and switched to traditional Chinese medicine treatment. Initially, he took Pneumonia No. 3 twice a day, and then switched to No. 2.
Wang Mei believed that the traditional Chinese medicine treatment at the shelter hospital was effective because her husband quickly stopped having a fever, and the coughing symptoms decreased.
On February 20th and 23rd, Li Liang underwent two nucleic acid tests at the shelter hospital, and both were negative. On February 23rd, he had a follow-up CT scan, which stated, "Scattered multiple areas of increased density in both lungs, mostly ground-glass density, some with reticular changes, mostly below the pleura. Small nodules were seen in the lower lobes of both lungs, with a maximum diameter of 0.4 cm. Follow-up examination is recommended."
Afterward, the hospital decided that Li Liang could be discharged on February 26th. The discharge summary dated February 25th stated that he had been in the hospital for 13 days, received symptomatic supportive treatment, had a normal body temperature for more than 3 days, significantly improved respiratory symptoms, two consecutive negative nucleic acid tests, and no oxygen saturation greater than 95%. After evaluation by an expert group, he was allowed to be discharged.
On February 18th, the National Health Commission issued the "Diagnosis and Treatment Protocol for Novel Coronavirus Pneumonia (Trial Version 6)," which listed four criteria for discharge: body temperature recovery for more than 3 days, significant improvement in respiratory symptoms, significant improvement in acute exudative lesions on lung imaging, and two consecutive negative respiratory pathogen nucleic acid tests (with a sampling interval of at least 24 hours). These four discharge criteria remained unchanged in the updated seventh version of the treatment protocol on March 3rd.
An unnamed expert from the Chinese Center for Disease Control and Prevention believed that Li Liang was discharged too early. "On the 23rd, there were still typical images of COVID-19 on the CT scan. How could he be discharged two days later on the 25th?" A doctor in Wuhan also pointed out the issue with the CT scan, stating that in some hospitals, "the CT scan is the least important factor" when determining whether a patient meets the four discharge criteria.
However, Yang Xinghai, the director of Han Yang Fangcang Hospital, told Caixin reporters that their discharge criteria are stricter than the national guidelines. Every discharged patient must have two negative nucleic acid tests, significant absorption improvement on CT lung imaging, and blood oxygen saturation above 95%.
"Whether a patient is discharged usually goes through several reviews. First, the attending physician and the leader of the medical team here need to approve it. Then we also submit it to the expert group for further review. If they find no problems, the patient can be discharged," said Yang Xinghai.
After Transfer to the Community Isolation Point
Li Liang was transferred to the community isolation point at the Vienna Hotel at 4:37 pm on February 26th. Yang Xinghai stated that Li Liang had mild symptoms when he was transferred. "We don't have information about his condition after discharge."
Wang Mei recalled that after Li Liang was transferred to the Vienna Hotel isolation point, the doctor recommended that he take Pneumonia No. 1 traditional Chinese medicine daily. However, Li Liang brought a few packs of No. 2 medicine from the shelter hospital and continued taking it for a few more days.
On February 28th, Li Liang started telling Wang Mei that his mouth was dry. Wang Mei said the doctor told her husband that it was because of the traditional Chinese medicine and advised him to drink more water. So Li Liang bought a lot of water and fruits to eat in the room.
But on March 1st, Li Liang told Wang Mei that he didn't feel like eating anymore and was drinking less water. He lay on the bed without energy and didn't want to move, always wanting to sleep.
At 8 am on March 2nd, Wang Mei sent a video request to Li Liang, but he couldn't answer for a long time. Wang Mei said she found the phone number of the Vienna Hotel on Baidu and called the hotel front desk to ask for a doctor to come and check on him. Li Liang finally answered Wang Mei's video call after 10 am, and a doctor appeared on the screen, telling Wang Mei that her husband might be under a lot of mental stress.
Li Liang told Wang Mei that he didn't want to eat and that his body temperature was only 35 degrees Celsius. His pulse was weak, and he couldn't muster the strength to sit up. Afterward, Li Liang ended the call. "He said it felt like his tongue was sticking to the roof of his mouth." Wang Mei recalled. After this final call, she was called to the isolation point in the afternoon and "watched him die."
Caixin called the phone number provided by the Vienna Hotel isolation point, and the person who answered said they were only security personnel and that they needed to contact the Health Commission and other departments regarding Li Liang's death. Along with Li Liang, several others were discharged from the Han Yang Guobo Fangcang Hospital and stayed at the Vienna Hotel for rehabilitation and isolation.
Strengthening the Management of Discharged Patients
It is not yet clear whether Li Liang's condition was a recurrence.
A senior critical care medicine expert previously analyzed to Caixin reporters that there are still a large number of patients being treated in hospitals in Wuhan, many of whom are critically ill, and the disease is very complex and severe. "Some patients have tested negative for nucleic acid multiple times and it is no longer a viral problem." He suggested that there should be proper arrangements for the management of discharged patients. (See: Diary of Pneumonia | March 4th: Multiple "re-positive" cases, should discharge criteria be reconsidered?)
On February 27th, an 80-year-old man in Shanxi, who had been declared cured after receiving plasma treatment, passed away. The man, Yao Mou, and his family drove from Wuhan to Shanxi on January 20th. He was diagnosed with COVID-19 on February 7th and received 600 milliliters of convalescent plasma from another recovered patient on February 9th. Chest X-rays showed that the inflammation in his lungs had significantly improved, and lymphocytes had also increased. However, he died 18 days later due to his advanced age and underlying conditions.
The management of discharged patients has attracted attention. On March 3rd, the Jiang'an Fangcang Hospital in Wuhan issued an emergency notice to its patients, stating that according to the latest notification from the city's epidemic prevention command center, there have been many cases of recurrence among discharged patients, leading to readmission for treatment. In order to reduce the recurrence of the disease and ensure that everyone is completely cured, and to achieve the goal of "no turning back," the hospital has decided to conduct virus antibody Ig-M and Ig-G tests on all patients who are about to be discharged from the shelter hospital, to ensure that they have fully recovered before being discharged. (See: Study: Discharged COVID-19 patients may still carry the virus, infectiousness needs to be observed; Antidote | Not only the team led by Zhong Nanshan, multiple rapid COVID-19 test technologies are sprinting)
Some experts believe that antibody testing should be used in conjunction with nucleic acid testing at the time of discharge to improve accuracy. Nucleic acid testing is still the gold standard for diagnosing COVID-19. The procedure requires medical personnel to insert a swab into the patient's throat to extract RNA, which is then amplified through enzyme-catalyzed chemical reactions to detect the presence of viral genes in the sample. The success of the test depends on whether a sufficient viral load can be extracted from the sample and visualized through real-time fluorescence RT-PCR. If the virus has left the upper respiratory tract and infiltrated the lower respiratory tract or is hidden deeper, it cannot be determined whether there is residual virus in the body through a throat swab.
On February 5th, Wang Chen, an expert in critical care medicine and president of the Chinese Academy of Medical Sciences, publicly stated that the nucleic acid testing for novel coronavirus infections has a "positive rate of only 30% to 50%." This statement caused controversy. In clinical practice, multiple consecutive tests are generally performed to obtain results that are close to the true situation, but false positives are still difficult to avoid. (See: Review | How many missed diagnoses are there in nucleic acid testing for COVID-19? Clinical diagnosis is the top priority)
Changes in patients' conditions after discharge, in addition to their underlying diseases, have drawn attention, especially cases of re-positive results. On February 28th, at a press conference of the State Council's Joint Prevention and Control Mechanism, Guo Yanhong, the commissioner of the Medical Administration and Supervision Bureau of the National Health Commission, reported that some provinces had reported cases of cured patients testing positive again in re-examinations. She pointed out that the novel coronavirus is a new virus, and its pathogenesis, the full picture of the disease, and the characteristics of the course of the disease still need further research. "Therefore, on the one hand, we need to further strengthen the management of discharged patients and require 14 days of medical observation. At the same time, we will organize experts to conduct further research on this situation and deepen our understanding of the entire process of the disease's occurrence, development, and outcome."
A radiologist at a hospital in Wuhan analyzed to Caixin reporters that Li Liang's cause of death after discharge may be due to "insufficient adherence to the discharge criteria." He said that there have also been cases of people dying after being readmitted to his hospital after discharge. "These are individual cases, and it is difficult to say whether COVID-19 is a direct cause. From a medical perspective, such patients have great research value."
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