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Am. J. Trop. Med. Hyg., 00(0), 2020, pp. 1–3
doi:10.4269/ajtmh.20-0203
Copyright © 2020 by The American Society of Tropical Medicine and Hygiene

Case Report: Walking Pneumonia in Novel Coronavirus Disease (COVID-19): Mild Symptoms with
Marked Abnormalities on Chest Imaging
Chaisith Sivakorn,1 Viravarn Luvira,1* Sant Muangnoicharoen,1 Pittaya Piroonamornpun,2 Tharawit Ouppapong,3
Anek Mungaomklang,4 and Sopon Iamsirithaworn5
1
Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; 2Hospital for Tropical Diseases,
Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; 3Division of Epidemiology, Department of Disease Control, Ministry of Public
Health, Nonthaburi, Thailand; 4Department of Disease Control, Institution for Urban Disease Control and Prevention, Ministry of Public Health,
Nonthaburi, Thailand; 5Division of Communicable Diseases, Department of Disease Control, Ministry of Public Health, Nonthaburi, Thailand

Abstract. This case report underlines the appearance of a “walking pneumonia” in a novel coronavirus disease
(COVID-19) patient, with evidence of progressive lung involvement on chest imaging studies. The patient traveled from
Wuhan, Hubei, China, to Thailand in January 2020. One of her family members was diagnosed with COVID-19. She
presented to the hospital because of her concern, but she was without fever or any respiratory symptoms. Three days
earlier, her nasopharyngeal and throat swabs revealed a negative severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) test by real-time reverse transcriptase polymerase chain reaction (RT-PCR). Her initial chest radiography
was abnormal, and her first sputum SARS-CoV-2 test yielded inconclusive results. A subsequent sputum test was
positive for SARS-CoV-2. Diagnosis in this patient was facilitated by chest imaging and repeat viral testing. Thus, chest
imaging studies might enhance capabilities for early diagnosis of COVID-19 pneumonia.

INTRODUCTION a blood pressure of 105/64 mmHg, and an oxygen saturation of

98% while breathing room air. She had no cyanosis, no clubbing,
Since late December 2019, there has been an outbreak of no pursed lips expiration, no use of accessory respiratory mus-
a novel enveloped RNA betacoronavirus1 called severe acute cles, and no nasal flaring. Auscultation of the thorax was normal.
respiratory syndrome coronavirus 2 (SARS-CoV-2). This virus The history of close contact with one COVID-19 case and the
causes coronavirus disease 2019 (COVID-19), which has become noticeable cough during the physical examination warranted fur-
an ongoing pandemic. The novel coronavirus SARS-CoV-2 is the ther investigation. Her chest radiography (CXR) revealed an alveolar
seventh member of the Coronaviridae family known to infect opacity in the left middle lung field (Figure 2A). Thus, a diagnosis of
humans.1 The estimated mortality rate of COVID-19 so far is lower pneumonia probably due to COVID-19 was made. She was ad-
than that of SARS or Middle East respiratory syndrome COVID- mitted to an airborne infection isolation room, and empirical treat-
19.2 However, the ongoing COVID-19 pandemic is a significant ments were started with ceftriaxone, azithromycin, and oseltamivir.
health threat worldwide.3 We report an important case in which Initial blood tests apart from mild leukopenia showed no other
COVID-19 was identified earlier by pneumonia on chest imaging abnormalities. Reverse transcriptase polymerase chain reaction of
than by clinical symptoms and reverse transcriptase polymerase sputum obtained on day 1 of admission was inconclusive for
chain reaction (RT-PCR). Adding this clinical picture of “walking SARS-CoV-2, but sputum obtained on day 4 of admission was
pneumonia” to surveillance case definitions may limit trans- positive.4 Furthermore, she started to develop sore throat, mild
mission and contribute toward containment of the disease. Fur- cough, and diarrhea on day 3 of admission (Figure 1). Antibiotic and
thermore, enhancing the capability of the COVID-19 diagnosis antiviral treatments were discontinued because RT-PCR for other
with the use of the chest imaging modality is discussed. respiratory viruses and bacteria from sputum was negative. Two
rectal swabs were negative for SARS-CoV-2. She continued to
CASE REPORT receive supportive care and isolation until two consecutive sputum
specimens were negative for SARS-CoV-2. All other family mem-
A 56-year-old Chinese woman traveled with her family from bers who were previously screened negative remained asymp-
Wuhan, Hubei, China, to Thailand for leisure on January 22, 2020. tomatic, but one daughter tested positive for SARS-CoV-2. She
Four days later and 8 days before her admission, her husband was was admitted for treatment and isolation in another hospital.
admitted to a private hospital after being diagnosed with COVID- A follow-up CXR obtained on day 6 of admission (Figure 2B)
19. Four days before her admission, all the other family members showed progression of the opacity in the left middle lung field and
including our patient, her two daughters, and her three-year-old of her symptoms of cough, sore throat, and diarrhea. Further
grandchild were screened for SARS-CoV-2 from nasopharyngeal imaging studies were performed for educational purposes on day
and throat swabs using real-time RT-PCR and had negative 12 after admission, when her symptoms were resolved, and the
results (Figure 1). On the day of her admission, she sought health sputum RT-PCR was negative on two consecutive specimens.
care at our outpatient department because she worried about her Chest radiography (Figure 2C) showed improvement of the al-
condition. She denied history of fever and respiratory symptoms. veolar opacity in the left middle lung field. Lung ultrasonography
Physical examination revealed a temperature of 37°C, a pulse rate (LUS) (Figure 2D) was found to be positive for B lines and dynamic
of 88 beats/minute, a respiratory rate of 20 breaths/minute, air bronchogram sign at the posterior part of the left middle lung
field. A high-resolution computed tomography (HRCT) scan on
the same day (Figure 2E) showed a localized subpleural region of
* Address correspondence to Viravarn Luvira, Department of Clinical
Tropical Medicine, Faculty of Tropical Medicine, Mahidol University,
ground-glass opacity with superimposed inter- and intralobular
420/6 Ratchawithi Rd., Ratchathewi, Bangkok 10400, Thailand. septal thickening (crazy paving pattern) at the supero-posterior
E-mail: [email protected] segment of the left lower lung lobe.

1
2 SIVAKORN AND OTHERS

FIGURE 1. Timeline of exposure and disease course, from January 22, 2020 to February 14, 2020.

DISCUSSION along with hospital-based surveillance for symptomatic patients

since early January 2020. However, detection of the disease is
During the initial phase of the COVID-19 outbreak, Thailand complicated by the diversity of symptoms and the severity of dis-
implemented temperature and other symptom-based screening of ease at the time of presentation. This family cluster of cases reflects
travelers at all points of entry (airport, ports, and ground crossing) the real-life situation of screening contact persons and the

FIGURE 2. Three modalities of chest imaging studies in coronavirus disease 2019 patient. Chest radiographies (A, B, and C) were obtained on February 3, 8,
and 14, 2020; chest ultrasonography and axial high-resolution computed tomography were obtained for the follow-up lung lesion on February 14, 2020.
 WALKING PNEUMONIA IN CORONAVIRUS DISEASE 3

challenge facing surveillance systems. As we expected, the Received March 18, 2020. Accepted for publication March 26, 2020.
snapshot single screening of contacts of confirmed cases might be Published online April 1, 2020.
inadequate for those with prolonged exposure, such as in family/
Acknowledgments: We would like to express gratitude to the patient
household situations. Continuous symptom-based surveillance, and the staff of the Hospital for Tropical Diseases, Bangkok, Thailand,
self-isolation, and other preventative measures have been imple- and the staff of the Department of Disease Control, Ministry of Public
mented to all contact persons for 14 days, leading to early detection Health, Nonthaburi, Thailand. Our special thanks to Dr. Kittiyod Poo-
of the subsequent cases. The incubation period of the presented vorawan and Dr. Watcharapong Piyaphanee for their continuous
support. The American Society of Tropical Medicine and Hygiene
case was 8 days, which is much longer than the median incubation (ASTMH) assisted with publication expenses.
period of 4 days reported in the literature.5 However, it was still
within the 14 days observation period for contact persons.3 To date, Financial support: The publication of this work was granted by the
Faculty of Tropical Medicine, Mahidol University.
the disease was confined only to this family, and there have been no
new transmissions related to this family cluster. Authors’ addresses: Chaisith Sivakorn, Viravarn Luvira, and Sant
Muangnoicharoen, Department of Clinical Tropical Medicine, Faculty
The presented case report shows the clinical picture of “walking of Tropical Medicine, Mahidol University, Bangkok, Thailand, E-mails:
pneumonia” in a COVID-19 patient whose clinical symptoms did [email protected], [email protected], and sant.mua@
not correlate with the evidence of progressive lung involvement mahidol.ac.th. Pittaya Piroonamornpun, Hospital for Tropical Diseases,
demonstrated by multiple chest imaging modalities. This case Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand,
echoes the latest reports, including the outbreak in a family clus- E-mail: [email protected]. Tharawit Ouppapong, Division of
Epidemiology, Department of Disease Control, Ministry of Public
ter,6 which includes the absence of fever at presentation, the Health, Nonthaburi, Thailand, E-mail: [email protected]. Anek
majority of cases demonstrating mild symptoms,5 and the utility of Mungaomklang, Department of Disease Control, Institution for Urban
chest imaging to facilitate early identification of the disease even in Disease Control and Prevention, Ministry of Public Health, Nonthaburi,
asymptomatic high-risk contacts.7 There is also strong evidence Thailand, E-mail: [email protected]. Sopon Iamsirithaworn, Division of
Communicable Diseases, Department of Disease Control, Ministry of
that COVID-19 can be transmitted by people who are only mildly ill Public Health, Nonthaburi, Thailand, E-mail: [email protected].
or even presymptomatic.8 Therefore, apart from symptoms and
RT-PCR, chest imaging could enhance capabilities for detection of This is an open-access article distributed under the terms of the
Creative Commons Attribution (CC-BY) License, which permits un-
COVID-19 pneumonia among patients with COVID-19 with mild restricted use, distribution, and reproduction in any medium, provided
symptoms similar to the presented case. the original author and source are credited.
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