What was the first case of 2019-nCoV infection confirmed in the United States, and how was it identified, diagnosed, and managed?

Bottom Line

This case report emphasizes the importance of obtaining a travel history in a patient presenting with acute illness symptoms to ensure identification of the virus and prompt patient isolation.


Holshue M. L. et al., First Case of 2019 Novel Coronavirus in the United States. New England Journal of Medicine (2020). doi:10.1056/NEJMoa2001191

Date Published

March 5, 2020


Cases of 2019-nCOV were originally reported in association with exposure to the seafood market in Wuhan, however further data indicates that person-to-person transmission of the virus is occurring. Respiratory swabs from the patient discussed in this report were obtained on day 4 of his illness and tested positive for 2019-nCoV with a high viral load (low cycle threshold [Ct] values between 18-22). Upper and lower respiratory swabs (Ct values, 23 to 24) and stool specimens (Ct values, 36 to 38) obtained on illness day 7 tested positive for 2019-nCoV, while specimens obtained on illness days 11 and 12 showed decreasing virus levels. Although a return traveler from Wuhan, the patient reported no exposure to the seafood market, health care facilities, or to sick contacts, suggesting that his case was acquired via community transmission. The case presented on day 4 initially with mild cough and low-grade intermittent fever, with later onset to shortness of breath and evidence of pneumonia on chest radiography on day 9. Importantly, despite mild symptoms between illness day 4 and 9, patient-derived samples had a high viral load, suggesting a potential for transmission of the virus to others. Patient was managed with antiviral remdesivir based on worsening clinical status, although no current studies have supported its use. This report highlights the importance of screening patients presenting with acute illness symptoms for recent travel. However, it also highlights the emerging potential for person-to-person transmission of the virus and the need to better understand the disease itself to inform clinical decision making.

Summary by Kathleen Simms