A Rare Case of Human Coronavirus 229E Associated with Acute Respiratory Distress Syndrome in a Healthy Adult

Abstract

Human coronavirus 229E (HCoV-229E) is one of the first coronavirus strains being described. It is linked to common cold symptoms in healthy adults. Younger children and the elderly are considered vulnerable to developing lower respiratory tract infections (LRTIs). In particular, immunocompromised patients have been reported with severe and life-threatening LRTIs attributed to HCoV-229E. We report for the first time a case of LRTI and acute respiratory distress syndrome developed in a healthy adult with no comorbidities and HCoV-229E strain identified as the only causative agent. A 45-year-old female with a clear medical history presented with fever, cough, and headache. Respiratory tract infection was diagnosed, and empirical antibiotics were started. Within two days, she developed bilateral pleural effusions, diffuse consolidations, and ground glass opacities involving all lung fields. She needed immediate oxygen supply, while ABGs deteriorated and chest imaging and PaO 2 /FiO 2 indicated ARDS. Early administration of systemic corticosteroids led to gradual clinical improvement. Multiplex PCR from nasal secretions was positive only for HCoV-229E and negative for multiple other pathogens. It remains to be elucidated how an immunocompetent adult developed a life-threatening LRTI caused by a “benign considered” coronavirus strain, the HCoV-229E.

Full text

Case Report
A Rare Case of Human Coronavirus 229E Associated with Acute
Respiratory Distress Syndrome in a Healthy Adult
Foula Vassilara,
1
Aikaterini Spyridaki ,
1
George Pothitos,
1
Athanassia Deliveliotou,
1
and Antonios Papadopoulos
2
1
Hygeia Hospital, Athens, Greece
2
4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
Correspondence should be addressed to Aikaterini Spyridaki; kspyridaki@yahoo.gr
Received 19 January 2018; Accepted 26 March 2018; Published 15 April 2018
Academic Editor: Sin´esio Talhari
Copyright ©2018 Foula Vassilara et al. is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Human coronavirus 229E (HCoV-229E) is one of the first coronavirus strains being described. It is linked to common cold
symptoms in healthy adults. Younger children and the elderly are considered vulnerable to developing lower respiratory tract
infections (LRTIs). In particular, immunocompromised patients have been reported with severe and life-threatening LRTIs
attributed to HCoV-229E. We report for the first time a case of LRTI and acute respiratory distress syndrome developed in
a healthy adult with no comorbidities and HCoV-229E strain identified as the only causative agent. A 45-year-old female with
a clear medical history presented with fever, cough, and headache. Respiratory tract infection was diagnosed, and empirical
antibiotics were started. Within two days, she developed bilateral pleural effusions, diffuse consolidations, and ground glass
opacities involving all lung fields. She needed immediate oxygen supply, while ABGs deteriorated and chest imaging and
PaO
2
/FiO
2
indicated ARDS. Early administration of systemic corticosteroids led to gradual clinical improvement. Multiplex PCR
from nasal secretions was positive only for HCoV-229E and negative for multiple other pathogens. It remains to be elucidated how an
immunocompetent adult developed a life-threatening LRTI caused by a “benign considered” coronavirus strain, the HCoV-229E.
1. Introduction
Coronaviruses (CoVs), a genus of the Coronaviridae family,
are positive-stranded RNA viruses. e first human corona-
virus (HCoV) appeared in reports in the mid-1960s and was
isolated from persons with common cold. Two species were
first detected: HCoV-229E and subsequently HCoV-OC43
[1, 2]. Since then, more species were described [3–5].
e HCoV-229E strain was associated with common cold
symptoms [6]. Younger children and the elderly were consid-
ered more vulnerable to lower respiratory tract infections. Severe
lower respiratory tract infection so far has only been described in
immunocompromised patients [7, 8]. To our knowledge, there
is no report describing life-threatening conditions in immu-
nocompetent adults attributed to HCoV-229E. We report a case
of acute respiratory distress syndrome developed in a healthy
adult with no comorbidities and HCoV-229E strain identified
as the only causative agent.
2. Case Presentation
A 45-year-old female patient presented to the emergency
department with dry cough, headache, and fever up to
39.5°C lasting a few hours. Her past medical history was
unremarkable, and she did not take any medication regu-
larly. She has never smoked, worked as a teacher at a local
high school, and has not recently travelled.
Clinical examination revealed rales at her left lower lung
fields. Chest X-ray showed diffuse opacities and consoli-
dation at this field. e arterial blood gases (ABGs) were
normal, and intravenous ceftriaxone and azithromycin were
empirically administered for lower respiratory tract in-
fection (LRTI). S. pneumoniae and L. pneumophila antigen
in the patient’s urine specimen was negative, and blood
cultures were sterile.
Over the next two days, the patient’s clinical condi-
tion rapidly deteriorated, with development of tachypnea
Hindawi
Case Reports in Infectious Diseases
Volume 2018, Article ID 6796839, 4 pages
https://doi.org/10.1155/2018/6796839

(34 respirations/minute), dyspnea, and hypoxemia. ABGs
changed to PaO
2
of 55.3 mmHg, PCO
2
of 31.4 mmHg, and pH of
7.487. Lung auscultation revealed diffuse rhonchi symmetrically
all over her chest, bronchial breathing at her right and left lower
lobes, and diminished vesicular sounds. Chest CT scan displayed
bibasilar pleural effusions and diffuse consolidations plus ground
glass opacities involving all lung fields (Figure 1). Oxygen was
supplied at 5 L/min, and antimicrobial therapy was changed
to levofloxacin 500 mg/day. Systemic corticosteroids and
bronchodilators were added about 40 hours after her hos-
pitalization. Samples of the pleural fluid showed exudate with
260 cells/mm
3
, negative Gram stain, and sterile cultures.
Nasal secretions were collected, and multiplex PCR tech-
nology was applied targeting multiple pathogens (RespiFinder®
22, PathoFinder), including coronavirus 229E; coronavirus NL63,
HKU1, and OC43; influenza A, B, and H1N1; parainfluenza 1, 2,
3, and 4; Mycoplasma pneumoniae;Legionella pneumophila;
Bordetella pertussis; bocavirus; rhinovirus/Enterovirus; adeno-
virus; RSV A and B; and Chlamydophila pneumoniae. e
result was positive for HCoV-229E, while negative for the
other tested pathogens; PCR for SARS-CoV and MERS-
CoV was also negative.
Within the next few hours, the patient’s clinical con-
dition further worsened and she required increased oxygen
supply. New ABGs showed PaO
2
�76 mmHg, PCO
2
�33 mmHg,
and pH �7.45 at FiO
2
�0.50 with PaO
2
/FiO
2
�152, indi-
cating ARDS. e patient was in severe respiratory distress
and remained febrile and tachypneic, and a new chest X-ray
showed multiple consolidations all over her lung fields
(Figure 2). Intravenous linezolid was added to her regimen
(a) (b)
(c) (d)
Figure 1: Chest CT scan and chest X-ray (semisitting position, posterior-anterior view) of the patient after clinical deterioration depicting
diffuse bilateral opacities.
Figure 2: e patient’s chest X-ray showing extensive bilateral
airspace disease consistent with ARDS.
2Case Reports in Infectious Diseases

empirically in order to treat a possible community-acquired
Staphylococcus aureus pneumonia.
A repeat one-step RT-PCR in a nasal sample (Taqman, in-
house protocol, Hellenic Pasteur Institute) confirmed the ex-
clusive presence of human coronavirus 229E (HuCoV-229E).
After the administration of systemic corticosteroids, the patient
started to display clinical improvement within the first 24
hours. Further laboratory analyses did not reveal any immune
defect. After a week, she was discharged from the hospital well
and remained healthy 23 months later (Figure 3).
3. Discussion
e initially described coronavirus strain 229E has been
previously identified as the second most frequent cause of
common cold after rhinoviruses in healthy adults. Pre-
dominant symptoms were acute rhinorrhea, nasal conges-
tion, and/or sore throat [9, 10]. Nasal discharge was the
hallmark of all symptoms after inoculation of HuCoV-229E
to healthy volunteers, and further observed symptoms were
malaise, headache, chills, and cough [6].
HCoV-229E has been associated with bronchitis, acute
exacerbations of COPD, and pneumonia in infants, children,
and elderly persons with underlying illnesses [11–13]. Life-
threatening infections have only been described in immu-
nocompromised patients [7, 8], but the correlation of
HCoV-229E with LRTI in healthy adult individuals is un-
certain [9]. An adult patient with pneumonia tested positive
for HCoV-229E has been described in a study conducted in
rural ailand, but it is not made clear if other comorbidities
were present [14]. Nine Italian patients hospitalized with
LRTI have also been tested positive for HCoV-229E; however,
their age is not specified [15]. Although numerous studies
have tentatively linked 229E infections to severe respiratory
tract illness over many years, no study controlling for age and
underlying illness has demonstrated an epidemiologic asso-
ciation between infection with HcoV-229E in healthy adults
and any illness other than the common cold. Furthermore,
no case of HCoV-229E-associated ARDS has been re-
ported in immunocompetent adults. Only a few cases of
pulmonary infection and ARDS have been described in
a 76-year-old woman infected with the closely related
alpha coronavirus HCoV-NL63 [16] and in a 39-year-old
woman with poorly controlled DM and infected with the
beta coronavirus HCoV-OC43.
e patient was a teacher and thus exposed to multiple
pathogens from her students. She was an immunocompetent
adult with no underlying disease. Her symptoms progressed
rapidly, despite the immediate administration of broad-
spectrum antibiotics, and clinical, laboratory, and radio-
logic findings were compatible with ARDS [17]. e patient
came very close to intubation and mechanical ventilation,
but early addition of corticosteroids in her therapeutic
regimen seems to have played a decisive role towards her
favorable outcome. Close monitoring and continuous re-
cording and assessment of her vital signs warranted the
borderline avoidance of her transfer to the ICU.
HCoV-229E was isolated twice from the patient’s nasal
secretions; she was not intubated, and thus, the BAL sample
was not taken. Extensive workup did not reveal any immune
defect; all microbiological and serological studies remained
negative for other pathogens. Rapid and reliable diagnosis of
human coronavirus infections is of pronounced clinical
importance. New RT-PCR methods [18] in sputum and
nasal aspirates successfully have diagnosed human coro-
navirus infections. Multiplex RT-PCR is used increasingly to
diagnose respiratory infections and has shown to be more
sensitive than viral culture and antigen detection and also
rapid and cost-effective [19], with greater sensitivity and
similar specificity compared to real-time RT-PCR [20].
4. Conclusion
To our knowledge, it is the first time that human coronavirus
HCoV-229E has been detected in severe lower respiratory
tract infection with ARDS of a healthy adult with no
comorbidities. Although it is considered as a “benign”
microorganism and linked to mild respiratory symptoms,
the presence of HCoV-229E should not be underestimated
and considered as a possible pathogen even in coinfections
with other microorganisms and in more serious LRTIs. e
reason why HuCoV-229E causes different clinical mani-
festations in diverse patient groups has not yet been an-
swered. e process through which HCoV-229E may evade
normal immune defense and cause life-threatening illness
remains to be elucidated.
Conflicts of Interest
e authors declare that they have no conflicts of interest.
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4Case Reports in Infectious Diseases