Middle-Aged Man Recovers from COVID-19 Infection with Timely Antiviral and Supportive Care

Overview: A Case Study in Early Intervention and Effective Treatment

A 38-year-old male patient with a confirmed history of exposure to individuals infected with SARS-CoV-2 presented at Liaoning Provincial People's Hospital in February 2020 with mild fever and cough. Laboratory tests revealed elevated white blood cell count, while chest CT imaging showed signs of pneumonia in the right lower lobe along with pleural effusion. Subsequent nucleic acid testing confirmed a positive diagnosis for the novel coronavirus (COVID-19). The patient was hospitalized for three days and received antiviral therapy combined with symptomatic treatment, including both oral and intravenous medications. His condition improved significantly within days, allowing for safe discharge and continued recovery at home.

Patient Profile and Clinical Presentation

Demographics and Initial Symptoms

The patient, a 38-year-old man, reported experiencing low-grade fever (self-measured temperature of 38.4°C) and persistent cough for one day prior to seeking medical attention. He had taken over-the-counter ibuprofen without full symptom relief. Notably, he had been in close contact with someone later diagnosed with COVID-19, placing him at high risk for infection. Upon arrival at the hospital's fever clinic, a comprehensive diagnostic workup was initiated.

Diagnostic Findings

Blood analysis showed elevated inflammatory markers: C-reactive protein (CRP) at 57.32 mg/L, white blood cell count of 13.86 × 10⁹/L, neutrophil percentage at 83.2%, and lymphocyte percentage reduced to 10.4%. Procalcitonin levels were slightly elevated but not indicative of severe bacterial sepsis. Chest CT scans revealed increased lung markings, patchy high-density shadows in the right lower lobe consistent with pneumonia, and fluid accumulation in the right pleural cavity—findings suggestive of an active pulmonary infection complicated by inflammation.

Given the clinical presentation, exposure history, and radiological evidence, suspicion for SARS-CoV-2 infection was high. Nasopharyngeal swab testing returned positive for viral RNA, confirming the diagnosis of COVID-19.

Treatment Strategy and Medical Management

Inpatient Care Plan

Upon admission, the patient was placed under Level 2 nursing care, advised bed rest, and encouraged hydration and light nutrition. Initial lab results showed no significant abnormalities in liver or kidney function, with D-dimer below detectable limits (<0.21 mg/L), indicating a low immediate risk for thromboembolic complications.

Pharmacological Interventions

The treatment regimen included a combination of antiviral and anti-inflammatory agents aimed at targeting both the virus and secondary infections:

• Moxifloxacin hydrochloride tablets – initially administered orally, later switched to intravenous infusion due to concerns about mixed infection;
• Oseltamivir phosphate granules – discontinued after two days due to lack of significant improvement;
• Arbidol hydrochloride tablets – used for its potential antiviral effects against enveloped viruses;
• Lianhua Qingwen capsules – a traditional Chinese medicine formulation known for reducing fever and respiratory symptoms;
• Ribavirin tablets – added on day two to enhance antiviral coverage;
• Acetylcysteine tablets – introduced to help liquefy mucus and support expectoration;
• Intravenous moxifloxacin – upgraded from oral form to ensure broader antimicrobial coverage, especially considering possible co-infection.

Daily monitoring of nasopharyngeal samples confirmed persistent viral presence, reinforcing the need for sustained antiviral therapy.

Clinical Progress and Recovery Outcome

Symptom Evolution During Hospitalization

Despite ongoing fever and respiratory discomfort during the first 48 hours, the patient remained stable with normal oxygen saturation (97% on room air), no shortness of breath, chest tightness, nausea, or vomiting. Sleep and appetite were maintained throughout his stay.

Positive Response to Therapy

By the third day of hospitalization, marked clinical improvement was observed: body temperature normalized, cough frequency decreased, and follow-up chest CT demonstrated a reduction in the size of inflammatory lesions. Based on this favorable response, the decision was made to discharge the patient with instructions for continued self-monitoring and home-based recovery.

The overall treatment outcome was assessed as excellent, with significant alleviation of symptoms and radiographic improvement—all achieved within a short 72-hour inpatient period.

Post-Discharge Guidance and Preventive Measures

Key Recommendations for Continued Recovery

To ensure full recovery and prevent relapse or complications, the following post-discharge advice was provided:

1. Rest and Immune Support: Continue adequate rest, maintain balanced nutrition, and avoid physical exertion. Psychological well-being is crucial—maintaining a positive mindset can boost immune resilience and improve healing outcomes.
2. Infection Control Protocols: Given the highly transmissible nature of SARS-CoV-2, thorough terminal disinfection of the patient's room and surrounding areas was conducted after transfer to a designated isolation facility to prevent nosocomial spread.
3. Lung Function Rehabilitation: As residual lung infiltration and pleural effusion may persist post-infection, patients are encouraged to engage in gentle breathing exercises and early pulmonary rehabilitation to prevent complications such as pleural adhesions and long-term restrictive lung disease.

Insights and Broader Implications

Evolving Understanding of COVID-19

This case highlights several important aspects of managing early-stage COVID-19:

• Transmission Prevention: Wearing masks, practicing hand hygiene, and maintaining social distancing remain foundational strategies in curbing transmission, especially among asymptomatic carriers.
• Vulnerable Populations: While the virulence of the virus has diminished compared to earlier strains, older adults and those with comorbidities—such as diabetes, hypertension, immunodeficiency (e.g., HIV), or cancer—remain at higher risk for severe illness.
• Viral Variability: As an RNA virus, SARS-CoV-2 is prone to mutations that may enable immune escape, complicating vaccine development and therapeutic efficacy over time.
• Prognosis with Timely Care: With prompt diagnosis and appropriate multidrug therapy, even symptomatic cases can resolve rapidly. This patient's recovery within just three days underscores the importance of early intervention and tailored treatment protocols.

While public fear around COVID-19 remains understandable, this case demonstrates that with proper medical care, most patients can expect favorable outcomes. Public education, access to testing, and adherence to preventive measures continue to play vital roles in global pandemic control.