Diagnostics for Coronavirus Disease 2019 (COVID-19) Patients
The incubation period for coronavirus disease 2019 (COVID-19) is 14 days, with a median time of 4-5 days from exposure to symptomatic onset. 
Most patients with coronavirus disease 2019 (COVID-19) will experience the following (in descending frequency)  :
Shortness of breath
Atypical presentations have been described, and older adults and persons with medical comorbidities may have delayed presentation of fever and respiratory symptoms.
Frequently reported signs and symptoms of patients admitted to the hospital include fever (83-99%), cough (59-82%), fatigue (44-70%), anorexia (40-84%), shortness of breath (31-40%), sputum production (28-33%), and myalgias (11-35%) at illness onset. Fever has been present in 44% at hospital admission and has developed in 89% during hospitalization.
Less common symptoms include headache, rhinorrhea, sore throat, and hemoptysis. Some patients have experienced gastrointestinal symptoms such as diarrhea and nausea prior to developing fever and lower respiratory tract signs and symptoms. Anecdotally, anosmia or ageusia may preceed the onset of respiratory symptoms, but more information is needed to understand its role in identifying COVID-19.
Signs/symptoms in pediatric patients are similar to those of adults but are usually milder.
Critically ill patients with coronavirus disease 2019 (COVID-19) generally have the following characteristics  :
Are older (median age 66 years)
Have underlying comorbid conditions (72%)
Need high-flow oxygen therapy (11-64%)
Need mechanical ventilation (47-71%)
Need advanced organ support with endotracheal intubation an mechanical ventilation (4-42%)
Need respiratory support with extracorporeal membrane oxygenation (ECMO) (3-12%)
Hypoxemic respiratory failure/acute respiratory distress syndrome (ARDS)
Diffuse alveolar damage
Secondary bacterial infections
Sepsis and septic shock
Sudden cardiac death
Acute kidney injury
All testing for COVID-19 should be conducted only for patients demonstrating symptomatic disease.
Specimens should be collected as soon as possible once a decision has been made to pursue COVID-19 testing, regardless of the time of symptom onset.
For initial diagnostic testing, collect and test an upper respiratory specimen.
A nasopharyngeal specimen is the preferred choice for swab-based severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) testing.
When collection of a nasopharyngeal swab is not possible, acceptable alternatives include an oropharyngeal (OP) specimen, a nasal mid-turbinate (NMT) swab, or an anterior nares (NS) specimen.
For NS, a single polyester swab with a plastic shaft should be used to sample both nares. NS or NMT swabs should be placed in a transport tube containing either viral transport medium, Amies transport medium, or sterile saline.
If both NP and OP swabs are collected, they should be combined in a single tube to maximize test sensitivity and limit testing resources.
The Centers for Disease Control and Prevention (CDC) also recommends testing lower respiratory tract specimens, if available.
For patients who develop a productive cough, sputum should be collected and tested for SARS-CoV-2. The induction of sputum is not recommended.
When it is clinically indicated (eg, those receiving invasive mechanical ventilation), a lower respiratory tract aspirate or bronchoalveolar lavage sample should be collected and tested as a lower respiratory tract specimen.
Healthcare providers should contact their local/state health department immediately to notify them of patients with fever and lower respiratory illness who they suspect may have COVID-19. Local and state public health staff will determine if the patient meets thecriteria for testingfor COVID-19. The state and local health department will assist clinicians to collect, store, and ship specimens appropriately, including during afterhours or on weekends/holidays. Clinical specimens should be collected for routine testing of respiratory pathogens at either clinical or public health labs. Note that clinical laboratories should NOT attempt viral isolation from specimens collected from persons suspected to have COVID-19 unless this is performed in a BSL3 laboratory. Testing for other pathogens by the provider should be done as part of the initial evaluation but should not delay testing for COVID-19.
Store specimens at 2-8°C and ship overnight to the Centers for Disease Control and Prevention (CDC) on an ice pack.
Label each specimen container with the patient’s identification (ID) number (eg, medical record number), unique specimen ID (eg, laboratory requisition number), specimen type (eg, serum), and the date the sample was collected.
Complete a CDC Form 50.34 for each specimen submitted. In the upper left box of the form, (1) for test requested select “Respiratory virus molecular detection (non-influenza) CDC-10401” and (2) for At CDC, bring to the attention of enter “Stephen Lindstrom: 2019-nCoV PUI”.
Lower respiratory tract
For bronchoalveolar lavage, tracheal aspirate, collect 2-3 mL into a sterile, leak-proof, screw-cap sputum collection cup or sterile dry container.
For sputum, have the patient rinse the mouth with water and then expectorate deep cough sputum directly into a sterile, leak-proof, screw-cap sputum collection cup or sterile dry container.
Upper respiratory tract
For NP swab/OP swab, use only synthetic fiber swabs with plastic shafts. Do not use calcium alginate swabs or swabs with wooden shafts, as they may contain substances that inactivate some viruses and inhibit polymerase chain reaction (PCR) testing. Place swabs immediately into sterile tubes containing 2-3 mL of viral transport media. In general, CDC now recommends collecting only the NP swab. If both swabs are used, NP and OP specimens should be combined at collection into a single vial. OP swabs remain an acceptable specimen type.
For nasopharyngeal swab, insert a swab into the nostril parallel to the palate. The swab should reach a depth equal to the distance from nostrils to the outer opening of the ear. Leave swab in place for several seconds to absorb secretions. Slowly remove the swab while rotating it.
For oropharyngeal swab (eg, throat swab): Swab the posterior pharynx, avoiding the tongue.
For nasopharyngeal wash/aspirate or nasal aspirate, collect 2-3 mL into a sterile, leak-proof, screw-cap sputum collection cup or sterile dry container.
Store specimens at 2-8°C for up to 72 hours after collection. If a delay in testing or shipping is expected, store specimens at -70°C or below.
Specimens and PUI forms must be packaged, shipped, and transported according to the current edition of the International Air Transport Association (IATA) Dangerous Goods Regulations external icon. Store specimens at 2-8°C and ship overnight to the CDC on an ice pack. If a specimen is frozen at -70°C, ship overnight to the CDC on dry ice.
Coronavirus Disease 2019 (COVID-19) (Medscape Drugs & Diseases article)
Coronavirus Disease 2019 (COVID-19): A Global Crisis (slideshow)
COVID-19 Infographics (slideshow)
[Guideline] Centers for Disease Control and Prevention. Coronavirus disease (COVID-19): Interim clinical guidance for management of patients with confirmed coronavirus disease (COVID-19). Available at http://cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html. Reviewed: March 20, 2020;
[Guideline] Matos RI, Chung KK, for the US Department of Defense. DoD COVID-19 practice management guide: clinical management of COVID-19. March 23, 2020. Available at https://health.mil/Reference-Center/Technical-Documents/2020/03/24/DoD-COVID-19-Practice-Management-Guide.
[Guideline] Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): Interim guidelines for collecting, handling, and testing clinical specimens for persons for coronavirus disease 2019 (COVID-10). Available at http://cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html. Reviewed: March 25, 2020;
[Guideline] Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): Information for laboratories. Available at http://cdc.gov/coronavirus/2019-ncov/lab/index.html. Reviewed: February 20, 2020;
Medscape Novel Coronavirus (COVID-19) Resource Center. Available at https://www.medscape.com/resource/coronavirus.
Medscape Drugs & Diseases
Disclosure: Nothing to disclose.
Diagnostics for Coronavirus Disease 2019 (COVID-19) Patients
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